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Wednesday, March 20, 2019

Big Toe Joint Arthritis: Email Advice

Hi Dr. Blake, 
I recently found your videos on YouTube.

I was wondering if you do any Skype evaluations. 
Dr. Blake's comment: I am sorry, right now I do not. I will in the future however. 

I have a problem with my right big toe lacking full ROM. I jammed it really hard about 7 years ago going from a headstand into chaturanga (low push up position) intentionally in a yoga class.

I guess I did not have my right foot flexed enough. It really hurt my big toe which felt sore to walk on for several weeks. It never had full ROM after that when I flexed my foot. But I kept working that range of motion until my toe would not bend anymore thinking I needed to work the ROM so I would not lose it.

Six months ago I went to a physical therapist and asked him to work on my big toe. He held my big toe and extended it and moved it around. He said he felt increased ROM when he was moving my big toe but I did not feel anything. However after I left my foot really hurt around my 4th metatarsal which turns out had a stress fracture that I discovered after I finally went to a podiatrist for an x-ray. 
This really made me pay a lot of attention to my foot. I attached the x-rays. It looks to me like the sesamoid bones are out of alignment. But I am not sure - the podiatrist did not say anything about that.

This x-ray shows lateral compartment arthritis in the big toe joint

Do you do Skype consultations? Does it look like the sesamoid bone is out of place and if so is there a way to heal that without surgery?
My posterior right arch collapses a bit when weight bearing.

I live in Asheville, NC and do not really know of anyone who is really good at helping me from a holistic point of view.
Dr. Blake's comment: Look at the AAPSM directory list. This is the sports medicine aspect of podiatry. See who is near you in North Carolina. I think your treatment is for Hallux Rigidus, or just arthritis of the big toe joint. Rich

I would appreciate any advice. I really want to address this problem and find a good solution. I am willing to do the work to make changes.

Thank you. 

Monday, March 18, 2019

For Podiatrists: The Significance of Heel Bisections

This is the second of many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

     For me, I need to be able to draw a line on the back of the heel that represents the bisection of the heel. I am sure my measurement is only accurate within a few degrees. I am trying to have a line represent an entire heel bone and I try to do this the best as I can. I should be able to draw the same line with the patient prone or standing. It is one of the basic skills taught podiatrists. 
I use the heel bisection to see how my orthotic devices are helping, or if more correction is needed. 

The ruler is just a reference line as the orthotic device on the right foot straightens up the everted heel below

This right foot is everted to the ground . I use a bisection line that I was taught in Podiatry School, to represent whether the heel bone is everted to the ground, vertical, or inverted to the ground. Then I can check (be honest) if my orthotic device is helping make the foot more stable. You should first look at the back of the heel and decide if it is everted, vertical or inverted. Then draw your line and see if you captured this heel position. If you are performing this at orthotic dispense, then this should correlate to what you see in gait. Or, you just keep learning.

Here a goniometer is being used to measure the degrees at the heel.

Of course, when we are designing orthotic devices, we try to make everted heels generally less everted, vertical heels inverted when the foot is pronated, and inverted heels generally less inverted unless there is significant rearfoot varus conditions. 

Saturday, March 16, 2019

Hallux Limitus: Email Advice

Hi Dr. Blake -

I stumbled onto your blog while searching for information on hallux limitus, which has been suggested to be by a podiatrist and PT. I'm a 33 year old man, in general good health and consider myself to be an active person.
Here's a brief background around the hallux limitus:
  1. I started walking about 10k steps per day in October 2017. (Roughly double what I was doing before Dr. Blake's comment: That total is one of my mantras for life. 
  2. In January 2018 (4 months later), I began a transition to moccasin-style (SoftStar) shoes with CorrectToes silicone toe spacers.
    • Both of these were in hopes of improving knee and hip pain that doesn't allow me to run and shows up while hiking long distances, but that wasn't a problem during everyday walking.
    • About 10 years ago, a PT told me I had "runners knee", "patellofemoral syndrome" or "IT band syndrome" causing pain in my right knee that required me to stop a training program for a marathon. This diagnosis was when I got interested in minimalist shoes and other 'alternative' approaches, and why I began this transition in January 2018.
  3. In March 2018 (about 2 months into the footwear transition) - during one of my walks I had a sharp pain develop quickly (over the span of probably one minute) in my right big toe. It was bad enough that I had to stop walking and get a ride home.
    • That evening I noticed some bruising that wrapped basically from the underside of the proximal phalanx to the right side of the IP joint on my right big toe. Not sure exactly how to explain this, but it looked like bruising that originated from inside the toe somehow - i.e., not from some kind of trauma. Dr. Blake's comment: I do not know how much you pronate, which could be the issue, or just the correct toes pulling on the ligaments too much with that amount of walking. I tend to use correct toes just around the house, at least for several months until you get used to them. They are powerful tools, but of course you probably had no guidance. 
  4. My physician ordered x-rays - which he said just showed soft tissue swelling under the joint but nothing specific. Dr. Blake's comment: Good start. 
  5. In April 2018 - A podiatrist examined me and suggested I had Hallux Limitus. Dr. Blake's comment: Is it functional or structural, or a combination of both. What were the degrees that they measured? Normal big toe dorsiflexion (upward bend) is 75 to 90 degrees and Hallux Limitus is between 30-60. 
    • His recommendations were: orthotic inserts, shoes with a 1/2 to 1 inch heel, and shoes with a rigid midsole. Dr. Blake's comment: With hallux limitus, all three of those things can help or hurt based on several factors. If you get them, and they bother you disregard. Try everything together, and also separate to see what the effect is on the big toe. 
    • I ended up using Vasyli Dananberg First Ray Orthotics, which claim to help with hallux limitus by having a 1st MPJ cutout. Dr. Blake's comment: These are to increase the motion in the big toe joint, so why a rigid shoe? Of course there are times to limit the motion, and times to free up the motion. Do the self mobilization video a couple of times a day to see if that helps.
    • And I moved to walking primarily in hiking boots which met the podiatrist's suggestions.
    • The footwear and orthotics didn't really help - and I developed gait compensations around the toe pain that caused me to develop some hip and knee pain just from everyday walking. Dr. Blake's comment: It can just be the timing of the treatments. If the joint is sore, the treatments may best be spica taping, no orthotics to increase motion, and stiff shoes. You can also get Hoka One One shoes for a while to limit the toe motion but allow walking. 
    • In June 2018 - I saw a PT to help me with some stretching and exercises.
    • This seemed to help a bit, though I couldn't resume my 10k steps walking program. Dr. Blake's comment: Do you think it is weight bearing pressure causing the pain (then dancer's padding is apropriate) or the bend of the big toe joint (then spica taping, rigid shoes like Hoka One One). Both seem would be made worse with an elevated heel unless it supinates you so your weight is more lateral near the 4th or 5th toes. 
    • I kind of gave up at this point in frustration.In August, I realized I had taken a couple long hikes with no pain or toe problems - so I cautiously started my 10k daily steps program again.Over the 5 months since then, I've continued the walking. I have had some pain, but never to the point where I had to stop walking. And I could manage things with achilles tendon stretching, dorsiflexion exercises, and general funny business with ankle movements.But now in the last couple weeks, the big toe pain has come back big time and I've had to stop my walking program.Dr Blake's comment:  I am glad you mentioned achilles flexibility, since tight achilles puts extra load on the metatarsals and is helped with stretching. Joint pain can come and go. Now is the time to see if Hoka One One, spica taping, dancer's padding, and ice 10 minutes three times a day will help. Do you have a walking boot to maximally rest it? 

I have a couple goals:
  • Keep up my walking.
  • (Stretch goal) Start running again.
  • Importantly: Don't harm my joints in a way that will be debilitating later.

I'm open to a variety of interventions to reach these goals - but in general, I would prefer things that involve strength, flexibility or gait improvements rather than footwear, orthotic or surgical solutions.

Your blog and youtube page seem to have a lot of really good information about hallux limitus - so I figured I would reach out and see if you have some suggestions for me.

I also see that you're in San Francisco - I live in Oakland and I would be interested in scheduling a visit if you thought that could be productive.

Thanks so much - for your excellent information online, and for reading this (Dr. Blake's comment: only read to this comment, no farther!!LOL) far!


Friday, March 15, 2019

For Podiatrists: Biomechanical Discussion Points #1

This is the first of hopefully many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

Bio-mechanical Point #1: In what position of the heel are the patients most stable: is it heel vertical, heel inverted, or heel everted?  

     The best heel position for stability depends on several factors. One concept was first introduced by the ballet world in the 1700's that the most stable position of the heel is when it is stacked directly under the talus, and the talus is stacked directly under the tibia. I have always found that patients, and especially dancers (who are very attuned to their bodies), can feel this inherent stability. This has been termed the neutral position of the subtalar joint (neither inverted or everted) from that position, much as the neutral position for stability of the ankle joint is where the tibia is at a right angle to the foot (in which the ankle is neither dorsiflexed or plantar flexed from that position). 
     That stable subtalar joint neutral position is inverted to the ground when we have tibial varum and other forms of rear foot varus. That stable subtalar joint neutral position is everted to the ground when we have tibial valgum or other forms of rear foot valgus to treat. Therefore one person can be in their most stable heel position to the ground 5 degrees inverted and another person 5 degrees everted. The most common will be tibial or rear foot varus that will set the ideal heel position to the ground somewhat inverted. Too often orthotics are set at vertical for these patients meaning that the orthotic holds them pronated or everted from their most stable position, which means makes them more unstable. If we measure these positions, or at least recognize these deformities by observing the patient in angle and base of gait, we can be more thoughtful in prescribing an orthotic device's heel position. 
     When does this thought process get thrown out the window? All the time. Patients present with certain needs that may have higher priority than simple Root Bio mechanics (not that there is anything simple about Root Bio mechanics). This need may be permanent or temporary, but must be addressed. What are some examples? A patient presents with terrible pronation due to a high degree of tibial varum (bowlegged) mechanics, but they have had 3 ankle sprains and are trying to avoid ankle reconstruction. Root Bio mechanics would have them Inverted due to a high rear foot varus, but their injury with lateral instability requires a vertical heel pour or even slightly everted if they have the range of motion. The goal of the orthotic device, which may change down the line, is for elimination of the supination forces, not correcting the abnormal pronation. This is so common in a sports practice. 
     Another example which is very common in my practice, almost daily, concerns lateral wedging for medial meniscal at the knee problems. If you pronate the foot for a period of time, and open up the medial knee joint line, you can let an injured meniscus have time to heal. You are not concerned about the ideal heel position for stability, but only to generate enough pronatory force to off weight the medial compartment of the knee. This can be extremely important in documented medial knee compartment issues 50% of the time. The other 50% actually want more stability, and you may be inverting the heel to give them that. Inverting the heel 3-5 degrees in general, stabilizes the medial knee compartment, places more weight on the medial knee compartment, helping so many soft tissue medial knee torque or instability problems. 
     I hope to keep the thinking going. Thanks for reading. Rich

Monday, March 11, 2019

Chronic Pain: Curable App with Graph

I would love to have any patient with chronic pain from all different sources download Curable App and see how it works for one month. I am so hopeful it can help reduce your pain. 
This wonderful chart is reprinted courtesy of Curable App. 

Saturday, March 9, 2019

Use Code to help Dr. Blake's Travels. Why not?

Hi Richard,

Have a great trip! Why not make it even better by earning a reward for you and your friends?
All your friends have to do is book using your referral link. When they get back from their trip, they’ll get a US$25 reward, and you’ll get US$25, too!

To All my Blog Friends, if you travel, you know is a great site. If you use the code above, both you and I get $25 each. Good deal right? Thank you in advance. I love Rich

Start Standing: A help for Back Pain

We all know we must stand more to help our bodies, especially the low back. I hope this website helps in your journey toward better health. Rich

Sesamoid Fracture Treatment: A hope to avoid Surgery

Hello Dr.Blake!

I am happy I found your blog post about fracture seasmoids. I’m hoping to get some advice or maybe just some encouragement!

So here goes! I am pretty active and enjoying hiking, running and workout classes. I suffered from turf toe back in 2016...after therapy and taping it got better. A few months later similar pain returned and it was diagnosed as sesamoiditis. Last year we found I had a complete fracture of my medial seasmoid. I was put in a walking boot for 6 weeks and the pain went away but fracture didn’t heal. The podiatrist told me to leave it alone if it didn’t hurt. Fast forward to a few weeks ago when I finally got a second opinion and I am now non weight bearing and using a bone stimulator twice a day. My biggest question is this, do you really think that after a year this fracture could heal without surgery? I’m pretty skeptical.
Dr. Blake's comment: Depends on the gapping or the fragments, the amount of avascular necrosis that has sent in, the biomechanics of your foot and activities placing stress or little stress on the fracture area, the overall fragmentation, the bone density and Vitamin D levels, eating habits, etc. You want to do the contrast bathing as a deep flush. A CT scan would give us the best imaging at this point.
     I have many patients that the sesamoid does not look great on any imaging, but do fine, and as long as we can keep the pain between 0-2, and they are happy with activity levels, I just follow them.

The pain wasnt unbearable I just wanted the second opinion because I am 32 and work a pretty physical job (PT assistant in an inpatient setting) so on my feet many hours a day.  I also enjoy running and hiking. Those are things I wasn’t able to do the past year so I have substituted with using a stationary bike and weight lifting. I have been using a dancer pad and started wearing hokas which I love but the pain still lingered. I feel like I’m too young to just give up but I am really hesitant to get surgery for this. My podiatrist said if this doesn’t heal she would like to do a bone graft and use it to pack in between the non healing fracture. It seems like more trauma to my foot than I’d like to deal with. I know I should be more positive because maybe this can heal with NWB and bone stimulation but again I’m skeptical. I should also mention I started taking a vitamin supplement to help bone healing.

I’m sorry for the long email I just thought you should have all the info.
Dr. Blake's comment: Unfortunately, I have had no experience the results of bone grafting. If you find any articles, please send my way. I just want to know if you have surgery, they are just not experimenting with you. I am not a surgeon, so I have to leave final decisions to surgeons, but send me one or two images of the fracture from a CT scan and I will give you some thoughts. Have your Vitamin D level measured. Go 6 months on this course, although at some time you will have to switch from NWB to a weight bearing boot for 4 weeks and then back into your Hokas. The bone stimulation should be 9 months period. Hope this helps. Rich

Thank you in advance for even reading this and thank you for what you do!

Wednesday, March 6, 2019

Nerve Pain after Long Distance Bike Ride

Hello Dr Blake,

I found your email address after reading your blog and an article written by you in "Podiatry Today" on Morton's neuroma. I am writing to you from Australia seeking your medical opinion after seeing many specialists in Australia on my foot issue, with no real success. First a little background on my issue.

My problem started back in September 2018 whilst working overseas. I first hurt my right foot after training for a long distance bicycle ride. The initial symptoms were tightness in my calf, sole of foot and some heel pain. The heel pain would be shooting pain on the inside of heel whenever my foot was dorsiflexed. Over the following three weeks, whilst standing in my job, my condition worsened with the onset of pins/needles throughout the sole of my foot. At the end of a typical work shift my whole right foot would be completely numb and tingling. The GP's that I first saw thought it was plantar fasciitis and prescribed me anti- inflammatories which provided some relief.  I also saw a podiatrist who moulded me a set of orthotics with little improvement noticed.  After three weeks I returned to Australia in October and sought further investigation.
Dr. Blake's comment: There are 3 sources of pain: mechanical, inflammatory, and neurological. The cause of your pain was mechanical (the long distance bike ride), but the symptoms are all neurological. This is like overstretching the calf, and pulling too long on the sciatica nerve, and having the calf pain intensify. You have to treat this neurologically at first with treatments that help nerves. then work on the mechanics, and any inflammation that has set into the tissues.

Since I have been back in Australia I have seen the following specialists:
  • Neurologist (Nov) - performed a nerve conduction test, which was inconclusive, apparently quite often this happens with people over the age of 40.  Had an MRI (report attached below) which showed a thickening of the medial planter nerve throughout the mid-foot course involving up to 8 cm in length.  The Neurologist concluded that I had Tarsal Tunnel syndrome, informed me that surgery was my only option and referred me to an Orthopaedic surgeon.
          Dr. Blake's comment: Yes, there is 1-5% of almost any injury that has a surgical solution, but
          that is not where you start. Hopefully, you never have to go down that route.
  • Orthopaedic Foot Surgeon (Nov) - the orthopaedic surgeon said that I did not have tarsal tunnel syndrome as the thickened nerve was not in the tunnel.  He was reluctant to operate and advised me to take three months of rest and see if my condition improves.
  • Podiatrist (Dec) - visited a podiatrist who concluded that I may have medial calcaneal nerve entrapment and/or Baxter's nerve entrapment.  Advised me to keep wearing my orthotics.
  • Orthopaedic Foot Surgeon (Feb) - condition had improved after three months of rest, but still only limited function. Surgeon would not operate and referred me to a Anaesthetist/Pain Specialist.
       Dr. Blake's comment: When you irritate nerves, they can take a long time to relax, so most of this
       advice is good. It is using only rest as the number one treatment for nerve pain, but not bad
       advice. Glad that they sent you to a nerve guy (called pain specialists).
I am now awaiting an appointment with the Pain Specialist on March 27th.  My current symptoms are the following:
  • Can walk okay, but after one mile or so start to experience pain in the sole of my foot 4/10 (feels like a stone in my shoe). The pain extends from where the heel ends, along the mid-foot section. Dr. Blake' comment: Do not push through this pain. Do you guys have Uber down there?
  • Tightness in calf has disappeared. Dr. Blake's comment: Great, that means some of the neural tension is improving. Has the heel also resolved?
  • Cannot walk down stairs properly as the dorsiflexion of my right foot causes a shooting pain on the inside of my heel. Dr. Blake's comment: Just answered the above question. Remember the sciatic nerve, branches of the big nerve are irritated on you, is pulled too much right now with ankle dorsiflexion, straightening the knee, and bending over at the waist. Try to go downstairs leading with the bad side, and then lowering the good side to the same level. That is usually the best. Down with the bad, up with the good is the mantra.
  • Flat surfaces are okay for a mile or so, but inclines uphill or downhill really take a toll on my foot quite quickly. Dr. Blake's comment: Stay on flats right now as the neural tension resolves. It is never a fast process. Sorry.
  • Sometimes when I stand in one spot for an extended period my foot turns red.  Podiatrist was initially concerned that I may have the beginning of CRPS and encouraged me to keep walking. Dr. Blake's comment: This is called vasomotor insufficiency where the skin and soft tissue are influenced with nerve spasticity. This is part of the neural tension also. Nerves love motion, and not prolonged stretching. They do not like certain positions, so keep moving is a good thing, or at least finding comfortable sitting or laying positions when you can not move.
  • Still wearing orthotics which help a little.
  • Currently on Lyrica 150mg to ease pain on the days I walk more. Dr. Blake's comment: Typically I wonderful nerve treatment if you can tolerate.
Am I a candidate for Radio Frequency Ablation, cortisone injections, or alcohol injections?
Dr. Blake's comment: Unless someone can tell you that a neuroma, or entrapped nerve, is a constant trigger for the pain, it is best to not risk irritating it for now. As your symptoms get better, and one spot on a nerve remains super sensitive, then some discussion is in order. I doubt you will need these, but I am of course not sure. I would not do anything invasive to speed up the treatment. With nerves, that course of action tends to irritate more than help.
  Is there any value in having a diagnostic injection around the medial calcaneal nerve or Baxter's nerve to see if the shooting inside heel pain is relieved when foot dorsiflexed?
Dr. Blake's comment: Local anesthetic on an inflamed nerve could help, and you may need to do several over 3-4 weeks. That being said, it goes against my better judgement. Do this for me. Have you knee straight and then dorsiflex the foot, you should get nerve pain. Now, bend the knee to ninety degrees and then dorsiflex the foot. If there is no pain now with that change in position, it is most likely an irritated nerve, not an entrapped nerve (which should hurt both ways). It is another finding and for sure not conclusive. What I have not had you say is that the MRI showed a possible nerve entrapment in the heel with intense swelling, etc. I have also not heard you say anything about a low back MRI since this can be all coming from your back.

 Could I have a nerve entrapment that might be relieved with Radio Frequency Ablation?
Dr. Blake's comment: This is not a procedure I have any experience in. Start doing traditional treatments: neural flossing, Neuro-Eze or like products, get the Lyrica dose up to normal amount, add Cymbalta if you can tolerate, avoid positions that irritate the sciatic nerve, see a physical therapist skilled in nerve problems, try topical compounding meds that have Ketamine, get your low back pain eval, look into foods that irritate the nervous system, and get supplements that calm it down. Most of this is in my blog also. I hope I have been somewhat helpful. Rich
Be kind to yourself, and do not rush into treatments, meditate daily, acupuncture can be of great help.

I have researched a lot online and there is very little information about enlarged nerves, besides Morton's Neuroma.  I really don't wan't to be on painkillers the rest of my life and refuse to believe that this is the end of the road for me.  I recognise that I may never get full function back, but am searching for a procedure that could improve my condition a little. In Australia there does not seem to be any podiatrist surgeons that specialise in my condition, or at least I don't know who they are.  The Pain Specialist is currently my next avenue for help.  Any feedback you could provide would be greatly appreciated.


The Patient then responded:

Hi Dr Blake,

Hello from Down Under. Thank you so much for your quick and detailed reply.  I have already actioned a number of your suggestions, like taking supplements to calm down the nerve (Vitamin B12) and ordering Neuro-Eze to apply to the sole of my foot.  I will also explore acupuncture and physical therapy.

To answer some of your questions:

  • Heel Pain - For over a month now I have been going down the stairs by leading with the bad side and lowering the good side second, just like you suggested.  Then today I decided to try and walk down the stairs normally, so I could report back to you on my progress.  Good news, I managed to walk down the stairs with only minor discomfort which was a big improvement from a month ago. Still have tenderness around the inside of heel and the arch of foot though.
  • Dorsiflexion Test - I performed the straight leg and bent knee dorsiflexion test like you suggested.  In the straight leg position I felt no pain, however I have lost about 20% range of motion when compared to the other foot. I'm pretty confident that if someone pushed on my foot it would have elicited some pain as it did before. Dorsiflexion in the bent knee position hurt.  Is nerve entrapment still a possibility? Dr. Blake's comment: Yes.
  • Explore lower back possibility - When I see my specialist next week I will ask him for some imaging on my lower back, as you indicated it may be the source of the pain.

What I didn't mention in my first email was some other symptoms that presented when I first hurt my foot 5 months ago after the bike ride. The tightness in the calf was predominantly in the top outer side portion, combined with big toe tingling and sensitivity.  In fact, whenever I experienced the shooting pains through the sole of my foot, the big toe would end up throbbing.  After researching quite a lot I believe my initial injury may have been a sprain of the Flexor Hallicus Longus muscle, apparently a common injury amongst ballet dancers and bike riders. If the FHL was inflamed throughout the foot, could this have led to the medial plantar nerve enlargement ? Dr. Blake's comment: For sure, and that should be calming down. 

Thank you again and look forward to your reply.

P.S. We do have Uber down here! 

Every Single Street: Rickey Gates Runs San Francisco

Rickey Gates runs Every Single Street in San Francisco, very motivational, we can do perhaps smaller projects, but as mindful.

Friday, March 1, 2019

Sesamoiditis turning into Fracture: Email advice

Good evening Dr. Blake,

I am currently a student at a university. I suffered sesamoiditis in February of 2018. I visited the doctor and they took an MRI and Xray, and he said it was sesamoiditis. They gave a steel toe plate to insert in my shoe so I don't bend my toe too much and it did help for a little bit. A couple of months went by and I got used to the pain.
Dr. Blake's comment: I hope you understand that we must get the pain to 0-2, not just be helped, or you will not heal potentially. This is especially true with sesamoids that are slow healers in the first place.

I did try to ice as much as I can and the pain went away. I am a pretty active person, and just couldn't sit out during the summer while I trained. I didn't think much of the injury since it was a busy summer for me and didn't know that it is that big of an injury. I trained and ran with it and played basketball with it all of 2018. I adjusted my gait so I don't put pressure on it and that lead to other problems such as calf tightness and knee pain and hip pain.
Dr. Blake's comment: Thanks for being honest. I know we all try to just live with it with the eternal hope that it will eventually get better. At your age, I would have been doing the same thing, so no guilt allowed.

I stopped playing around a couple of months ago since I knew it wasn't really healing so I didn't want to risk it (Which I already did by running on it that whole summer.) I visited the doctor on 1/30/2019 and he took an X-ray where it was found that I completely broke it. The doctor said I have to get a procedure to take out the bone ASAP and referred me to a surgeon. I talked to the surgeon and he basically just told me about the recovery time and things of such and I told him that I read some people never return to 100% and he agreed and told me to just sleep on the option of surgery. He also said it has no chance of healing since there is no blood supply to this area. It doesn't look like it is a huge break, but is there a chance of it healing without surgery and could it union? I attached the X-ray picture to this email. I came across your blog because I was desperate and it has been so helpful. Please get back to me. 

Thank you so much

Even though this is alittle blurry one can see the obvious crack with jagged edges

Dr. Blake's comment: Okay, you got yourself in a bind. Please understand that there is no gap between the fragments, so the bone contact is good for healing. Yes, these heal slowly so the rest of this year will be dealing with your sesamoid in one way or the other. I am sorry when some of my patients need surgery after a long battle, but since the majority heal fine, the battle is always worth it. Plus, even if you need surgery, you will have the orthotics and dancer's padding that will protect the other sesamoid in high impact sports your whole life.
     So, you have to create the 0-2 pain level, get a bone stimulator, start doing daily contrast bathing for swelling reduction which improves circulation, get a Vit D test to make sure you are fine there to heal a fracture, eat healing, cross train with biking, swimming, flat footed eliptical, get Dr. Jill's dancer's padding at 1/8th inch and 1/4 inch for various shoes, get good custom orthotics to take pressure off the sesamoid, and learn spica taping and cluffy wedges and see if important for you. Some of my patients love some of the Hoka One One shoes, but that depends if the roll is in the right place. Zero drop shoes are better in general than traditional shoes. I hope this points you in the right direction. Rich

Thursday, February 28, 2019

Chronic Foot Pain: Email Advice

 Hi Dr. Blake,
I found your blog while doing some research for my husband, and I hope you don’t mind if I shamelessly solicit your opinion on the below situation J.
My husband had sesamoidectomy completed on both big toes well over 15 years ago and he continues to have very debilitating flare ups. He is 48, very active, and has a busy work travel schedule and an active job that requires him to be on his feet a large majority of the time. He frequently has flare ups where either his big toe, middle toe, or all toes will become discolored, very inflamed, and extremely painful. During these episodes he takes Naproxen and wears a boot, but he is still in pain even after taking the Naproxen. These events will last anywhere from 2-3 days to over a week, and although he probably wouldn’t admit it, cause him some degree of depression. He has been to his doctor and was recently diagnosed with gout, BUT, his uric acid levels are normal, so I don’t buy it J. I am trying to encourage him to seek out additional opinions on his condition and to get physical therapy of some kind, but I frankly think he is scared. He is very resistant to my suggestions to the point of stubbornness. I can’t quite understand it.
I am curious what information I might be able to share with him around physical therapies and exercises for his condition. Everything I have read around joint issues, such as arthritis, is to stay active and keep joints mobile. What are your thoughts?
Any feedback at all would be GREATLY appreciated.
Dr. Blake's comment: Thank you so very much for your email. This situation could be a lot of things, and I agree gout flare-ups quite commonly present like this. His gout test, uric acid in the blood, can just run high normal and he is prone. It would be great if you could find his uric acid level and email to me. I would need his level, and the range of the lab that they consider normal. Does he have any family history of gout? Do you think he has rich foods a lot? Or is he chronically dehydrated?
     What he is experiencing is not normal, and getting to the diagnosis is essential? Any other blood work abnormal? If he has one side that is worse, and he feels the trigger for the pain is the big toe joint, then he should get a CT Scan to look for pieces of the sesamoid that were left behind. That could be causing the problem. A Plantar Axial view of the feet shows the sesamoid area, and any doctor can order that. I hope this helps some. Rich

Monday, February 25, 2019

Crush Injury leading to Sesamoid Injury and CRPS

Dear Dr. Blake -

I am writing about a crush injury to my right foot 6 months ago (Aug 21 2018) when a large metal object fell from a top shelf onto my bare right foot  I’ve seen a variety of doctors and practitioners, but nothing I’ve learned has improved my condition, and I am in confusion and despair. I’ve read your blog during this time, and your recommendations always make more sense to me. I sent previous emails, but want to try one more time, because the end of my rope is near.

As a quick summary, the initial diagnosis was fractured 1st metatarsal. Second doctors found additional fracture to tibial sesamoid (also deformed), 2nd metatarsal (bottom), inflamed MTP joint, nerve sensitivity on top and bottom of foot.  

Pain has gotten worse rather than better.  Sesamoid/metatarsal area feels like shards of broken glass in my foot.  MTP joint is sensitive, and I keep my foot wrapped in sheepskin inside the boot for relief.
Dr. Blake's comment: That symptom would be intense nerve pain (neuropathic). 
During the day, pain increases the more active I am (light chores around house); better when I stay off it entirely.  During the night, pain can be worse, making it difficult to sleep. I’m still in boot, using wheelchair for total non-weightbearing, homebound from no driving.

Dec 2 MRI:
  • Bones and joints:  No dislocation.  Moderate hallux valgus alignment with mild lateral subluxation of base of 1st proximal phalanx.
  • Moderate 1st MTP osteoarthritis; severe sesamoid osteoarthritis. No joint effusions.
  • Ligaments:  Lisfranc ligament intact.  No evidence of acute injury to collateral ligaments at MTP or IP joints.
  • Tendons and muscles:  Mild edema/strain of the medial head of the abductor halluces muscle.  Mild muscle atrophy.
  • Soft tissues:  Mild soft tissue swelling, greatest along 1st to 3rd MTP joints
Dr. Blake's comment: Your symptoms are of nerve pain secondary to the crush injury to an already arthritic big toe joint. 

Dec 18: 2 Cortisone injections, which caused extreme pain, fever, disorientation. No pain relief, but some reduction in inflammation.
Dr. Blake's comment: This is diagnostic as it only addresses inflammation. Since it did not work, the neuropathic pain must be addressed. 

Physical therapist has helped flexibility/strength in foot, ankle and leg. Electrical stim and light massage reduce pain temporarily, but sometimes nothing can be done because foot is too sensitive.

My two doctors recommended 2 different courses of action, both surgery. I resisted.
  • Dr. 1:  Aggressive: remove both sesamoids, reconstruct MTP with pins, shave outside of bunion, all in one operation.
  • Dr. 2:  Conservative: remove tibial sesasmoid.  If that doesn’t work, then remove 2nd sesamoid.  If that doesn’t work, reconstruct MTP joint.
Dr. Blake's comment: No surgery should be contemplated until neuropathic pain is recognized and addressed. The treatment is not easy, so as soon as you can have the neuropathic pain treated successfully the better. 

Jan 19:  Woken up by worst pain yet, like broken beer bottle jammed in my foot.  Decided surgery was necessary.
Dr. Blake's comment: Again, this is neuropathic pain, surgery has to wait for now, but could be avoided. 
Jan 24:  Went to yet another doctor for 2nd option on which approach to use; aggressive or conservative.  He temporarily put the breaks on, wanting more info.
  • Increased nighttime pain may be related to L4, L5, SI nerve. I need to see ortho spine doc.
  • X-rays show osteopenia in MTP area.  Bones may not have integrity to hold pins/screws, creating worse problem in future.  I need to see osteoporosis specialist.
Dr. Blake's comment: Localized osteopenia could indicate that the neuropathic pain has developed complex regional pain syndrome. I have many blog posts on this subject. 

I sit here befuddled, exhausted, and defeated. I truly hope that you can provide some clarity on what is happening, and how to best proceed.  Thank you for your time and commitment to healing.


This is a foot that looks like CRPS Stage 2 (vascular stage)

Dr. Blake's comment: I wrote to the patient at this time that I was on vacation and my response was going to have to be delayed. 

Hello Dr. Blake.  I hope your vacation was rejuvenating!

You asked that I resend the email below after your return.  Here are a few updates as well.  Thank you so much for your generosity.

Pain Relief:
I got a medical marijuana card last week. A daytime tincture hybrid of THC/CBD keeps me alert while reducing pain.  The nighttime tincture is 100% Indica for sleep.  To my surprise, the daytime product has reduced my pain considerably, particularly around the tibial sesamoid.  I’m mainly feeling nerves, but in a lower pain range. 

The amount of pain I have right now is bearable, which makes me more resistant to surgery. It feels good to have the boot off.  I’m still putting all weight on my heel and outside of foot. Only a few steps here and there.  Doing exercises recommended by physical therapist.  Still in wheelchair most of time.

Doctor Opinions:
Here is the full array of opinions that have my head spinning.

Dr. A (podiatrist):  Recommends removal of both sesamoids, rebuilding of MTP joint, shave bunion bump. Should all be done all at once in order to maintain my gait, but also recognizes it will be a difficult recovery.

Dr. B (Dr. B's partner):  Recommends removal of tibial sesamoid only.  If that doesn’t work, then follow with 2nd sesamoid removal, followed by reconstruction of MPT.  More conservative approach, but possibility of 3 separate surgeries.

Dr. C (my chiropractor):  Advises against surgery because of complexity of foot, but if surgery is necessary, then do it all at once.  He recommended Dr. D for a second opinion.

Dr. D (third podiatrist):  Not rushing into surgery after reviewing the MRI.
#1 - He thinks the tibial sesamoid is not that deformed, and the pain/inflammation is likely severe osteoarthritis aggravated by the accident. He also thinks some nerve pain may be originating in my lower spine...L4, L5, S1. He asked for a workup from an ortho spine doc. If foot surgery is necessary, he recommends it all be done at once.
Dr. Blake's comment: This is my choice of direction, but CRPS has not been discussed?

#2 - He is concerned with osteopenia in the big toe joint, and not confident that pins would hold.  He wants a workup from an osteoporosis specialist, before he would consider surgery.

CNP (my primary provider):  She did not understand Dr. Haas’ concerns. 
#1 - She doesn’t agree lower spine should be an obstacle.  She ordered x-rays, and results were as expected. 
Mild degenerative disc disease at L4-L5 and L5-S1 with disc space
narrowing. Facet arthropathy is present throughout the lower lumbar
spine. No acute fracture or malalignment is seen. No evidence of

#2 - I had a bone density last March, and there is osteopenia everywhere. It's being treated with Vit D3 caps, and calcium through diet.  Marcie doesn’t see a problem with pins holding.

She said I’m between a rock and a hard place, but agrees with Dr. B; one bone at a time.
Dr. Blake's comment: In California we have pain specialists that are neurologists, physiatrist, or anesthesiologists who need to be consulted. Dr. D was right about the nerve part, but CRPS type 2 is nerve hypersensitivity from nerve injury. This has very specific treatments. 

Finally, my physical therapist): He has seen my ups and downs more than anyone. Most recent trend is down, so he can’t even do exercises with me, and we've cancelled appointments until this gets sorted out. He said it will be a difficult recovery, but he recommends the full surgery.
Dr. Blake's comment: The full surgery is only recommended by caring people who want desperately to help you. You can not blame, but if the pain is neuropathic, the surgery is going in the wrong direction. See if there is a neuro-physical therapist in your area. They have a national organization and are attuned to CRPS.

Me:  When feeling my foot prior to medical marijuana, I am resigned to surgery.  Feeling my foot right now, under the effects of medical marijuana, I don’t want surgery.  

Bottom Line:  where do I go from here?

Warm regards,

Common presentation of CRPS post injury

Dr. Blake's first response after vacation (3 weeks ago), but before the two photos above were seen. 

Just read through all the emails to get my brain working. Do you have any images you should send of xrays or MRIs? If you have surgery on your foot, you only want the tibial sesamoid removed for sure. More and more surgery at one time is less predictable, and more trauma to your body. You had a very bad accident, which everyone wants to help you with, but more surgery does not make sense right now.
Secondly, I treat patients every day with tibial sesamoid fractures, and no one hurts like this. The crush injury may have caused a complex regional pain syndrome to develop which behaves like this. If so, you need a sympathetic block in your back soon. So, please have a neurologist or pain specialist work you up for this to rule it out, but also to treat the pain. If you are having nerve pain from this, surgery may make you worse unfortunately. So, get away from the surgeons for a few weeks and focus on nerve pain and its treatment. Send me any images. Keep up with the cbd oil which works well for nerve pain in some/most patients. Rich

The Patient's response:

I’m writing because I’m stuck, and need to make a decision on treatment for my foot. Last night, I had another high pain episode. My physical and emotional reserves are depleted after 5 months since the injury. 

It is very generous of you to provide your expertise, and i cannot imagine how busy you are. While understanding that, I also need to make a decision soon about surgery. I’ve been putting it off for months, and my foot is only worse. 

Is it possible to talk by phone/Skype, or do you have enough info to make a recommendation in writing?  I am so happy to make a contribution to your blog or pay you outright for your time. I just don’t know where else to turn. 

With respect,

Dr. Blake's next response:
I just reviewed the foot MRI. The Spine MRI is out of my expertise. The fibular sesamoid is out of its normal position, probably from the bunion or possibly a ligament tear. It will probably have to be removed. There is some arthritis in the joint, which could be part of the pain. I will have to read your original email to put it all together tomorrow. There is a lot of swelling around the tibial sesamoid which also probably hurts. The L4 nerve root is problematic and this goes to the big toe. Lucky you!!. I will think more on it tomorrow. Rich

Image under the big toe joint showing the fibular sesamoid out of its normal alignment

Another image of the same thing

Arrow points to intense fluid under a normal appearing tibial sesamoid, the fluid seems to be why she is hurting

This is another image of the intense inflammation under the tibial sesamoid in the subcutaneous fat, the tibial sesamoid looks arthritic, but it does not looked fractured or needing to be removed.

Here is the comparison more normal fibular sesamoid and fat pad

The arrow is on the flexor hallucis longus showing intense inflammation above near the fibular sesamoid. I wonder with the injury if the ligament connecting the 2 sesamoids was not torn. This would explain why the fibular sesamoid in the earlier images looked way out of place.

This image points to the gap between the tibial and fibular sesamoids possibly created by a tear of the ligament.

The architecture of the tibial sesamoid does not look injured, but you can see the swelling below in the soft tissue which will hurt on pressure

This image shows the mild wear and tear of the joint itself, osteoarthritis, that could be stirred up in the injury and resulting demineralization process going on

Another view of some mild wear and tear.

Thank you, Dr Blake. This is important information.

I’ve been regulating pain with medical marijuana (mm), and also using the Curable app. Both are helping a lot with calming down my nervous system, reducing discoloration and swelling. Mm is supposed to be good for nerve repair. Reading that I probably need surgery has released a flood of anxiety, and I’ll focus on that now. 

You are most kind.

Dr. Blake's comment: Yes, if you need surgery due to the fibular sesamoid out of alignment, that can wait and you may avoid it. Get the CRPS evaluated. Sounds like you are already calming your nervous system. On your recommendation, I introduced the Curable app for nerve pain in a recent blog post. It definitely looks promising. Keep me in the loop.

Monday, February 18, 2019

CRPS following foot injury: Email Advice

Hello I’m recovering from two tendons and stress fractures in both my sesamoids.  I’ve also been diagnosed with CRPS which for me involves significant swelling and temperature changes in my left foot.  I’ve finished almost four months of immobilization and am starting to walk around in my insoles and orthopedic shoes.  My foot turns hot and cold though.  The injections I received for CRPS seemed to have resulted in little change in these symptoms.  Walking starts to really hurt after not too long and I fear I’m damaging my sesamoids again.  is there any way to tell?   How much pain do you have when you start walking and how long does it last?  Should you just stay off of it longer?  Any thoughts on CRPS?  Also what are your thoughts on other treatment modalities to boost recovery?  What about prolozone injections?  PEMF?  I have a bone stimulator.  Thanks

Dr. Blake's comment: CRPS is a complication from chronic pain or an acute injury. The changes in your foot is called vasomotor insufficiency and could mean that the tissue is not getting enough blood to heal. Typically sympathetic blocks and oral meds can help considerably. Do you know what type of shot you got? Movement is crucial, as the immobilization is terrible for CRPS. Make sure the sesamoids are protected with orthotics and dancer's pads, and you will have to tell me what tendons you hurt. But, they should be protected with taping and bracing if possible to decrease the pull of the tendons. If you can start contrast bathes at 1 minute hot (100 F) and 1 minute cold (60 F) for 20 minutes with it feeling better, try it since it is a great way to get the circulation moving. Acupuncture is also helpful. See if there are any neuro physical therapists in your area to consult. Your team should be podiatrist or foot orthopedist, neuro physical therapist, acupuncturist, and pain specialist to do the sympathetic blocks and prescribe oral meds to calm nerves down like Lyrica and Cymbalta and nortryptyline. Get the foot and ankle moving as much as you can without flaring it up. Consider the Curable app and NOI flash cards. Consider Quell (I think that there is some money back guarantee). If you can get Calmare treatments, that would be great. Tons of things to do.  Hope this helps some. Rich

App for Chronic Pain Sufferers: Curable

I am just learning about the app from a patient. It is called "Curable". I downloaded to my iphone and I my initial impression is favorable. We all know that when pain is out of control, and has a mind of its own, like hurting when you are not doing anything, the brain wiring to your foot or wherever can be too excited. You can then hurt just because your body senses danger, not because you really should hurt from the injury, or hurt as much as you do. My blog has many discussions and tips on dealing with chronic pain, but you can never have enough. Try it for a month and see if it works and calming down the pain. We are trying to relax the nervous system, give it time off, so it can go back to only its normal function of sensing pain.

Sunday, February 17, 2019

Chronic Pain and Possible Surgery: Email Advice

Dr. Blake,

I've posted on your blog in the past and have appreciated your advice more than you know. The advice you had given me a while back had given me some hope. After seeing a host of what I feel to be incompetent Foot and Ankle surgeons and Podiatrists who have all seemed to throw their arms up, I've finally gotten 2 new bilateral MRI's of the ankle and a new Podiatrist.

The report on both MRI's say:
1) Mild scarring of the anterior talofibular and calcaneofibular ligaments, remote inversion injury.
2) Dengeneration of the deltoid ligament complex deep fibers
3) No acute osseous injury or arthritic changes of the ankle
4) Small tibiotalar joint effusion.
Dr. Blake's comment: This is typical for anyone over 40 years old, and really not meaningful. It is the normal wear and tear of an ankle, injury or just life related and the march of time.

Upon seeing the new Podiatrist, he reviewed this with me. He said this was due to a childhood sprain and meaningless. (I don't recall ever spraining my ankles in adulthood or childhood)
Dr. Blake's comment: It does not have to be an acute injury. If you are over 40, it can just be wear and tear on the ligaments with some breakdown or repair with scarring. These problems can lead to some ankle instability and pain. You treat with braces, taping, or muscle strengthening, depends on the stage of Rehabilitation you are. 

I also had an MRI of my left leg which is the worst of the two ankles. It showed mild edema around the pre-tibia.
Dr. Blake's comment: Again, the edema is from pulling of the muscles, like shin splints, and should be treated with icing, some Physical therapy if limited area, and muscle strengthening of the extensors.

The Podiatrist went on to tell me that I had edema around the the muscles and tendons of the leg/ankle and foot. He wants to do a debridement of the achilles and peroneal tendons and a Strayer procedure bilaterally, which to be honest, has me panic-stricken. I had seen an Orthopedic doctor in his same building after both MRI's were complete and he thought that everything looked fine on all imaging. I don't understand why the Podiatrist would want to do such extreme surgeries on both feet if the Radiologist's report mentioned nothing except the above. The Orthopedic and Podiatrist only agreed on one issue, disuse atrophy.
Dr. Blake's comment: Sounds like a surgical podiatrist trying to find a reason to do surgery. Definitely, podiatrists and orthopedists should be in agreement with surgery in general, and they will have different surgical approaches. I can not tell you who is right for you, but you need some other opinions. I would find a conservative podiatrist who you can bounce off what the podiatrist said to see if there is any hidden truth. If you trust the orthopedist, find out how to treat it. That is what is really important here, but you need more options. You need to know what your diagnosis is!

I know you're a busy man but would it be possible for me to pay you for a consultation to read over these MRI's to get your opinion? I would be willing to either mail/upload my MRI's if you'd consider a consultation with payment, of course.
Dr. Blake's comment: Yes, but no payment is required. Just mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. I am reading one for a patient from New Mexico tomorrow.

To me, I've already been stuck in bed for nearly 2 years with minimal walking and all this surgery seems extreme to me. I wanted another opinion on these MRI's, didn't know who to turn to and you came to mind. You're an intelligent man (I've read over your site many times) and I'd like for another set of eyes on these MRI's to see if all of these surgeries are really necessary. I understand you can't physically examine me, but only to give your opinion on the MRI's prior to proceeding with such extreme surgeries on both ankles/feet.

I appreciate you taking the time to read this over. If you don't have the time, I understand. At this point, I feel so desperate and don't where to turn. I value your thoughts and advice. I often wished you lived here as I don't think I would've been in this condition for almost 2 years. 

Thank you for your time.

Take Care,