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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. $80 has been donated in June 2017. I am very honored and grateful. Dr Rich Blake


Dr Blake's Book to Learn the Secrets of successfully helping your problems

I would love you to consider purchasing my book from Book Baby publishing. The printed book goes for $79.95, but the ebook is now available for $4.99. I hope it helps many people. Thank you. Rich (eBook) (print)

Book image not available.


Tuesday, June 27, 2017

Running and Arthritis Concerns: Good Sense Article

Sesamoid Fracture: When One is Already Missing

Dr. Blake,

I'm a very fit and aggressive 65-year-old hiker and backpacker who left the Bay Area eleven years ago for a remote small town in New Mexico.

I have high arches and I pronate, and my left fibular sesamoid was diagnosed with a displaced stress fracture 27 years ago, and was excised dorsally. I was given no further recommendations or precautions at the time.

Pain in that area began recurring 15 years later. Since then, I've seen three different podiatrists, none of whom ordered radiology and none of whom diagnosed a sesamoid problem. No one has ever analyzed my gait. They all simply prescribed new orthotics, and now I have four sets of expensive prescription orthotics, only one of which provides reasonably good arch support.

The latest pain began three months ago. Our (only) local podiatrist likewise just recommended yet another set of orthotics, but it took over a month to get them, so I continued hiking with stiffer boots, adding a metatarsal pad to my best existing pair of orthotics, on my own initiative.

Within three weeks, the pain became acute and I had to stop hiking. I rested it for a couple weeks, but it got no better and began aching at night in bed. Then I iced it three times a day for another two weeks. The ache went away, and the pain (on loading) decreased, but only to a point, so I returned to the podiatrist and requested an x-ray. After reviewing it, he said the tibial sesamoid appears deformed and may be fractured. He said if it is, he will need to remove it and fuse the joint, likely resulting in permanent disability. He ordered a CT scan and left on a three-week vacation before the results arrived.
Dr Blake's comment: No, you first try save it with all the things in this blog, or out in the universe. 

As in the past, he didn't suggest any further precautions or limitations, but on my own initiative, I conscientiously keep the load off that joint. What little walking I need to do around the house, I use my best orthotics/met pad, take short steps, and walk on the outside and heel of the foot to keep pressure off the joint, and I also keep the foot flat to avoid extension of the big toe. For anything more strenuous, like driving my truck with clutch, I wear my heavy hunting boots with orthotics/met pad to distribute the load over the arch and outside of foot, continuing to avoid big toe movement. This way, I've been able to avoid all but intermittent light pressure on the sesamoid.
Dr Blake's comment: You are a better rehabilitation specialist than anyone you have seen. 

In the meantime, I've researched the condition online and find that time is of the essence in treating a fractured sesamoid without surgery. I'm already three months into this condition and I've read that four to six months is the window for preventing nonunion and potential avascular necrosis.
Dr Blake's comment: Sure, you want to catch them early, and you are doing good things. Try to create the 0-2 pain level environment for healing. I have seen them heal or not heal after 3 years undiagnosed, so there are so many factors like biomechanics, bone health, work, etc. 

My next appointment, to receive and discuss results of the CT scan, is July 6. I am EXTREMELY frustrated with how long this problem has been recurring, and how bad it's gotten, without adequate attention, diagnosis, and treatment. I'm concerned that my local doctor may only give me the option of debilitating surgery, and I've learned from previous experience that our local physical therapists have limited experience and limited availability, usually with a month-long waiting list.
Dr Blake's comment: See what he says. Bring in a copy of my blog post attached on treatment thoughts. 

I'm open to traveling anywhere, for example back to the Bay Area, for more aggressive treatment to keep the use of my foot. I've read about treatments like hyaluronic acid injections, platelet-rich plasma injections, rejoining a fracture with wire or screws, arthroscopic debridement, shock wave therapy, bone stimulator, biomechanical analysis, gait analysis, spica taping - none of which seem to be available here. Here, I haven't even been given a walking boot to keep the load off the sesamoid.
Dr Blake's comment: I do not do the PRP or surgery, but can establish in 2 weeks a good program. I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few. 

Do you think I should be patient and wait for a local diagnosis on July 6, or should I be looking into outside options ASAP?
Dr Blake's comment: You can mail the CT Scan to Dr Rich Blake 900 Hyde Street, San Francisco, Ca, 94109. Definitely have a long discussion after reading my post above with the podiatrist. 

And regarding outside options, it seems that sesamoid conditions are often difficult to treat. Should I really be looking for a medical team with deep experience in sesamoids, or do you think any general podiatry practice would be sufficient?
Dr Blake's comment: You just need a good rehab person, who can take the information, protect your foot, give it time to heal. You need an MRI 6 months after the first to check its progress, and another 6 months later. Anyone can do this, but they have to want to do it. Good luck my friend. 
Thanks for your consideration!

Monday, June 26, 2017

Big Toe Joint Problems: Email Advice

I wanted to reach out to you as I've been using your blog so much for my injuries and I was hoping for your opinion. About 6 months ago I started to notice pain in my arch and it almost felt like more of my arch was touching the shoe than I was used to. This pain then turned into pain in my heel and ultimately, plantar fasciitis.

I ended up getting a cortisone injection in my heel which did help with the inflammation. Unfortunately, I had to walk on the ball of my foot for 2 weeks after the shot because I had a really bad cortisone flare up and the pain was excruciating. Once the pain and swelling subsided, I felt so much better. Unfortunately 2 days later I woke up with awful pain in the ball of my foot, above the sesamoid bones, almost like it was between my 1st and 2nd metatarsal. I never had much pain when the actual sesamoid bones were pressed.

I went to my podiatrist again and he diagnosed me with sesamoiditis. The pain was worse than the PF and was felt every time I took a step. I tried dancer pads but those only made my PF start to hurt more. I went back to my podiatrist again and he ended up giving me another cortisone injection, this time for the ball of my foot. The pain was worse for the first week or so as I had a viable bruise but after 9 days the bruise and pain went away.

At this point I thought I was finally done with all the pain. Now I'm experiencing a lot of pressure and stiffness in my big toe. If I stand barefoot, there's a lot of pressure at the MTP joint. I still have range of motion in my toe and it doesn't hurt to use my hand to flex the big toe up but if I make my foot dorsiflex, I feel a lot of pressure in the joint. I can actually stand barefoot for once but the pressure is just so uncomfortable. I went back to the podiatrist again and he thinks it's just the sesamoiditis causing this pain. My concern is it's arthritis developing in the 1sr MTP joint.

I'm going back to the podiatrist again tomorrow as I would at least like an xray (he never did one but I had one prior to seeing him, maybe 1 month prior and it didn't show anything) just to make sure it's not arthritis. I'm still unsure if I had sesamoiditis in the first place.

I wanted to get your thoughts if this truly does sound like sesamoiditis and can sesamoiditis cause this much stiffness and pressure in my joint now? Or does it sound like I might have something else going on in my foot? Can sesamoiditis eventually cause arthritis?
Sorry for such a long email. I've been so anxious to heal since I've been so inactive for 3 months now trying to rest my foot and we've got a 12 day trip to Germany in 2 and half weeks.
Dr Blake's comment: It sounds like when you walked on your toes abnormally (never a good idea, but definitely what we all would have done in the circumstance) you sprained the big toe joint. The feelings of a sprained joint is stiffness, pressure, some loss of motion if real bad). See my postings on how to do contrast baths to reduce the pressure, and spica taping for long walks. I would also ice the joint with a pack for 15 minutes twice daily. 

Thanks for any advice possible.

And the patient also wrote:

Dear Dr. Blake,

Recently I started to have nerve sensitivity in my left foot right where my bunion is. I never paid attention to my bunions before because they aren't that big and never bothered me. I was trying a new pair of sneakers that creased every time I walked, and rubbed my bunion. This caused a nerve sensation to develop that I feel every day now. I've been using YogaToes everyday to help stretch out my toes but would you recommend anything else to help calm down the nerve sensitivity? It's not really a pain, it's more of just an irritation but definitely gets worse when I wear shoes now. Any advice would be greatly appreciated!
Dr Blake's comment: Order some Neuro-Eze gel to massage in 3 times a day for 2 minutes. Until you get that use any type of massage oil to do the desensitizing massage. 


Star Excursion Balance Test: Ankle and Lower Extremity Rehabilitation

Our physical therapists do this testing of stability all the time, but have the patients use it at home to rehab. It is easy to make with tape in your basement, and it shows deficiencies and progress. If you are doing any type of lower extremity rehabilitation, but ask your therapist if this is right for you.

Psoriatic Arthritis: Nice Overview

Downhill Running Techniques

Sunday, June 25, 2017

Metatarsal Fractures: Email Advice

I broke my feet (age 54 female with a great diet raw and grass fed only) and walked on them for four months orginaly at Christmas building fence using my feet in a way I should not have.  (lever)

 Upon x-ray last week after resting weight free for three weeks it showed the breaks and white line on my fifth where it was said to have started healing.    Broken: 5th and 4th metatarsals on left and 4th on my right foot.  My  Chiropractor  took the xrays and put me on a vibation machine for a bit but it was a killer.  I think I re-injured them with that or at least it felt like it.   Then I got the great idea to swim just the next day.  Not moving them but a bit. Then the next morning did a stretch a couple of times touching my toes and it felt like my tendons were going to pop out of my feet. 

My feet were in cam boots but that squished them too much. The pain is right at the tendon attachment on both feet. Right where the  Peroneus Brevis tendon inserts into the 5th matatarsal bone on the outside of the foot.  So i ordered the flat shoe you wear next and that is far more agreeable.  I have no insurance and live in a small town with no podiatrist I trust. I was just wondering since I walked on them so long after they were broken could i have also damaged this tendon on both feet?
Dr Blake's comment: Possible yes, probably no. Usually only with a severe fall. When the tendon is injured, it hurts back to the ankle, and sometimes, up the leg. Usually no localized. 

 I probably only had stress fractures as I only had pain on the right the lesser break but I did not know until it got to the point I could not walk then I gave in and figured they must be broken...Then the x-ray after three weeks with them up.  I have been doing the hot and cold baths and have a used Exogen on they way.  How long should i stay non weight bearing.  
Dr Blake's comment: You want to create the 0-2 pain level, but gradually weight bear to build bone strength. Inside the shoe you can take 1/8th adhesive felt (like from and build a base that has a float for the fractures. Need alittle experimentation, but important for weight shifting and gets you walking faster. 

A second hand exogen dealer gave me your blog and I have read about the hot cold stretching.  How soon can I do that?
Dr Blake's comment: You can use ice pack for 10 minutes twice daily now, and begin each evening with one minute hot one minute cold alternating for 20 minutes. It is not stretching, but range of motion in the hot water with your foot. You can start that now. 
   Also the good pain bad pain I am so unsure at this point.  can you please help with some advice?  It has been six days  since the x-rays and vibrator machine.  a couple since stretching. 
Dr Blake's comment: Bad pain is pain that is above level 3 that you ignore and push through. An occasional sharp pain that last 10-30 seconds is nothing. If you start doing something that starts to hurt, you have to listen to your body and stop. If you do something that does not hurt until later or the next day, you have to wait to the pain subsides for a day, before you can do the same activity. Since this is a bone problem, at some point consider a Vit D blood test, and a Bone Density Screening Test. Hope this helps some. Rich

Friday, June 16, 2017

Nerve Pain: Email Advice

Dear Dr. Blake , Thank you so much for your blog I just wish that I had found it 7 months ago!. Can you please help me? I have been a labour and delivery nurse for 30 years. 12 hours days and nights on  my feet. Last year I broke 2 toes on my right foot and very stupidly continued to work . I could not wear a closed shoe so I foolishly wore flat shoes with no support and flip flops all summer.  7 months ago I started to wear my new supportive work shoes and a 7mm  lift. ( During the summer my osteopath diagnosed me with a 7mm leg length discrepancy as the cause of my lower SI joint pain). Within weeks I started to have pain under my 2nd Metatarsal on my left foot ( the foot I limped on for 4 months).
Dr Blake's comment: Is it also the foot with the lift? Very important because, if it is a heel lift it can transfer the weight to the metatarsals, and if it is full length it could be too stiff in that area. 

 I went to a podiatrist and he recommended a metatarsal pad. I tried to wear the metatarsal pad but it seemed to make things worse.
Dr Blake's comment: Met pads can make nerve pain in that area worse, and tendon pain worse, since those structures run back into your arch. Met pads normally help bone and joint pain unless too far forward. Did you try to move it around? 

 The pain soon was at the base of my 2nd and 3rd metatarsal . I went to physiotherapy and they diagnosed me with plantar fasciitis both feet ( no heal pain but pain under arches and below ball of feet worse on the left foot. Also they diagnosed me with possible capsulitis and neuroma. I ordered custom orthotics at this time. While waiting for the orthotics I continued to work. I started to experience intense burning and tingling shooting neuralgia. My feet were so painful the sheet could not touch them. 
Dr Blake's comment: The orthopedic problem had become neurologically over sensitive to protect itself. You now had the original problem, and nerve hypersensitivity, together. You have to take this very serious because it can lead to CRPS, so creating a consistent 0-2 pain level is crucial. 

I went back to the Podiatrist and he gave me a celestone cortisone injection between my 2nd and 3rd and 3rd and 4th metatarsal. After a couple weeks I started to get alot of relief in the burning and nerve pain the inflamation went down considerably. The cortisone allowed me to  receive physio therapy ( ultrasound and aggressive manipulation of my feet) I did all of the exercises I was given. 3 months later the symptoms returned with a vengence.
Dr Blake's comment: Unfortunately, it is common to have these long acting cortisone wear off and you need boosters. I tell my patients that they may need 3 total to address the nerve pain. While you are injecting a nerve, since it may wear off, consider oral nerve meds like Lyrica, topical Neuro-eze, neural flossing, ice pack 10 minutes twice daily. 

 I got another steriod injection this time Depro Medrol same locations.
Dr Blake's comment: Celestone is 6 mg per ml, whereas Depro is 20, 40 or 80 mg. It is very strong cortisone, as should not be used alot in the foot unless diluted. 

 After a very uncomfortable steriod flare 7 days later my foot started to settle down. I still suffer with the intense dull pain under my 2nd and 3rd metatarsal and my toes feel " out of joint" I can flex them but it feels swollen behind them and I cannot extend them without great ripping pain. I finally got an appointment with an orthopedic surgeon and he did xrays which showed no fractures, small heel spur. He diagnosed me with Tenosynovitis of the 2nd and 3rd metatarsals and plantar fasciitis . I agreed to PRP injections . I had a 2 week inflammatory response from those ( very painful) but my plantar fasciitis is 75% better  and the  Tenosynovitis is finnally settling down. I am icing several times a day. I was doing calf stretches but stretching irritated the tenosynovitis so I have stopped. The only advise I was given from this doctor was to rest and return in 5 weeks. I have been wearing a very flat firm slipper that my orthotic fits in I can't seem to wear my running shoes because they make my toes flex. It has been 3 weeks with very little ambulation in the day I am couch bound. I tried wearing a Budin Splint but it seamed to irritate the tenosynovitis on the toes. I plan to remain on the couch another 2 weeks then I see him again for the 2nd PRP injection if needed.

My questions are. 1) I think my orthotic is making it worse. When I walk I feel like I land right on the 2nd metarsal and when I tried a met pad it seem to cause the plantar ligament to pull on the capsule and the 2nd and 3rd metatarsals making the tenosynovitis worse. What do you recommend I wear on my feet? How long should I wait to try a met pad? How long should I wait to try the Budin splint again.
Dr Blake's comment: Orthotics are tricky for metatarsal issues since the end of the plastic is where you hurt. You can try a full length Sole (I prefer the red ones) with or without a loose fitting Budin Splint. Use a single loop Budin and open it up and place around the 2nd and 3rd toe, or the 3rd and 4th toes together. Yes, avoid met pads when there is nerve hypersensitivity. 

2) What types of shoes should I wear with this history.
Dr Blake's comment: Definitely try the Hoka One One Bondi or similiar to give you rocker. You may also need a Hike and Bike shoe for the rigidity right now.  How do you feel in a Danco clog, for cooking or short spurts?

3( Should I give up on the orthotic?. I pronate on both but much worse on my right foot . My arch is falling on the right. And the right foot is my good foot.
Dr Blake's comment: Give up on it right now, until we experiment with full length ones from Sole, Powersole, Lynco, etc. 

4) How long  should I remain off my foot? Should I completely immobalize my foot? How would you recommend I do this?
Dr Blake's comment: Nerves like warmth, motion, not prolonged stretching, non painful activities like walking. So, being immobilized is may help orthopedic injuries, the nerves hate it. I would have to know how you feel walking with crutches in a removable boot.

5)How will I know it is time to start restrengthening and returning to normal activities ie work?
Dr Blake's comment: Strengthening should be happening right now. This is usually organized by the PT. If you can not balance on one foot due to pain, you at least should be able to use a stationary bike with your weight in the heel for an hour a day. You should be doing a gym program for at least ankle strengthening, knee, hip, core, cardio, some upper extremity. Consider experiment with various beginner yoga poses or pilates exercises. Over the next month, every day find one exercise that does not hurt, and keep building.

6) I'm sure the 7mm lift in my right shoe has changed the weight distribution between my feet and has probably caused the perfect storm. I have been wearing the lift for 7 months now and it has been the answer for the S.I. joint pain I have had for 7 years ( GONE !!!) Should I have new orthotics made with no lift? I could get a separate lift made and add height a bit at a time.
Dr Blake's comment: The relief of the SI pain is pretty striking and emphasizes the need for the lift. I am glad the lift is not on your injured side. I love orthotics and lifts separate, so you can experiment. If the lift is only a heel lift, try to take that off and use a 1/8th inch full length lift (spenco insert) for the next month on the one side to see what happens. Hope all this helps some. I do want to say that lifts under your foot on one side have a very dramatic effect on the base of the spine. If I was treating you, I would order an MRI of the injured foot, and a Standing AP Pelvic xray with your 7 mm lift and orthotics to see how the spine, hips, and SI joints look. How level are they?

Please help me I am desperate to return to work and my life I love walking. I have been limping for 12 months now!

When Something is not Plantar Fasciitis: Email Condition

Dr. Blake,

I've been diagnosed with Plantar Fasciitis 3 months ago,  however I'm not sure if  I actually have that condition.

The Doctor did zero testing. I had googled heel pain and up came Plantar Fasciitis and I have high arches.  I found a local podiatrist and I sent a message asking if she treated this condition as well as plantar warts.

Turns out I don't have plantar warts but I definitely do have heel pain which came on suddenly for no apparent reason and has gotten steadily worse. 
Dr Blake's comment: Typically plantar fasciitis (an inflammatory condition) has a gradual onset over weeks, and usually months. 

I've been told that usually PF cause pain first thing in the morning but not for me. I have no pain in the morning. My pain appears after I been walking slowly and gently for a limited period. 
Dr Blake's comment: Definitely this is not plantar fasciitis, more like a heel bruise, heel bursitis, or some tendinitis/myositis of the local muscles. 

The doctor suggested the following treatment which I have done.

I purchased a compression sock and I wear it .
I take Aleve on off for selected period of times.
I soak my foot in Epsom salt until its a prune
The doctor taped my foot (made it more painful).
The doctor wrapped my foot in gauze with a cushion inserted and then applied a lite casting plus another wrap on top for a sprain. This was a disaster because the cushion had slipped to a position on the top of my foot where the foot and ankle meet.  I took it off in two days it was supposed to stay on for 7.

I have a prescription for PT but have yet to attend as I am not convinced about the diagnosis.
Dr Blake's comment: Sometimes PTs just blindly follow the Rx, and sometimes they try to give you an independent diagnosis. They can still follow the doc's RX if it is general enough. Definitely ask around to find a good independent thinker. 

The doctor has also suggested cortisone shots which I have declined.
Dr Blake's comment: Good for you. If you have a small fracture or small tear, these can be made worse. 

I also have all sorts of inserts which maybe ​contributing to making things more painful.
Dr Blake's comment: You have to try these, and sometimes you will be surprised what feels good, and what increases your heel pain. Amazing how many people continue to wear inserts that bother their feet in some way, although sometimes they have no other option. 

The issue  is that this condition is getting worse a case of the creeping pain, which is now gone up to the ankle and calf in the affected​ foot and also to a lesser degree in the other leg/foot which I believe is responding to my change in gait. I am hobbling around almost to the point of immobile.

Can you help me. I live in Emeryville CA . I have Medicare and AARP Supplemental policy. This situation is rapidly becoming debilitating and I really need to do something.
Dr Blake's comment: I am just across the bay. Come see me after an MRI if you can get it, and bring anything you have. 


Fractured Sesamoid: Email Advice

Hi Dr Blake!

After scouring the internet in a desperate search of hope for my sesamoid injury, i have stumbled across your blog (thank goodness)!

I am dealing with a fractured sesamoid that i believe may have occurred in April 2017. When i originally felt the pain from the fracture, i did not think anything of it , as i have suffered from PF for years ( I am a 24 y/o female ). 

The pain began to increase in my left, big toe, so I finally made the decision to visit an orthopedist on May 12th. I was beginning to worry how my pain would affect my 1 year work trip to an unsafe location in the middle east, where i would be on my feet 7 days/wk , ~12 hrs/day. 

The orthopedist x-rayed my foot and told me, "you have an old split bone in your toe". Because he did not go into any further detail and simply told me to cushion my foot better, I continued on thinking this was an injury i had acquired many years ago from dancing ( and that has simply flared up temporarily ). 

As the pain became more severe, and my time in the US limited to only a few wks, I found a podiatrist. He immediately diagnosed my problem as a fractured sesamoid (left, big toe) and put me in a Cam Walker (which i have been wearing now for about 3 weeks). He wanted to over-treat the injury as he knew i was intending on leaving the US very soon.

I was also given 2 separate EPAT treatments to help with my PF.

Fast forward to my appt. this week, I told him i was  not getting any better and i had doubts that my foot would improve before my deployment. We both decided I should tell my employer that i needed to delay 2-3 weeks and they were OK with that.

My podiatrist ordered an MRI (which i had just a few days ago) and the results are disheartening. It says it is looking like a non-union and i am devastated as i have been planning for months to move overseas for this work trip.. I am now unsure what kind of time-frame to put on this injury and do not think i will be ready to leave in 2 weeks.

I am still in the cam walker (about a 3 pain level, i mostly feel a constant dull ache), i am trying gentle massage, cold/hot therapy, etc. I do get nerve pain/tingling in my toes when i lay down/ sit down. And my big toe has definitely lost its range of motion (which i am now starting to work on).

I am at a loss. Do you think this has any potential to heal in the next 2 months? 

I really don't know what to do at this point.

I really appreciate any insight and thank you so much for your time!


Dr Blake's comment: These injuries can take quite a while (6-9 months) to heal, and if you rush them for whatever reason, you risk starting over. You are in the right boot now. You need to maintain a 0-2 pain level over the next year. You need an orthotic with dancer's padding to off weight the area, and can allow you to get out of the boot faster or get into a Hike and Bike shoe. instead of the boot. These shoes are not to be bent across the ball of the foot in an active pushoff, but are easily adapted by my patients and will protect the sesamoid. So, if you can get a protective orthotic to shift from boot, to Hike and Bike, to normal athletic shoes (consider Hoka One One Bondi), over the next two weeks, you should be well protected and can go on your trip with the Hike and Bike shoes, and a removable boot as a backup. Continue to ice twice daily, and do a deep flush with contrast bathes in the evening. Good luck and I hope it helps some. Rich

Wednesday, June 14, 2017

Fractured Bipartite Medial Sesamoid: Email Advice

Dr Blake

My 14 year old son was hit during a soccer game and fractured his bipartite medial sesamoid in his right foot. They are still in the same two pieces but considered fractured from each other.

We know he naturally has bipartite sesamoid a due to an unrelated X-ray 3 years earlier.

He was in a boot for 4.5 weeks but is now in a tennis shoe w custom orthotics.

We are supposed to wait 4 more weeks.
This is a unique injury, and I pray I am doing the right things.

He is resting for the most part. He says he is not in pain in his shoe or if any at a low level.

I would fly to California or anywhere to help him.

You are an expert on these injuries so any advice is appreciated.

He is eating healthy. Vitamin c, calcium, magnesium for calcium absorption, etc.

Should I be icing his foot or anything if he seems to be resting calmly.

Thank you

Dr Blake's comment:
     I am just back from vacation, and alittle jet lag, but I hope this makes sense. First of all, everything sounds fine as you are creating a 0-2 pain level for healing. I am assuming this is all x-ray based decisions, and not MRI, which is fine for now. Make sure you are icing the foot twice daily for 15 minutes and doing contrast bathes for a deep flush in the evening. If he walks with the shoes and orthotics, you should feel that he can walk through his foot, but the orthotics take some of the weight off the sesamoids. If not, the doctor should experiment now with higher arch, dancer's padding, or cluffy wedges. All of this is found in the blog. Once he can walk comfortably for 2 weeks straight, he can start a walk run program. That will typically take 10 weeks, and there should be no increased pain. Once you start the walk run program, you can do sports specific non-running activities, like free throws in basketball, volleying in tennis, etc. Nothing to increase pain. The walk run program is typically accompanied with Hoka shoes and spica taping (as needed based on pain). I hope this helps some. Rich

Friday, May 26, 2017

Big Toe Joint Pain: What is it?

I’ve been reading your blog for many months and it has been comforting to know that so many others have trouble getting well after a sesamoid injury.  It seems everyone’s story – like mine – has many twists and turns and failed attempts at pain relief.  I would not be writing you if I were not at my wits end.

Let me preface my story with saying that I am extremely active and physically fit.  I regularly (at least weekly) swim 30 laps, hike 10 or more miles, bike 10 or more miles, play tennis or racquetball, take 2-3 pilates and yoga classes per week, lift weights, do yardwork/landscaping, house repairs, etc.  I am about 5’ 3”, weigh about 120-130 lbs, female, and although I am currently in my 50’s, I can out-do any 35-year-old.  Since so much of my life revolves around an active lifestyle, you can imagine how devastating it is to have my whole world changed by a foot injury.  I have never had any foot or leg injuries before, and am in good health, take vitamins (Calcium, D, multi, fish oil, baby aspirin, etc.), and take no prescription medications other than an estrogen patch (for hormone replacement post-menopause).
Dr Blake's comment: You are a great example of cross training to vary stresses we put on our bodies. 

On October 2, 2016, I was doing yardwork and had a set of long pruning shears hit my foot.  Immediately I could feel my foot (around the big toe area) swell up inside my shoes (sneakers) and I knew by the amount of pain it was bad – very bad.  Nevertheless, I had to finish the yardwork because I was getting ready to show the house the next day (in the process of selling it), so I pressed on without icing it right away.  After doing yardwork I took a hot shower, and it swelled further and became more painful.  So it was only many hours after the injury that I started icing it.  I thought it was a broken toe and since there is nothing to do for that really, I did not seek professional help.  A week later, when I still could not walk in a regular shoe, I made an appointment with a podiatrist, but the first opening was not until October 17, so I had been walking on my foot for 15 days before I had an x-ray which showed a broken sesamoid bone. He put me in a walking boot which came up to my knee and showed me how to make the “L” shaped pad to affix to my foot underneath.  After a week, my ankle began to swell and the walking boot became uncomfortable, requiring I have my leg elevated most of the day. He prescribed compression stockings.  The compression stockings increased the pain, and after a week, I quit using them.
Dr Blake's comment: We call this vaso-motor insufficiency, when the protective nerves cause too much discomfort. The body rushes in fluid to heal something, but it is only the nerves screaming that is causing the pain. It is an over reaction to the injury that involves the sympathetic nervous system, but it makes the pain terrible. 

November 2016: I began using a knee walker “scooter” at work (I’m a medical writer). However, I could not use the scooter at home because of the stairs (my house was on 3-levels). I was walking in the boot (or slipper) while at home. I began working from home part-time, and due to the impending sale of my house, I was packing (requiring being on my feet a lot), and searching for a new place to live (requiring being on my feet a lot)… most of the time in the boot.  The pain was bad enough to require icing it down daily. I experimented with a small boot (that only came up to the ankle) but that was much worse.
Dr Blake's comment: I am not sure why 2 or 3 of those scooters can not be dispensed at the beginning. So many patients complain of the same thing. They need a scooter at home, at work, and one in the trunk of their car. The larger the boot, the less tight around the ankle it has to be, since it has a bigger area to grab your leg. The smaller ones only have the velcro down by the ankle to crank down on. Unfortunately, this is all usual stuff with easy cures. 

December 2016:  The foot pain was getting worse and ice no longer helped. I had a car accident which totaled by car, so now, on top of packing and moving, I also had to start car shopping and test-driving cars.  An MRI at end of December showed the bone still had not healed and there was significant bone marrow edema in the medial sesamoid.
Dr Blake's comment: The MRI is going to be hot for a year or so. I like to wait 6 months between MRIs and definitely get a comparison of the two done. At some point, the hypersensitivity of the nerves really started going. Nerves hate ice and like warmth, gentle motion, gentle massage, no prolonged stretching, etc. 

January 2017: I was moved, unpacked, lost my job, and was finally able to stay off my foot, and use the scooter in my new house (no stairs).  After 6 weeks of total rest, an x-ray showed no healing of the fracture. Indeed the pain was still as severe as it was the initial day I hurt it.  I experimented with creating home-made orthotics inside the boot. I tried applying heat (heating pad) because ice was no longer helping.
Dr Blake's comment: Xrays are poor at showing the internally healing, and you have to go mainly on the pain. In your case, that was not helping us either. 

February, 2017:  I purchased an Exogen bone stimulator (low-intensity pulsed ultrasound) and have been using it twice per day for 20 minutes each time, beginning mid-Feb. (a total of 93 days now). Because I was in the boot for so long, I developed plantar fasciitis, which was even more painful than the sesamoid!  I also began having knee and hip/back pain due to the altered weight-bearing, and multiple bruises on my leg from using the knee walker.  I started physical therapy 2-3 times per week, with the goal to increase circulation in my foot. Since I was still non-weight-bearing, the exercises I could do were limited: ankle and toe calisthenics. Although the exercises hurt at first, I did them and gained excellent flexibility and range of motion.  The physical therapist also used deep tissue ultrasound and taping for my plantar fasciitis. I had a custom orthotic made (they took a mold of my foot), but it was many weeks before I received it due to insurance snafus. After being totally away from all exercise since my injury, I began swimming again, and worked up to my “usual” 30 laps each week.  Initially, it was hard, with lots of foot cramps and stopping, but it got progressively better.  In an effort to find some reason why the bone was not healing, I had a bone density scan to rule out osteoporosis, and a Vitamin D3 test, which both came back normal.
Dr Blake's comment: You are doing all the right things. The pain can intensify with limited weight bearing due to fluid buildup  and nerve hypersensitivity. I hope the sesamoid is hurting because of that and not lack of healing. 

I came across an article ( that described inserting a screw into the sesamoid (to hold the broken pieces together) which obtained excellent results, and I sought about trying to find someone who does this procedure.  I consulted with 3 different doctors, and all said no one in the U.S. does this procedure (the research for the article had been done in Australia). I was told about one orthopedic surgeon in NC who tried an open (not percutaneous) screw fixation procedure years ago and had bad results, so stopped.

March, 2017: I consulted with an orthopedic surgeon who said the quicker I get into a “regular shoe” with an orthotic and out of the boot, the quicker all my plantar fasciitis, knee, hip, and back problems would improve.  He was right.  I wish this would be widely known and become the standard of care in medicine.  I feel I endured much more pain, discomfort, decreased mobility, and harm to other parts of my body needlessly.  On the advice of the orthotic maker (who also makes custom prosthetics for amputees), I purchased a pair of New Balance sneakers a size larger than normal and an extra wide width, and the orthotic was fitted to it.  The purpose of the orthotic was to push the weight to the outside of the foot and force me to walk “unnaturally” so as to alleviate pressure on the sesamoid.  A “regular” insole was put in the right shoe (good foot) so I could wear the same pair (both feet) and be level.  I returned to doing as much exercise as I could: weight-lifting, pilates, swimming.
Dr Blake's comment: I do also. And I am sorry, but old rules sometimes never die. Many readers will benefit from your wonderful descriptions. 

The orthopedic surgeon told me the objective should not be to get the two broken pieces of sesamoid bone to unite, but rather to walk without pain.  He explained that many people have a bipartite sesamoid and do just fine.  Both he and the podiatrist told me if I still cannot walk after 12 months, that they would remove the bones – both broken pieces.  I found articles on using platelet-rich plasma injections for helping to heal broken bones, and looked into that.  Unfortunately, my insurance would not cover these and they are $700 each.  Also, my podiatrist said although he has had good results with PRP for wound healing, he said the probability it would help for a broken sesamoid is extremely low.  What is your opinion on PRP?  I found a doctor who not only does PRP but also amniotic membrane injections, and injections of stem cells made from your own fat cells.  All of these things are considered experimental and so are not covered by insurance.  However, at this point I am willing to try anything!  But for what the cost of these injections would be, I could probably fly to Australia and have the screw fixation!
Dr Blake's comment: They are experimental. Patients flood my office after unsuccessful PRP or stem cell injections for another opinion, but I am sure I do not see the successes. Limited and biased experience. I totally disagree with not letting them unite!! And, I totally disagree allowing you to walk on the outside of your foot (called supination). I can name you 20 injuries or pain syndromes at least caused by this abnormal walking. You need the weight through the first and 2nd mets, evenly, not the 4th and 5th metatarsals. 

April, 2017: Because the orthotic was causing me to walk unnaturally, I now developed ankle and knee issues, and had to return to the orthotic maker for revisions of the orthotic twice.  After the second revision still did not making any sustained walking possible, he suggested I purchase a pair of Hoka One One shoes (still a size larger and extra wide), which I did.  They have been a big improvement, and I noticed you also recommended them in your blog.  I continued experimenting with making my own orthotic in it.  I found that I could bike with less pain than I could walk, so I went biking when I could.  But still, the amount of walking needed to load the bike rack on the car, etc., was painful.  Keep in mind that all this time, I am still having to use the knee scooter when doing grocery shopping, and even getting in and out of the pool in the gym.  In other words, I still cannot walk more than about 3-4 steps without pain, and still having to elevate it at various times throughout the day (hurts to keep it down too long) and also still needing to ice it down occasionally (especially after bike riding!).

May, 2017: After 93 days of using the Exogen bone stimulator, I had an x-ray which showed the sesamoid looking EXACTLY the same as it did in my original x-ray from October – not the slightest bit of healing.  Up until this time, I resisted getting a steroid shot, because steroids are known to inhibit bone growth. But now I figured, it doesn’t look like the bone is ever going to grow, so I might as well. What is your opinion about steroid shots?
Dr Blake's comment: No, not in a joint that is trying, even though unsuccessfully, to heal a fracture. With the bone looking the same, impossible for a fracture due to bone remodeling, the whole cause of your pain is in question. You really do not know if this is fractured. Your original injury could have jammed a congenitally bipartite sesamoid against the ground bruising it. The 2 pieces will have look like they are coming together. Was the bottom of the metatarsal where it hits the sesamoid also injured? A repeat MRI will help. 

The podiatrist is concerned, as am I, that my pain level is way out of whack for a typical broken sesamoid, now 7 months later.  I wondered whether we were missing something, like a torn tendon or joint problem, but he said any problems like that would have shown up in the MRI and didn’t.  He suggested I may have nerve damage and should see a pain management specialist.  From what I know about nerve pain in feet, I do not have those kinds of symptoms (like tingling, numbness, “pins and needles”, etc.), so I am not convinced of that.  However, it could be that in the injury I had with the yard implement, I damaged the nerve and that was the problem all along… that perhaps the broken sesamoid was an existing condition (for example, an injury I sustained in childhood and forgot about because it was never diagnosed or treated?).  What is your opinion?  Would you treat this as a nerve injury at this point?  What types of therapies or diagnostic measures would you recommend?  I am afraid of getting the sesamoid removed only to find out that was not the source of my pain.  Should I abandon the bone stimulator altogether? My podiatrist said I might as well stop using it because it obviously is not helping.
Dr Blake's comment: Sounds like you are on to something. And yes, typically broken sesamoids can be walked on with removable boots and dancer's pads within the first month of treatment as the inflammation goes down. Look at all the possible sources of pain. Are we sure the MRI, and you are due for a 6 month comparison one right now, did not show anything else. Limited weight bearing in a boot with a dancer's pad will not hurt your foot (and you can use crutches) and may begin to add tone and circulation back into your foot. A pain guy should be versed in nerve hypersensitivity and know what creams, pills, TENS units, etc will help the nerve. Sounds like the orthotic guy is skilled, so keep pushing him to make you something you can walk with. I would love to see a photo of an xray at least that shows, but I will be out of the office until 6/13, so I am rushing at least to get this done.  

As you can imagine, after 7 months and getting no pain relief, still unable to walk more than a couple of steps,  cannot wear “normal” shoes, and dealing with lots of crap from insurance companies (I wound up paying 100% out-of-pocket for my scooter, bone stimulator, and orthotics), I am frustrated and tired.  Any ideas, suggestions, or comments you have would be greatly appreciated and heartily welcomed.
Dr Blake's comment: I think we are ending this communication with the impression that you may not have a fracture at all, you are treating this with limited weight bearing that greatly increases pain (not decreases pain) in most people by allowing the normal weight to push abnormal fluid out of the area, and allow nerves to get hypersensitive. It is impossible for a healing fracture to look the same on xray, but what is going on. Please let me know mid June if you have found something out. 

The Steph Curry Ankle Brace: 2 MVPs and 2 Championship so far!!

One of my kind patients sent me the link on the famous Stephen Curry ankle brace!! Give it a try or leave your comments below this post!

Sunday, May 21, 2017

Diabetic Foot Check

Stegmann Wool Clogs for comfort and stability

A patient recommended these for comfort and stability, especially around the house. Thought I would pass it along.

Hike and Bike Shoes for Immobilization of the Bend at the Forefoot

I have been using Hike and Bike shoes to immobilize the foot while not having the negative impact of a removable cast in some patients. There is one used in a plantar fascial tear for the 3 months I normally cast the foot with a removable boot. If the patient especially has a back problem, the evenness of wearing a pair of shoes like these can be great. Remember you are not able to bend your foot in push off, or it will hurt you. Therefore, it immobilizes the pull of the plantar fascia. Any metatarsal  problem could be helped by this, even if it is only part of your treatment to vary the stresses 2-4 hours a day. Sesamoid problems, turf toe, metatarsalgia or stress fractures may be helped.

Saturday, May 20, 2017

Navicular Fracture: Email Advice

I am a 41-year-old single mom of two very active boys ages nine and eight. In April, I walked right off of a pedestrian sidewalk not realizing it had ended and landed right on top of and rolled my foot and ankle.

I have been in one of the immobile walking boot since 4/17. They elected not to cast immediately due to an open wound.
The fracture was only visualized on the lateral x-ray. Was not until we got the CT scan that we realize the extent of the injury.

What do you feel is my best option? The doctor feels a compression screw to attach the two pieces or six weeks in a hard cast at this point. I continue to use KT tape as well as lidocaine patches. I am in active as I can be given my current situation.

If I do get out of the house I remove my boot each time I drive and also use the knee scooter when there are long distances to travel.

Any advice or input would be greatly appreciated

Dr Blake's comment: This can heal, although there is no guarantee, with casting and bone stimulator, as long as everyone agrees there is good alignment and the blood supply had not been compromised. There is just so much pressure on the fragment, and the navicular itself is known for its bad blood supply, and there is another injury at the cuboid, and as you weight bear the talus pushes against the navicular with tremendous force. You are young, and need to be active quickly with your responsibilities, so I think the surgical screws across the fragments would do you best. That being said, every injury, and especially if you have surgery, requires a lot of rehab. As a single mom, you may not have the time to dedicate, especially if there are problems or complications with the surgery. That commitment has to be worked out. Also, the fractures are the obvious, but there can be hidden injuries that will slow the recovery.  At least, as the article below points out, a simpler percutaneous screw fixation will dramatically reduce the post op recovery time over a completely open procedure. This 6 weeks post injury is important to let the soft tissue heal, and any change of infection pass, before the bone is fixated. I hope this helps some. Surgery makes sense if percutaneous where the alignment is good. Should allow activity faster overall.  But, like you should not be driving now, if the surgeon tells you some restriction, you have to oblige whatever the costs. Surgery just starts the injury over again, but the bone will heal quicker this time. Rich