What does Sesamoid Avascular Necrosis (osteonecrosis) Look Like?

Bone Fragmentation is Noted in AVN (here of the lateral or fibular sesamoid

This view showed the tremendous inflammation between sesamoid and metatarsal (this is actually why the patient hurts)

Another view of the fragmentation on CT Scan (these pieces will never come together)

The view is T1 (meaning healthy bone should be white) of the bottom of the foot

This view is T2 (normal bones can look like this) but the T1 and T2 should be different. You can tell the lateral sesamoid is both darker than the medial sesamoid and the white within is just the inflammation seen between the fragments.

So, it you just looked at T2 here, you would be misled as the sesamoid are darker, and there is tremendous inflammation within the joint.

This is crucial to making the diagnosis of AVN with the lateral sesamoid dark on the T2 above and T1 here. A fractured sesamoid can be dark on T1, but should be very bright with inflammation noting healing potential on T2. 

I discussed with the patient, who has had 2 years of pain, that AVN has occurred and removal of the lateral sesamoid is recommended. However, if he wants to try one more year of conservative treatment, even when the fragments will remain separate (some of these just do not hurt), then daily Exogen bone stimulation, contrast bathing twice daily, and some regimen of acupuncture, could be tried. 

Video Greeting from Dr. Blake and Happy Thanksgiving

Gout love Ice Better than other Inflammatory Problems!!

The following article presented a discussion on ice versus heat. It seems that if you are having a gout attack, ice packs for 10-15 minutes prevail. Some of the other forms of inflammation actually prefer heat like in wear and tear arthritis. I will have to rethink my recommendation of "When In Doubt, Always Ice!" I still feel the patient must experiment to see what makes them feel better. Rich 

Schlesinger N, Response to application of ice may help differentiate gouty arthritis and other inflammatory arthritides. J Clin Rheumatol. 2006 Dec;12(6):275-6

https://pubmed.ncbi.nlm.nih.gov/17149056/

Hallux LImitus: Can I Avoid Orthotics?: Email Advice

Hello Dr. Blake, 
I came across your article  “ Treating a runner with Hallux Limitus who does not want to stop running.” while searching online for advice to keep running after being diagnosed with Hallux Limitus with bone spurs. 
Is it possible to keep running with this diagnosis without orthotics?     I run in Brooks Ghost and put in about 15 miles/ week. Can I run in my Brooks with the medium gel toe separator and avoid additional injury to the joint ? 

Any advice is greatly appreciated. 

Thanks,

Dr. Blake's Response:

Hallux limitus is a slow gradual progressive degenerative process when there are spurs. I have had runners for 30 plus years continue running, but there is no magic cure. The goals are to protect the joint with decreasing stress somehow, never run with pain over 2, and especially no limping. Running itself is very natural for the body building strength in muscles and bone, and has a huge emotional aspect. It is part of any athletic participation program, and I think vital to people’s health. 

    The goal in the short term is to continue running your 15 miles per week, while you build a program to keep the pain level between 0-2. Orthotics themselves can both hurt and help, so typically not my #1treatment unless you are a moderate to severe pronator. Pronation jams the big toe joint into the ground increasing the stress. The orthotics have to be full length and require expert attention since the rigidity under the big toe joint in a full length orthotic device may be too much pressure to the joint and have to be modified.
    So, in achieving this 0-2 pain level, without going over the physics of each one, include the following which predictably decrease stress on the big toe joint: spica taping, dancer’s padding, hoka running shoes with rocker bottoms, cluffy wedges, arch supports, Morton’s extensions, shoes with great forefoot cushion like the Ghost, etc. 
    My blog talks about this individual treatment options. I hope this makes sense. Rich 

Sesamoid Break with Pain Out of Control: Email Advice

Hello Dr. Blake-

Looking for an opinion and I have hit a wall I feel like. I have 4 year old twins in this past June they ran over my feet while riding in their power wheels (accidentally) causing my Sesamoid bone to break.

 I had xrays to confirm it (Drs were able to confirm it was a break by comparing previous xrays two years ago showing the bone was not broken). I was immediately put into an air boot and for the first two months followed with xrays each time showing no healing. I then was sent to an orthopedic who recommended foot orthotics however after going from the boot to the sneaker with orthotics the foot got worse and my tendon between the big toe and the toe next to it became irritated.

 I was then sent to a podiatrist who put me back in the boot and had me tape the big toe 24/7 and xrayed me each month through September, still no signs of healing. In September he gave my a cortisone injection which was horrendous but after two weeks it did calm the area down but that only last until about two weeks ago.

 I saw him at the end of October and he has me taping 24/7 the toe next to the big toe and staying in the boot fulltime other than to sleep. Now my entire foot is swollen, I have pain not only where the Sesamoid break is but now across my toes, top of my foot, and it wraps around my ankle to the achilles and back to the inside and underneath the arch of my foot. I have swelling and bruising in all of those areas and have also started to bruise just above my joint where the foot meets the leg (lower shin area).

 The pain in my ankle and achilles is almost unbearable in and out of the boot. My podiatrist has requested me to have an mri but hasn't scheduled it yet and I don't go back for xrays again until next week. Since June I have had it elevated every night and use ice packs. I can’t take any anti-inflammatory medications because I have an allergy to nsaids and ibuprofen which has made it difficult to control the swelling and pain. The podiatrist did try me on prednisone before the cortisone shot but it did not work and gave me arrhythmia so he discontinued that.

 I am a 35 year old Mom of 3 all under the age of 10. I am extremely frustrated but also worried that we are missing something. Does it normally take this long to heal and also can other ailments occur from the Sesamoid taking so long to heal? How concerned should I be regarding the new areas of extreme pain and swelling? I feel like my doctors down play it and I just don’t want to keep getting worse. Is there maybe some other diagnoses I should suggest being checked for now? 

Maybe someone not from my area like yourself may have other suggestions that I could inquire with my doctor about when I go back this month? I have included pictures. The first three photos were from Friday and the last one with painted toenails is from tonight. The swelling is all over the place and up and down consistently since June. I am not a diabetic, I am not severely obese (5”7 160lbs). My only medical history is allergies to medications, graves disease that I take thyroid medication for, and I had a hysterectomy after my twins 2 years ago and take estrogen every day as a replacement. Thank you in advance.

Dr. Blake's response: Thank you so very much for your email. Initially, you were just treating a broken sesamoid which is in some form of healing or non-healing, but that is not what you should really work on now. You have developed perhaps a nerve hypersensitivity from the chronic pain and prolonged immobilization. Go to the doctors, and say CRPS has been suggested as your pain is out of control. The treatment for this should be now, so I would forget the broken down until this is addressed. The mottled skin in the photos could be a sign of CRPS which stays for Complex Regional Pain Syndrome. You may need a sympathetic block in your back. I developed CRPS personally after a herniated disc in my back, and I was literally rushed to get the injection. You need to throw this word around until someone takes you seriously. Typically you may have to go to the ER to start the process, but any doctor who agrees with me can get you going. If it is not, great!! If it is, the sooner you get treatment the better. Rich 

Hamstring to Quadricep Ratio: Normal and When Greater Hamstring Needed

https://www.peakendurancesport.com/endurance-injuries-and-health/muscles-and-tendons/a-balanced-approach-to-leg-strength/

Article Emphasizing the Safety of Alcohol Injections for Neuromas with the Need for Mechanical Treatment Also

https://www.sciencedirect.com/science/article/abs/pii/S1067251618300759?via%3Dihub

Big Toe Joint Pain after Immobilization: Email Advice

Hello Dr. Blake,

I feel very fortunate to have found your blog. I recently suffered a Jones 

Fracture and had

 surgery to implant a titanium screw in the 5th metatarsal in early July. 

The first x-rays from the 

break also showed mild great toe arthritis (I had some pain in the toe, 

but no problems putting weight on it at all). The most recent x-rays from 

September 

show the 5th metatarsal healing well, but significant arthritis in the great 

toe, and now it 

is painful to push through (I am wearing Hoka shoes now and having an

 orthotic made). 

My podiatrist/surgeon immediately suggested a joint fusion of the great 

toe despite the 

fact that the recent surgery and non-weight bearing recovery was quite 

traumatic for me, 

and I still have movement in my toe and am in physical therapy. I would 

love any insights 

you may have as to why my toe arthritis may have worsened so much 

while in a boot, and 

most importantly, if you could suggest any doctors in the 

Seattle/Bellevue, Washington area 

who are more in-line with your way of approaching Hallux 

Limitus and Hallux Rigidus. 

Thank you so much for your time and wisdom.

Dr. Blake's comment: My job is so easy when I can sound smart using 

common sense. You

do not need a big toe joint fusion, at least for now, and hopefully not for

 a long time. Immobilization 

for whatever the reason causes joints to freeze up. Arthritic joints love motion, 

not excessive, but they love to 

move since it helps them to lubricate. Email me how you are doing in 3 months 

and attach this post 

so I can refer to it. But, what to do now?

The Hokas with their rocker sound great. The orthotic can be helpful or 

not at this stage, if not, it may be 

helpful later. Learn about dancer's padding and spica taping and experiment. 

Do not let the physio try to increase range

of motion, it tends to backfire. The goal is to reduce pain, not increase range 

of motion. You can review 

my video on self mobilization which may help. Ice 3 times a day for 10-15 

minutes to cool off the joint. 

Again, non weight bearing does not help, so gradually try to find the amount 

of day to day walking you 

can do and keep the pain down. Since I would rather you walk 10,000 

steps aday than not, this is where 

the shoes, orthotics, dancer's padding, and spica taping come into play. 

What helps when?

The PT can do iontophoresis to the joint to calm it down if you can get 

a script for it. 

I would rather you back in a walking boot for 2 months, with the emphasis 

on walking, then not walking. Give me

an update soon. I will try to find someone in Seattle. It is a great place 

with good podiatrists. Rich

Good luck!!

Severe Ankle Pain after Working Out: Email Advice pre-flying internationally

Hello, Dr. Blake -

I have been reading your blog quite a bit lately.  It’s very informative, thank you!  Unfortunately I’ve got some pretty debilitating pain in both of my feet.  I noticed the pain about 3 weeks ago.  I woke up one morning, and on my way to the bathroom I felt a pop! in my right foot and it was quite painful to walk.  I went back to bed and thought it was just a strange thing that happened.  When I got up for the day, I again felt some pain, but it went away quite quickly as I walked around the house.  I routinely do High Impact HIIT classes at home and the day before I felt this pain, I did a workout that I have done many times before but with a different pair of shoes. (Long story short, they were the only shoes I had).  

After that, I stopped any working out that required standing up, jumping or weight-bearing.  However, I did not stop walking or standing.  As time went on, my movement has been more and more restricted.  I am using crutches to get around.  I do not walk anywhere except to the bathroom, bed and kitchen.  It is awful.  I use ice, NSAIDs and rest, rest, rest.  I tried some ankle braces, but they feel too tight now.  The pain started in the inside of my foot, below the ankle.  I notice inflammation and warmth in that area after use.  

I cannot walk normally on my right foot and if I do, I feel it in my arch.  I do not even attempt a one leg lift.  The pain started in my left foot (same area, below ankle near arch) about a week and a half or 2 weeks after the right.). The pain has at some points in time migrated to other areas, such as below the arch, above the ankle bone on the inside of the leg and even an almost pinching sensation on the outside of the ankle.  I have also had pain at the top of the ankle when I step (upon waking up) and shin splints pain on the left leg, soreness in the ball of the foot and even on the heel.  At times my calves feel pretty tight, but I have stopped doing stretches because I don’t want to aggravate anything.  I am pretty sure it is PTTD, but I need to go to the doctor for a proper analysis. 

Dr. Blake's comment: It sounds like some version. Do you have a history of flat feet? Or a history of other foot problems? Can someone take a photo of both feet standing, that I will attach to this post, one from the front, the inside arch and one from the back of the heel? And, while you are at it, a good photo of the original injured ankle area? 

We are currently abroad but flying back to the US in 3 days.  Once we return, all doctor’s offices require 14 day waiting period (Coronavirus requirement) before coming in.  So I just have to be patient.  I have two young children and am a stay-at-home Mom.  I am physically fit and normally very active.  I am so incredibly frustrated that I have admittedly started crying.   I am trying to be patient.  My question is, what can I do in the next few weeks before my appointment to try to improve the situation?  How can I manage an international flight with 2 toddlers, crutches and luggage?   Is there anything I can do beyond RICE? 

Dr. Blake's comment: Yes, try to get a below knee boot for the worse side and the posterior tibial tendon dysfunction brace by aircast for the other side. You have to carry things evenly on your back with a backpack, and walk slow if you can. You could switch to hiking poles from crutches. A local pharmacy may have the boots, but maybe Amazon can rush them. 

Oh, I just bought new shoes yesterday that are softer on my feet than the ones I was wearing.  (I tried to get the Brooks Ariel that you had suggested in a separate blog, but they did not have it.  I just bought the type of shoes I was working out in before I switched.). Also, while the past few days I have noticed that the pain/swelling is occurring earlier and earlier in the day and will come back sooner, the pain has remained localized near the arch of the foot.

I went to urgent care here in Switzerland.  They said it did not appear to be a bone issue, that I would likely need an MRI for proper diagnosis.  She said it is possible there is a very small fracture, but that is all speculation.  She did say it was concerning that it was worsening.

Dr. Blake's comment: During the flight, swelling can increase your chance of blood clots. Get some 20-30 mm Hg compression hose to wear on the flight and keep your feet up and moving up and down at the ankle 20 times every hour. If you went to an urgent care, maybe call them for any other advice. Get some form of baggie, and apply ice (that the plane will have) 15 minutes every hour to hour and a half to the ankles. Maybe plan on going there one more time the day before you leave for advice. Ask the crucial question if you should fly in the first place. 

At this point I feel like I will never walk again.   I am so afraid that it is degenerative and I have already done too much damage that I will not be able to reverse.  Any recommendations or even words of encouragement would be extremely helpful.

Dr. Blake's comment: It is rare to have a permanent situation days after doing high level workouts. I think you have not immobilized enough, first phase of rehab, so get to it. It is something you can control. I await the photos, etc. Rich 

Thank you so much,

Sesamoid Injury: Email Advice

Good afternoon Dr. Blake,

I hope this email finds you and yours well. Your foot and ankle injury blog and videos have been a great resource for me as I have been dealing with a sesamoid fracture/injury since late Feb/Early March. 

Essentially, I'm not sure how I fractured my sesamoid, but I didn't have a great podiatrist at the beginning of the injury, which, coupled with the quarantine (I'm in NYC), essentially means that I lost 3 months of proper treatment right away. I had x-rays and MRI with this doctor, but everything was taken very lightly. I was told it was maybe fractured, then just an itis, with no clear plan of how to get it to heal. I had to wait til June to get an MRI (now I know I should have had one right at the beginning.) It was all downplayed a lot and I even had to ask for a boot but with no instruction of how long to wear, when to wear, include dancer's padding etc. I stayed in the boot on and off for March/April but with no dancers padding and only outside. Inside I used slippers but was sometimes barefoot. Then in May/June (what is time anymore!?) I went to an orthopedic surgeon who saw me for 15 minutes and told me to get custom insoles, which I did get and now have for sneakers. I still knew something was wrong because I still had pain walking in the sneakers and did not feel comfortable putting all the weight through the ball of my foot and it just wasn't getting better. Fast forward to July, after getting more x-rays and a CT scan with a different podiatrist, he confirmed a fracture diagnosis, put me back in the boot and now I'm using a bone stimulator. I've been in the boot since July 29th and have been using the bone stimulator since August 17. Sometimes I use it twice a day. I've attached my MRI and CT scans below (if you'd prefer access to the portal to view all the images, I can certainly provide that).

Dr. Blake's comment: So sorry for the delay, but it did not sound like you made it worse, and it is sounds like good progress now!

As I've read from so many people who have this particular injury, it is incredibly frustrating, with little understanding of it, and very prone to setbacks. Right now, I'm wondering what else I can do besides the contrast baths, taping etc. I have gone to PT but haven't gone as much since I am back in the boot and am trying not to travel extra to the city. Plus I do a lot of leg strengthening at home. Should I be refraining from walking as little as possible and pretend as if this fracture happened yesterday and not in March? 

Dr. Blake's comment: Create the 0-2 level, walking within at framework actually is better for the muscle strength, bone demineralization, sanity!! There is no guarantee of complete healing for many reasons, but 3 straight months of immobilization in the walking boot, and then another 3 months of keeping the pain between 0-2 as you wean out seems vital to alot of these injuries. Unfortunately, the initial trial of boot does not count. 

I really want it to heal, yet I feel that this is going to be another 3 months, at least. It's so sensitive and a tiny little thing seems like it causes a flare up. My legs/feet and left foot just feel off/bad from being in the boot and even up on the left foot for so long, on and off this year, and I'm honestly afraid I'm not going to remember how to be in sneakers or how to eventually transition back into wearing them.

Dr. Blake's comment: It is not a waiting game since there are some many things to do now to prepare for the weaning out of the boot period. You need to make sure that your orthotic devices and dancer's padding off weight the area (so some visits with good shoes to the podiatrist office to make sure all is well is important). You want to have perfected spica taping, and have some stiff dress shoes for the holidays so you can place in Dr. Jill's Gel Padding as protection. PT is less important now since you are back in the Immobilization Phase, but without irritating the sesamoid, you need to keep strong, flexible, and with infrequent flare ups (but they will occur even in the best situations). 

I do ride my bike sometimes (walk down the stairs in the boot, switch to sneakers with insole etc-it's a process!) but sometimes even if my steps add up to 1 mile each day, that seems to aggravate my foot. It's all very frustrating :) I really want this to fully heal as it's been many months now. If you have any additional insight on my particular case, I would be so grateful! 

Dr Blake's comment: The 4 common areas you need to deal with are: protection (just discussed with boot, orthotics with dancer's padding, dancer's padding alone, cluffy wedges, spica taping, stiff shoes, or rocker shoes like Allegria dress, or Hoka One One type), inflammation (ice and contrast bathing very important, NSAIDs and cortisone shots can slow bone healing, and PT when needed), nerve sensitivity (pain free massage 3 times daily, big toe joint gentle range of motion with your muscle strength only, occasional topical or oral nerve stabilization meds), and bone health (eating habits, low vitamin D, smoking, etc). 

Thank you so very much.

My Best,

Dr. Blake's comment: So, now to the images you so kindly sent. A question I have was there a fall or accident before your symptoms developed since they have a diagnosis of medial sesamoid chronic ligament sprain? Also, any sesamoid injury which is definitely bipartite we need to know if you have a possible turf toe injury also. This is where the ligament is sprained, and the joint can become looser, and possibly require surgery. I assume since you did not mention anything, the doctors have ruled it out, but ask them about it and also if they have done bilateral Lachman tests for joint stability. The sprain can also just cause excessive scar tissue that gets in the way. 

Possible AVN in definite bi-partite. You can fracture the junction between the 2 pieces and the treatment may be the same. 

Here less AVN looking with bone marrow. Bipartite pieces are different sizes

Here T2 MRI clearly shows no AVN!!

Turf Toe Possible Raised when Ligament Sprained

AVN Sesamoid: Email Advice

Hi Dr. Blake,

I’m so happy to have found your blog and YouTube videos, and I hope you can provide some insight and guidance for my situation:

About me: 38 y/o female, chemistry professor by day, professional belly dancer by night and aspiring amateur Muay Thai fighter all day, every day (thai kickboxing).

History: late in 2019, I started noticing some pain in my left big toe upon extension. The pain was never severe, so I kept training. Nothing a little tape wouldn’t fix (or so I thought). Then the pandemic hit, and I started running a lot since my gym was closed. The pain got worse, I did less and less. Still, the pain was never terrible but it was persistent. I saw my podiatrist, and he diagnosed me with AVN of the fibular sesamoid by MRI in early June 2020. This was confirmed with spect CT in early July. My x rays were normal, there was no apparent fracture or degeneration. Both the MRI and CT showed some soft tissue inflammation/edema but no tears. I went in a boot for 6 weeks, and I was given a bone stim (ortho fix) that I’ve been wearing for 3 hours a day for almost 3 months. My pain was at a 0-2, so I have been attempting to gradually step up my activity, but it seems that it’s always 2 steps forward, 2 steps back. My PT primarily does manual therapy, and I’ve been doing toe yoga and trying to go for walks or short hikes (In the shoe recommended by my podiatrist - hoka Bondi 6). Anytime I do this, my foot starts to swell again and be painful. I am so frustrated.

Here is my dilemma - I also have some mild/moderate scoliosis, and the lack of activity has severely flared up my back pain - to the point that the idea of spine surgery has been floated by my sports med doctor. As a result of the crooked spine, I have degenerative disc disease (Several herniations, stenosis and facet joint arthritis) that I have been keeping in check by remaining fit and active. Resting my foot and doing seated exercises (like a stationary bike) has been hell on my back. Obviously, abnormal gait and wearing a boot didn’t exactly help my back either. I need to get back to my regular training/dancing schedule to ensure that my spine stays functional and I avoid back surgery.

What is the best course of action to return me to normal activity as soon as possible? In your experience, does this type of injury heal with conservative treatment and is the person able to return to their activity? I’ve scoured the literature, and the lack of studies is frustrating, and what little there is focuses on surgical treatment. How do people fare after surgery in your experience? I’m not keen on doing unnecessary surgery but I am trying to balance the needs of my back with the needs of my foot. Lastly, what is your opinion on the use of NSAIDS during AVN? I am concerned about the anti-angiogenic effects.

Thank you for taking the time to read this and consider my case.

Kind regards,

Dr. Blake's comment: Definitely switch out of the boot for your back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides, something your back will be happy for. Your physical therapist should be able to put you on a program to keep your back loose and strong as you go through the foot rehab. When will you get another MRI? I usually wait 6 months, but in your case, every 3 months to see some light at the end of the tunnel with the AVN healing. In your whole discussion, you mentioned nothing about all the other things besides Hokas: orthotic devices, dancer's padding on the orthotic and separate, cluffy wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. Send me a photo of coronal view injured sesamoid both T1 and T2 weighting to see the AVN. And yes, no NSAIDs, but you should be doing contrast bathing for deep bone flush and circulation every evening. Rich 

Article on Hamstring Tightness and Plantar Fasciitis

https://journals.sagepub.com/doi/10.1177/1938640010397341

     I have to admit that when patients present with plantar fasciitis I fail to measure hamstring tightness as much as I should. This is a good reminder that plantar fasciitis been be shown to be associated with achilles tightness, with pronation, with obesity, and with tight hamstrings. It is important to stretch out the tight hamstrings when plagued with plantar fascial symptoms. 

Liz, a nurse which used to work with me, discusses 7 principles of stretching while stretching the lower hamstrings. 

https://youtu.be/OfE3f-F_3wY

It is Just the Wrong Timing of Events: Athletic and Other Injury Rehabilitation

     I am saddened when patients prolong their injuries with the Wrong Timing of their Treatments. Many times it is only because the definitive diagnosis has yet to be made. Many times it is because the health provider has too short of range of options to offer (as I do sometimes). Many times it is because the patient is impatient for a cure, or the subtleties of any treatment regimen is not followed or fully explained (and thus the patient keeps irritating things). And thus there are so many variables, so many different provider that will practice their treatment protocols, that I have found following the 0-2 pain level in all treatment phases must be followed. I know only some good physical therapists that can make you hurt and still get you better. I know that when surgery is required (1-2% of all athletic injuries) you will have more pain for awhile. But, in general, after you get the proper diagnosis, you should get better and better on a month basis (so September should be better than August, and October better than September, etc). 

     So, you develop pain with or without an injury. If the pain is between 0-2, and you can do full activities, you can probably wait a month before you see someone (and maybe the pain will go away by then). Of course, when you do see someone, you expect their diagnosis to be correct (which it normally is by the way), and month by month you get better and better (I assume 3 months on average to greatly improve if the injury requires a doctor visit). It is important in my mind to drive the pain down to 0-2 as quickly as possible (a week for sure), and then keep it there. This could initially be done by stopping an activity, put in a cast, and/or up on crutches. This is how you know you have the right diagnosis and treatment plan. You should be able to increase function, with no increase in pain, month by month. Of course, if your diagnosis requires a cast or boot or surgery, you may not be able to start that progression to full function for several months. In these cases, the diagnosis is definitive from the start (verified by xray or MRI or ultrasound).

     So, that is the Right Timing of Events: Injury or Pain Development, Proper Diagnosis and Treatment, Pain Quickly Down to 0-2, and Pain Kept There as Full Function Returns. Sounds simple, but it gets messed up all the time due to the limitations on medicine listed above. And, we can add insurance issues that block both diagnosis (say inability to get MRI) and treatment (do not cover the expensive bone stimulator you need). The patient is carefully moved through the phases of rehabilitation (immobilization, re-strengthening, and return to activity) and all goes well. 

     I will give you 2 recent examples of the Wrong Timing of Events. The first was a patient that partially tore her achilles, pain level 6-7, limping. She went to the local hospital clinic, and received 3 stem cell injections one month apart as her only treatment. No cast. No driving the pain to 0-2. And, no better, so 5 months later comes to me for a second opinion. This is one of the top hospitals in the country, or so they advertise.  The second was a patient whose plantar fasciitis was improving with orthotics, taping, icing and stretching, but when she had a flare from running too much on the weekend, when the pain got to 5-6 from the 0-2, all the doctor did was put some more padding on her orthotic devices and give her a Rx for PT. This does not sound bad, but she had never had this much pain, and it took 3 weeks to see the PT for the first session (which is typically just information gathering). So, one month went by, the heel padding had made her worse, the PT really not started, and her pain from limping had increased to 6-7 levels. The doctor had a second chance to right the ship, but again the orthotics were adjusted, and taping was applied which did not help. She clearly had a severe flare of her plantar fasciitis or a new injury. After seeking a second opinion, due to the level of pain, an MRI revealed a calcaneal stress fracture, and definitive treatment started. So, when the pain you are treating gets worse, ask yourself if you still believe in your working diagnosis first, and ask how can I reduce this patients pain to 0-2. 

Excellent Video on other exercises for Posterior Tibial Problem!

https://youtu.be/zV6bbRaNhzk

Bi-Partite vs Fracture in the Sesamoid Bones

Hey, I came across your site yesterday while doing some research. I have been dealing with some pain on the side of my left big toe joint since December of last year. I initially went to a local orthopedic where they x-ray both feet and they said I have bipartite sesamoid on both feet. They didn't really have any answers as to why I am experiencing pain though. I am able to run fine but and the pain is more of an annoyance than a debilitating pain. I can run for 3 hours or even do hike/runs for 6 hours and the pain doesn't get any worse. I would say the pain level is between 4-6.

Dr. Blake's comment: To most of my patients, pain levels over 2 and they are going to the doctor, and over 5 they are not running at all. 

Just walking around the pain is at a 1-2.

I recently went to a podiatrist foot and ankle specialist and he immediately said I in fact have a fractured sesamoid on my left but the right is a bipartite sesamoid.

Dr. Blake's comment: Only an MRI is conclusive, but to me they both look bi- and tri-partite with smooth borders. Sesamoids that are in multiple pieces congenitally can get irritated, even the junction between the bone fragments sprained or fractured. If you are not getting an MRI, you have to go by the amount of swelling, the level of pain, and use comparison xrays 3 months apart or so that will show a change. A broken bone will change and the xrays after 3 months will show that difference. Month to month changes will be less definitive. Unfortunately, when I have a decision between fracture and bipartite, and I can not get a definitive MRI, I treat it as a fracture with a cam walker for 3 months and I definitely do not allow my patients to go over pain level 2. 

He said I could try some custom orthotics or have surgery to remove it and that would fix the issue. Attached are images of the x-rays.

Dr. Blake's comment: To do surgery on a probable in your case non-fractured sesamoid is pretty absurd. So, custom orthotics (which should be only one of 10 things you are doing for your sesamoid to drive the pain now and let this heal: removable boot, hoka one one rocker shoes, spica taping, dancer's padding, cluffy wedges, activity modification, icing, contrast bathing, bone stimulator, and some PT to get their advice). 

If I get the surgery will I be able to run again? I am a competitive trail and ultra runner and I also race mountain bikes.

Dr. Blake's comment: Typically, unless you are the 1 in 10 that gets some complication, or has other unknown factors at play, you can run again, but the sesamoid bone will have to always be protected. Always. And this is why patients fight getting the right diagnosis and right treatment no matter how long it takes. Good luck Rich 

thanks

Thank You Dr. Jane Denton for the Denton Modification

     Today is the last day I am practicing Podiatry with Dr. Jane Denton. She says she is around for September some, but nothing is fixed. So, after asking her advice for 38 years and using her brilliant orthotic modification for lateral stability for almost 35 years, I am finally saying thank you publicly. 

     Dr. Denton's modification has improved the stability for thousands of my thankful patients. A patient of mine last week told me that the difference in a good vs great professional is only in subtleties. The Denton modification is subtle, but powerful. It has been the difference in making my orthotic devices, and overall treatment, a success in both pronators and supinators alike. It is a vital part of the Inverted Orthotic Technique for severe pronators, and a crucial element of every orthotic device designed for supinators. I am attaching a video of the orthotic components crucial for supinators, and a photo of the Denton modification.

     So, Dr Jane Denton, I personally, and the world of podiatry, thanks you anytime the Denton modification is applied to an orthotic device. It always makes a difference, sometimes big and sometimes small, but it is always helpful in treating my patients. I will miss you. Rich 

Here is the Denton applied before ground down even with the floor or base of the shoe. 

https://youtu.be/hMhrTmWXfDA

<iframe width="560" height="315" src="https://www.youtube.com/embed/hMhrTmWXfDA" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Designing Orthotic Devices with Temporary felt support to predict Pain Relief

 The red is the outline of the orthotic device I am making for this patient. The pink is the placement of support the patient will have as a front section to the orthotic device. The patient experimented for several weeks to find the most comfortable placement utilizing the 1/8 inch adhesive felt I gave her. This will save us a lot of time in making her orthotic devices comfortable. 

Recent Interview for Spanish Podiatry on Biomechanics I Enjoyed Doing

Here I present during a Spanish interview 3 biomechanical cases with the thought process. Rich 

https://youtu.be/8VS1CBkfycY

<iframe width="560" height="315" src="https://www.youtube.com/embed/8VS1CBkfycY" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Inverted Orthotic Technique: The Reason the Device Works Still A Mystery??

As most of you know, I inverted an orthotic device almost 40 years ago that has been very successful. It has been the only orthotic device documented to help children outgrow their flat feet for instant. Yet, it is hard for researchers to grasp why. It is meant to change motion while walking or running into less pronation. Yet, studies have had a hard time studying this. The YouTube link below and the Podiatry Arena thread following is a wonderful example of this decision. The article they are referring to was on 11 symptomatic runners who when switched from standard orthotic devices to Inverted Orthotic Devices got better. But when studied, they could not find out why. I am actually learning a ton from these discussions and have my own theories. First of all, the study was done using the outside of the heel area of the shoe to represent the heel of the foot and this can be totally off. Secondly, the Inverted Orthotic Device is made for each foot individually, with different degrees for the right and left foot. And, when the foot does not respond, a redo is done to get it as perfect as possible. This was not done with the research. All patients, both right and left feet, got the same orthotic correction. In my mind, as a research project it was a failure from the beginning. This being said, it is my life's work, and I will continue to help it along as I can. 

https://www.youtube.com/watch?v=zLSdkIdn1K4&t=51s

Technique in Performing Biomechanical Tests are Crucial: Article on Achilles Evaluation

It is great that 43 years after I was taught how to properly examination the tightness of the achilles tendon, that the below article documents it is still ideal. The article also warns us about being sloppy with our examination techniques as errors can occur. Rich 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6996460/

Dr. Bruce Williams on Pressure Mapping

I am excited about adding pressure mapping to my practice over the next month for my patients. I will continue to treat my patients the same, and begin to collect data from them with an in-shoe pressure device. It will take me awhile to learn how my patients will benefit, but I respect Dr. Williams who was interviewed and he feels after the learning curve of a few months, the impact will be apparent. Rich 

https://youtu.be/ivk-JsFJ4kA

Great Article on Nerve Pain and Making the Diagnosis in Athletes

I have just starting treating a patient with 2 years of pain unable to get anywhere in treatment. She sent me this article this morning that I read from a physical therapist on nerve pain. I would have to say I agree with so much of this article, and although I am not sure yet if it applies totally to my patient, is a good discussion of the 3rd source of pain in my patient. The 3 sources of pain, each demanding separate treatments at times, are: mechanical sources (like your foot pronates too much or your hip muscles are not strong enough), inflammatory (where swelling in the tissues causes pain from injury or systemic causes), and finally nerve pain (which can be local like Morton's neuroma, referred pain from the spine, or combination of local and up-the-chain problems). 

The one aspect not discussed, and also may apply to my patient, is nerve overload with chronic symptoms. This basically means that there was a mechanical injury, that even with complete heeling, can leave you with nerve hypersensitivity, which now months later is the reason that you do not feel any better. This nerve hypersensivity can also need nerve treatments over mechanical ones. 

So, as I try to sort this all out for my patient, the body will continue giving us clues which can help if we listen. Rich 

https://www.irunfar.com/2017/08/six-signs-that-your-running-injury-is-nerve-pain.html/amp

Stage II PTTD: Email Advice

Dr. Blake --

Thanks so much for your blog, it's great.  I had a few questions I was hoping you might be willing to help me with.  Feel free to share on the blog so long as I am anonymized.

I'm in my mid-40s, am very overpronated in both feet, and have long-term PTTD in my right foot.  I used to be an active runner (many half-marathons, one full) prior to these problems.  Here's the details (all about right foot):

*  Started having ankle and arch pain (in retrospect, classic PTTD pain) in 2009.  Podiatrist believed pain related to accessory navicular.  Kidner procedure performed, hard orthotics prescribed.

Dr. Blake's comment: For the reader's benefit, the posterior tibial tendon is the most powerful tendon to support the arch. 10% of people have that tendon weakened by having an extra bone at its attachment into the navicular. This extra bone is called os navicularis, accessory navicular, or os tibial externum. The posterior tibial tendon is weakened when some of the tendon does not attach where it should to support the arch, it attaches into this extra bone. It would be like 30-40% of the achilles tendon not attaching into the heel bone, but just hanging out up the leg somewhere. 

* Generally pain-free until mid-2016.  Mild flare-ups occasionally.  Podiatrist recommended that I give up running, so I did.  I walk a lot for exercise (and still do), probably 15-20 miles per week.  I wore orthotics religiously, but my footwear was not the greatest (I loved wearing Chuck Taylors with orthotics, podiatrist said that was fine as long as I wore orthotics).

* Got new podiatrist in mid-2016.  Asked if I could try running again.  He said okay.  Started running in neutral New Balances with orthotics.  No issues for a week, then on a run felt sharp pain inside of foot and ankle.  Wore boot for a while and it got a bit better, but pain continued off-and-on for a year.

Dr. Blake's comment: With Neutral shoes, you need a lot of support from the orthotics, with stability shoes, you need less. Hard to know what did it, as it could have just been weak. You are not commenting on strengthening, but post Kidner you should be on life long posterior tibial strengthening. Simple maintenance 3 days a week. I have attached my video of the exercises. 

https://youtu.be/w3FXx4OFqec

* MRI in 2017 showed partial PTTD tear.  Podiatrist (who is also foot/ankle surgeon) says surgery may be needed if no improvement.  Got second and third opinions in Dec. 2017/Jan. 2018 from good surgeons (including Clifford Jeng at Mercy Medical in Baltimore).  All had same general take: PTTD stage 2, surgery likely needed, FDL/MDCO.  In this timeframe, I also tried UCBLs and a Richie Brace, which I could not tolerate very well (painful).

* I have small kids, so I told doctors that I'd like to grin and bear it if I could and push off surgery until kids were older if possible.  All said fine, and who knows, it could improve on its own.

Dr. Blake's comment: That is very unlikely, but Stage 2 is not a surgical stage. See if you can get some version of the Inverted Technique for PTTD, or at least varus wedge your current orthotics. Get the Aircast PTTD Airlift Brace and learn to tape like the video below. 

https://youtu.be/AcSSyBfFocE

* The very good news: it did improve on its own.  Been basically pain-free for almost 2 years now. 

Dr. Blake's comment: I am humbly happy I was wrong!!LOL

 Dr. Jeng recommended Brooks Beasts to me, which have been great.  I wear them or Brooks Addictions (their similar overpronation product for walking) religiously, with orthotics.  I wear a Bioskin trilok brace on right foot if I can't wear the Brooks (e.g., dress shoes).

Dr. Blake's comment: I am glad you bring this up. The Brooks Beast is an orthotic in a shoe, so when you add another orthotic, you have amazing support. The Brooks Ariel is the women's version of the Beast. 

I had a few questions,if you are willing and have time to respond.

*  As long as things continue okay, can I avoid surgery?  Dr. Jeng implied this when he told me that he doesn't do surgery on feet that don't hurt.  (Interestingly, he said that the overpronation on my left foot is as bad as the right, but it's completely asymptomatic -- this happens all the time, he said.)

Dr. Blake's comment: Usually this condition is bilateral, with one side many years in front of the other. It is a degenerative process so no one can guarantee that you remain asymptomatic. With your history, you stay in good shoes, keep strong, tape and brace when you are in over load (backpacking trip), ice when needed, and stay away from activities that put severe demands on your tendon (like downhill skiing is better then snow boarding, or running flats are better than rocky hill trails). I have many patients in Stage 2 for the last 30 years and doing great, and some progressed over 10-20 years and needed surgery. I think the flareup you had was a good lesson for you. Never treat flareups as anything but another episode that you have to rehab from. That is the mind set you have to have. 

* Any chance I can run again, trying your walk-run program? 

Dr. Blake's comment: I love to have my patients run, and the walk run program is perfect. You run every other or even every third day. You run with the Brooks Beasts, with orthotics, on level ground. I would personally not start this until you are at 2 sets of 25 Level 6 resistance bands (which will take you 6 months to get to and then maintain 3 days a week). Running is so nature to our bodies, and thus innately safe, but we can do anything too much. 

https://www.drblakeshealingsole.com/2020/03/walk-run-program-for-injury.html

 I very much would like to run again, I miss it.  I'd wear Beasts, orthotics, and the Tri-Lok.  I am willing to risk a small chance of recurrence (10%, say), but don't want to roll the dice with a more substantial chance.  Doctors I have seen have told me not to, though I get sense some of them don't understand runners.  So, I would take your advice to not chance it (if that is your perspective) very seriously.  I'd very much like to run again, but if I am really rolling the dice on a recurrence or worse if I run again, I understand that.  (I have also been told that it's very unlikely I could ever run after FDL/MDCO anyway.)

Dr. Blake's comment: To my above comment, do the posterior tibial taping also to hedge your bet. 

* If it was not too risky to run again, are Beasts/orthotics,Tri-Lok a good strategy? SEE ABOVE

* Are you aware of any business-type shoes that might work for someone like me?  I know they probably don't sell dress shoes with support like Beasts, but something in the ballpark would be nice so I don't have to wear a brace when I have to wear business shoes.

Dr. Blake's Comment: You can take a sturdy pair of Men's dress shoes (Wright, Allen Edmond, etc) and apply a 1/8th inch varus wedge to the out sole by a cobbler. Works like a charm for PTTD

Dr. Blake's comment: Of course, they blend it in. Good luck. Rich 

I very much appreciate any thoughts you may have.  I of course will take them in the spirit offered and not as specific medical advice, because you are not my doctor and haven't seen me in person.

Thanks again for your blog and doing this for folks!

Best,