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Saturday, November 26, 2016

Sesamoid and Sciatica? Email Response

Hello Blake, I have read many of your blog posts about sesamoiditis and have tried my best to apply them to my injury. After a long period of issues I have decided to reach out for you personally for help.

I am (was) a high school runner and this injury occurred during December of my junior year (nearly a year ago as I am now a senior.) I had been running 50-65 miles per week during my cross country season with no big Issues. Only this lingering upper hamstring/piriformis issue that would appear when sitting for long periods. A deep, stabby type pain in my upper hamstring/piriformis. This is important later. In early December I had been having issues with numb/burning/tingly toes on my run. Along with plantar fasciitis type issues. I had attributed these issues to new shoes I was trying out, but I am now guessing these issues were pre-cursors to my sesamoid issue.
Dr Blake's comment: The upper thigh, heel pain, and toe numbness could be a sign of sciatic nerve irritation. 

One day I was running when I suddenly got a piercing pain in the ball of my foot. I hobbled home and rested. I have to this day not run because of the injury. In the following weeks, a lot of inflammation and dull aching was common. Still having no idea what it was. I stayed off of it as much as possible and did some icing.

At one point I went to my massage therapist and she mentioned my right leg was basically twisted out side ways. My hamstring/piriformis/hip were all screwed up. This led me to (and I still) believe that due to those issues changing my gait, I was putting excess pressure on different bones in my foot; causing the sesamoiditis. This theory may or may not be true. She worked on me and said it was better than before, but still not good. I didn't touch it after that.

I got x-rays in January that showed no issues with my foot. Inflammation and occasional ache remained, but the ache was less frequent than before. In April I got more X-rays. This time with different angles at a foot specialist. This revealed inflammation in one of my sesamoid bones. They gave me a foot pad to offload the bone and claimed it would heal itself soon. At this point the inflammation was still there and the bone didn't ache as much as before. I never wore the foot pad due finding it to be uncomfortable, now I know this was probably dumb. I went around in flip flops and barefoot all summer and the inflammation remained. I specifically remember it would ache when I woke up.

I found your website in September/October and have been applying some of your recommendation since. I wear the foot pad at all times around the house and have a similar set up in all my shoes. I ice multiple times a day and every couple days I do the contrast bath. There is rarely ever any pain, so I would put it in the 0-2 range. Maybe slight pain every couple weeks, most likely after I do something stupid to it. I also supplement with some calcium/vitamin d/magnesium to be safe. My question is: What else can I be doing for this injury? I feel the bone is healed, but some inflammation remains, but I feel the bone has been just about healed for a long time. The inflammation has been the real issue that refuses to go away. I can't wear certain shoes because my right foot is bigger than my left, I don't dare to run on it, etc. It has been almost a year and while I have made much progress from where I was 6-12 months ago, I am still sick of this inflammation. What can I add in to help? Am I doing anything wrong?
Dr Blake's comment: I would definitely see a neurologist or physiatrist to rule out sciatic nerve irritation versus piriformis syndrome. This could be causing some hypersensitivity along the L4 nerve root distribution. See my video on this. 



Here is my issue with the upper hamstring/piriformis. It still gives me the deep stabbing pain when I sit in certain positions or for too long. I am wondering if you think there is any connection with this? Could my gait theory be correct? I have since begun hamstring strengthening exercises (specifically for my issue, which I believe may be a high hamstring tendinopathy injury) to try fix this issue as all the stretching/massaging in the world did not seem to fix it. I have been doing these for a couple weeks. Do you have any experience with this?
Dr Blake's comment: The pain syndrome seems to point to the sciatic nerve. Also, nerves hurt sitting or sitting or resting, and tendons with activity. So, that would be my next investigation. Good luck . Rich

Thank you for your time.

Friday, November 25, 2016

Sesamoid Injury: Email Advice

This is an email from a patient struggling with pain from a sesamoid fracture. We have had a few correspondences to help some. 

Hello Dr.Blake

I am attaching here the picture of the footwear I'm wearing these days.
Dr Blake's comment: The patient has a post operative stiff soled shoe with an ace wrap and Dr Jills Sesamoid pads. 

1) The post -op shoe which I got last week , I wear with a  sesamoid pad made by
 combining the Dr.Jill's pad and a pad cut out from felt .On top of that I tie a
bandage and then wear the shoe. Is this the right way of wearing these things?
Or the stiff shoe has to be worn on its own?
( I thought it was too hard to be worn without padding)
Dr Blake's comment: This is very good as long as you are achieving the 0-2 pain level consistently, and you are able to increase your weight bearing for mineralization. If not you would have to go to a removable boot, like the anklizer. 


2) I also wear the Crocs Clogs ,with cushioning and sometimes the bandage as
 well ,find this quite comfortable.
Dr Blake's comment: I am so happy you found a shoe/clog that gives good relief, and can rotate with the post op shoe. This will allow the stresses to be variable with each shoe. That is typically very good for overall healing. 


I am quite confused about the PT and the strengthening exercises which are
 recommended . I feel that some exercises which involve flexing of the toes 
forward and backward will not let the bone unite,is it so? What exercises and
 PT is one supposed to do ?
Dr Blake's comment: When you are trying to heal the sesamoid, you want to avoid bending the toe forcefully upwards. Typically, I will have the patient do metatarsal doming, flat footed balancing with a sesamoid protection (a hole of the sesamoid in the middle of 4 books), and posterior tibial and peroneus longus theraband (resistance bands). These strengthening exercises can be found on the blog. 


The calf muscles of my left leg (fracture in left foot)  has really become loose,
can it become firm again or is it permanent atrophy? How does one make
 them firm again ?
Dr Blake's comment: The flat footed balancing will start getting them strong as you build up to 2 minutes. You can do weight bearing squats with the well for the sesamoid, you can do 2 positional theraband calf strengthening (just without having the band push hard on the sesamoids. These can be found on the blog also.


There are days when walking does not cause pain and then there are days the
 pain is too much and even travels upwards to the leg. Why is it so?
Dr Blake's comment: It is always a good sign when there are good days, and hopefully the periods of good days will last longer and longer. However, the area can get inflamed from what you did yesterday, and not bother you until today. Typically, it is limping from you protecting the area that can give you shooting pains which are muscular. But if it feels neurological, it can be that you are picking on the sciatic nerve. Definitely try not to limp, and you should be going gentle calf, quad, and hamstring stretches twice daily. For the calf stretches, try using a towel to pull you foot towards you without pushing on the sesamoids. 


How much should one walk or stand?
Dr Blake's comment: You are trying to both re-strengthen your feet, and return to normal activity. These are two distinct phases of rehabilitation that we are always trying to blend together. Based on your circumstances, you try to increase both activities gradually, sometimes breaking the activity into small sections. So, a runner must do a walk run program first before they can run without stopping. I love 2-3 fifteen minute walks daily, no limping, 0-2 pain level, and gradually weekly bounce it up by 5-10 minutes. It is based on how you feel. The standing is actually sometimes harder, but the dancer's padding helps, or the soft Crocs. When you stand, try to get your weight even from front to back, and right foot to left foot. Get off your foot when you can, ice when you have irritated it. 


Will life ever get back to normal ? If yes ,then how long will it take?( I've been
 like this 10 months)
Dr Blake's comment: No guarantees, but are you making progress. Are you somewhat better than where you were 3 months ago? I find for these situations making benchmarks can be psychologically beneficial. Spend a day making 5 functional levels of what you can do now? This is what we will look at each month. These benchmarks may include: the duration of a walk before pain, the time standing before pain, the number of weekly bad days, etc. The progress may be slow with one of these 5, but significant in another. At least look at this for 3 months, and report back based on those benchmarks. Good luck again, and thank you for the donation to the blog. Rich



Thank you

PS Here is the ordering sites for my new book (and it's ebook version). 




The Patient then replied to my comments.




Thank you so much for helping me! I cannot express how relieved I am to hear that there is still hope for my sesamoids, even after 8 months of pain. It really made my day, as I’ve been rather pessimistic after the visit at the orthopedist.

Attached are some of the MRI images showing the sesamoids in addition to the x-ray of the right foot. It was a bit difficult to pick images showing bone marrow edema, since I’m not sure about what I’m looking at (no doctor has explained it to me, I’ve only been told that the MRI is showing bone marrow edema).
Dr Blake's comment: You sent a beautiful image of the bone marrow edema in the tibial sesamoid. 



-       Dancer’s pad/other orthotics: I’ve been using a dancer’s pad (home-made of felt) for only a a couple of weeks because I discovered your blog only recently. Before that, I used the blue sole into the post-operative shoe I’ve got (images of both attached in the first mail), but this sole only seems to provide some arch support, it doesn’t protect the sesamoid specifically. Right now I’m trying to wear the blue soles combined with a dancers pad in Hoka (One One) shoes because this feels most comfortable. Before I’ve been thinking that the Hoka shoes haven’t got soles stiff enough, but perhaps they are acceptable? Especially since you recommended rocker bottom shoes. I can also mention that I will have somewhat more customized soles made soon.
Dr Blake's comment: You are creating a good healing environment to spend the next 3 months in while you increase your weight bearing. There are no surprises in the MRI suggesting difficulty in healing, and that makes sense based on the history of where you are at right now. There is nothing all-important except creating that 0-2 pain level, and increasing your weight bearing. Everyone will be different in the stiffness needed, rocker needed, cushion needed, off weight bearing needed, and arch support needed. And what combo works well in one shoe, may not do the trick in another shoe. Experimentation to create that 0-2 pain level is crucial. 
-       About the pain: As I mentioned, I find it quite difficult to find an acceptable pain range. Still, I think I am in the 0-2 pain range most of the time and have been for about 1,5 month (after getting that post-operative shoe). However, I feel very constrained by how little I can do when staying in the 0-2 range. Luckily, I can still work because I have a sedentary job, but that’s about it. To be honest, I don’t really have a plan for staying in the 0-2 range other than not walking too much on the foot (which is perhaps a bad plan in the long run).
Dr Blake's comment: Make sure you read the post on good versus bad pain. It is almost a new month and December should be 10% more active than November, with the same for January, and so on. Each month you need to do a little bit more, and ice after you walk, try short walks twice daily, experiment with arch massage, get an anklizer boot that rolls more for increasing your walks,etc. 
-       I began doing contrast baths about two days ago
Dr Blake's comment: I love the daily contrast bathing, with twice daily (especially after exercise) icing for 10-15 minutes. 
-       I will have my vitamin D level checked the next time I have an appointment with my doctor (which is in about a week).
Dr Blake's comment: Great, it will be good to know how if your overall bone health needs some work. 

I have also scheduled an appointment with a physical therapist next week, because this was what the orthopedist recommended. But I’m still not sure how that can help me right now, considering that I feel quite immobilized for the time being.
Dr Blake's comment: You are in the Re-Strengthening Phase of your rehabilitation. You should be learning safe lower extremity exercises without putting too much pressure on the sesamoid. Remember, if they ask you to do something that hurts, do not do it as politely as you can. Get the calf tension stretched and massaged out would also be great, along with arch massage to make your foot more pliable. Alot to do!!

This also leads me to what you said about the different aspects of treatment – e.g. dancer’s padding and orthotics, but also activity modification and foot strengthening. I guess I’ve been doing quite a lot of activity modification for the last months – namely going from being active to being inactive. However, since I get very restless from not being able to do much physical activity, I’ve done a lot of exercises at home (e.g. push-ups on the knees), focusing on not doing anything that puts weight on the left foot. Maybe the physical therapist can help me find even more appropriate alternative exercises?
Dr Blake's comment: Perfect!!

I’m not entirely sure about what you mean with foot strenghtening, although I can understand why it might be needed. After I began the contrast baths, I’ve tried to wriggle my great toe in a non-painful manner when in the warm water – and I’m quite shocked to see how stiff and difficult to move it has become! Therefore, I would really appreciate more advice on the different aspects of treatment – especially foot strengthening. If you have the time to do that in separate posts, as you mentioned, that would be really great.
Dr Blake's comment: Since you are seeing a PT, ask them to make sure you know how to do metatarsal doming, posterior tibial and peroneus longus resistance bands, flat foot balancing with the sesamoid in a well between 4 books, same for the 2 positional calf stretches, and self mobilization for a stiff big toe joint. I have made posts on all of these. 

Finally, having read about sesamoid fractures in medical journals, it worries me a bit that avascular necrosis is said to be a potential complication of sesamoid fractures. When having a sesamoid fracture for months (and potentially 1-2 years, in my case), do I run a risk of avascular necrosis? Is the risk higher the longer one has a sesamoid fracture?
Dr Blake's comment: Yes, and yes. You need to focus now on the opposite of avascular necrosis which is re-vascularization with contrast bathing daily, bone stimulation daily, creating that 0-2 pain level so the inflammation stays in control. 

Again, thank you so much for helping me! I’m looking forward to your next post. If you need other MRI images than the ones I sent, just let me know and I will try to pick some better images.

Best,

Wednesday, November 23, 2016

Sesamoid Injury: Email Advice


Thank you for all the helpful information on your blog, especially what you have written about sesamoid injuries. I have also begun reading your book, which I find very helpful and educative. Yet I need to ask you some questions about my specific “sesamoid case”, and I do hope you have the time to answer them as I am clueless on what to do from here.

I am a 27-year-old woman, and I have been struggling with pain in my left foot for about 8 months. It began in the end of March 2016 and I cannot recall having hurt my foot in any way. After the pain began in March, I didn’t pay it much attention because I just thought it was the same kind of pain I have experienced before. I stopped jogging for a while and tried to wear better shoes, but the pain kept increasing. It was highly affected by the level of activity – I could be almost pain-free when I awoke in the morning, but during the day the pain would increase, even after short walks. I have tried to think about possible causes, but cannot think of any, other than that I have a high-arched foot.
Dr Blake's comment: High Arched feet are a curse on shoe buying and both heel and ball of the foot pain. Too much pressure is put normally in these areas leading to injury without apparent cause. 

Since the pain didn’t go away, I went to see my GP in June. She sent me to x-ray, which showed both of my sesamoids to be split or bi-partite – I was told that this might indicate stress fractures, but they could also be naturally occurring. Nevertheless, my doctor recommended me to wear stiff-soled shoes for about 4 weeks to see if the pain would subside.
Dr Blake's comment: This was good initial advice. 

6 weeks later the pain was even worse, and I had trouble walking short distances. I went back to see my doctor in the beginning of September, and then she sent me to MRI, which showed the same split in both of the sesamoids in the left foot, in addition to bone marrow edema. My doctor interpreted this to confirm the diagnosis of sesamoid stress fracture, and not naturally occurring bi-partite sesamoids. She then referred me to an orthopedic specialist, and I was told to use an even more stiff-soled shoe (which is actually a post-operative shoe, as I had trouble finding a shoe with soles stiff enough) while waiting for the appointment with the orthopedist. She also recommended me to be even more conservative with weight-bearing. I used crutches for some time (about 3 weeks), and the pain got better – but only when not putting much weight on the foot. When I tried to walk a bit further than walking around in my apartment, the pain got worse and was about the same as before. Lately I have also begun experiencing the same kind of pain in my right foot. However, x-ray of this foot was normal, although I was told it cannot be ruled out that I might be developing a stress fracture in this foot as well unless an MRI is taken (which has not been done).
Dr Blake's comment: Hopefully, you are making dancer's padding for both sides to help the left and protect the right. You can get the 1/8 inch adhesive felt at www.mooremedical.com and design your own. 

A couple of days ago, I finally had the appointment with the orthopedist. However, this was far more confusing than helpful for me. In contrast to what my doctor had recommended, he told me not to wear a stiff-soled shoe. Rather, he recommended orthotic soles to relieve pressure on the sesamoids (I haven’t had these made, yet), in addition to seeing a physical therapist. He said my gait was wrong due to being in pain for several months (which I admit is true). However, what confused me the most was that he said he found it very unlikely that my sesamoids would ever heal. My immediate reaction to this was of course that I thought my foot would never be ok again. I asked him repeatedly what he meant, but didn’t get a clear explanation. Having thought about it afterwards – and having read about different sesamoid injuries myself – I think he might have been unsure as to if I have an actual sesamoid fracture. In my understanding, the treatment he has recommended indicates that he might think I have sesamoiditis rather than sesamoid fractures, and that the non-union of my sesamoids might be naturally occurring. However, he never expressed explicitly his view on diagnosis to me. Further, when I asked about how I should “treat” my injury in a practical sense – e.g. should I walk for more than a few minutes on the foot even though it hurts; should I use crutches; can I drive in spite of the pain; and so on – I got no or very vague replies. These questions have important practical implications for me, and I feel I have no one else to ask.
Dr Blake's comment: Golden Rule of Foot: Sesamoid Fractures Rarely Never Heal. I find that they can take awhile, but they heal. Even if you are stiff soling it, trying to transfer to the arch and off the big toe joint is a great idea. 

Some background information:
- I’m living in a European country with a public health care system (which I’m grateful for), so that I’m not suffering large financial expenses due to my foot pain – however, this also means that I have to wait quite a long time before seeing any specialists, as my type of foot problem is not prioritized 
- When I was pregnant in 2015, I gained about 55 pounds (but I am normal-weight now) 
- Although I am definitely not an athlete, I enjoy physical activity and used to engage in some form of physical activity (including jogging/running, lifting weights) about 3-4 times a week before the pain began
- I have experienced pain in both of my feet a couple of times before, but the last time was about 4 years ago and lasted only 3-4 weeks when I stopped running/jogging for a period and made sure to wear good shoes 
- I don’t take any pain killers now and haven’t at any point since I’m skeptical about using such medication
- Although I didn’t think about it at the time (but I have after reading your blog), I think my intake of vitamin D and calcium was far below the recommended levels prior to the pain debuted – yet I think I am too young to have any osteoporosis-issues although I haven’t had a bone density scan.
Dr Blake's comment: There is an epidemic of Vitamin D deficiency leading to stress fractures, so it only takes a couple of months of low Vitamin D3 to cause a stress fracture. At least see if you can get the Vitamin D level measured and see where you are and what the range of normal is. I love my athletes to be in the middle of the range, around 50-55. 

So now I feel lost and confused. Here are my questions, and I will be extremely grateful if you could answer any of them:
1.     It is my understanding that the correct treatment depends (in part, at least) on the correct diagnosis. Can you please help me get a second opinion? Do I have sesamoid stress fractures in my foot or not?
Dr Blake's comment: It looks like from the 2 x-rays that I saw that you do have a stress fracture. I was not able to look at the MRI images for some reason. If you can send 2 or 3 images like the x-rays showing the supposed bone edema, that would be great. When there is any doubt however, we must treat it like a fracture, which you are. 
2.     Could it be that I have naturally occurring bi-partite sesamoids in my left foot, but whole sesamoids in my right foot, and would that indicate that I have sesamoiditis rather than stress fracture?
Dr Blake's comment: Sure, but sesamoiditis does not hurt like this. The history is one of a fracture. 
3.     Is it true that my injury will never heal, and in that case, what is the point of treatment from here? Can some form of healing occur even though the sesamoids stay non-unioned, or is the goal treatment that the sesamoids must be united again? 
Dr Blake's comment: Some sesamoid fractures do not heal, but the majority do. I am sure that with poor treatment, and mis-diagnoses, your need for surgery goes way up. This is why you emailed in the first place. How can we do inter-galactic (you could be an alien LOL) or at least inter-national consulting? 
4.     What would you advise me to do from here? Should I continue wearing a stiff-soled shoe, even though the orthopedist told me not to? Should I be wearing another shoe than the one I have now? Can physical therapy help me, and if so, how?
Dr Blake's comment: This will take some Q & A. The first thing you need to do is develop a program that you maintain 0-2 pain level? Are you there with your present situation?
5.     What should I do about my right foot? The pain is not as bad as in the left foot, but I definitely feel it. Is MRI indicated? If I indeed have a stress fracture in that foot too, how can both of my feet heal?
Dr Blake's comment: It is okay to get at least an x-ray on that side, and make sure you are designing dancer's padding for both sides, and some arch support for both sides, and ice pack both sides for 10 minutes twice a day. For the left, if there is bone edema, you should do contrast bathes each evening. 
6.     I really want to avoid surgery if I can, but: Am I a candidate for surgery, and if so, what kind of surgery would that be?
Dr Blake's comment: In my practice, it takes at least one or even two more MRIs to get a feel that surgery is needed. Each MRI is 6 months apart, and there are treatments of contrast bathing, bone health issues, orthotics, dancer's padding, activity modification, foot strengthening, etc. I am happy in separate posts to address each aspect for you. 
7.     I feel that walking even very short distances is too painful, but how much can or should I walk or even do anything at all? It is really difficult for me to know when there is too much pain (i.e. pain level exceeding 3), so can you please elaborate on how to find that “acceptable pain range”? I’m not afraid of the pain, but I’m afraid of making it worse (and beyond repair) if I try to do too much stuff.
Dr Blake's comment: If you can not walk in the 0-2 pain range, you need to use inserts for dancer's padding and arch support, shoes with rocker bottom, removable boots, etc. You can not just go outside the 0-2 range and expect to heal (less predictable). 
8. Finally, my husband and I are considering having more children, but we have postponed it due to my foot problems. From a podiatric point of view, would a pregnancy be ill-advised (e.g. in terms of weight gain, hormonal changes, etc)? If we should continue postponing it, when can I be well enough to manage a pregnancy? 
Dr Blake's comment: Pregnancy will change the demands needed to maintain a 0-2 pain level, but should not be a reason not to have children. Of course, what do guys know about such matters!! I just think you can deal with it during that time. 

I have attached MRI- and x-ray images, in addition to pictures of the last stiff-soled shoe I used together with a sole I put into it in order to relieve the pressure on the sesamoids.


Dr Blake's comment: I could not get the MRI images to open. Please just send 2-3 images of the sesamoids where the bone should be dark from at least 2 angles. I sure hope this helps you some. Rich


Thank you in advance, and I really hope you can help me!

Best wishes,

The Patient then replied to my comments.


Thank you so much for helping me! I cannot express how relieved I am to hear that there is still hope for my sesamoids, even after 8 months of pain. It really made my day, as I’ve been rather pessimistic after the visit at the orthopedist.

Attached are some of the MRI images showing the sesamoids in addition to the x-ray of the right foot. It was a bit difficult to pick images showing bone marrow edema, since I’m not sure about what I’m looking at (no doctor has explained it to me, I’ve only been told that the MRI is showing bone marrow edema).

Addressing your other questions:
-       Dancer’s pad/other orthotics: I’ve been using a dancer’s pad (home-made of felt) for only a a couple of weeks because I discovered your blog only recently. Before that, I used the blue sole into the post-operative shoe I’ve got (images of both attached in the first mail), but this sole only seems to provide some arch support, it doesn’t protect the sesamoid specifically. Right now I’m trying to wear the blue soles combined with a dancers pad in Hoka (One One) shoes because this feels most comfortable. Before I’ve been thinking that the Hoka shoes haven’t got soles stiff enough, but perhaps they are acceptable? Especially since you recommended rocker bottom shoes. I can also mention that I will have somewhat more customized soles made soon.
-       About the pain: As I mentioned, I find it quite difficult to find an acceptable pain range. Still, I think I am in the 0-2 pain range most of the time and have been for about 1,5 month (after getting that post-operative shoe). However, I feel very constrained by how little I can do when staying in the 0-2 range. Luckily, I can still work because I have a sedentary job, but that’s about it. To be honest, I don’t really have a plan for staying in the 0-2 range other than not walking too much on the foot (which is perhaps a bad plan in the long run).
-       I began doing contrast baths about two days ago
-       I will have my vitamin D level checked the next time I have an appointment with my doctor (which is in about a week).

I have also scheduled an appointment with a physical therapist next week, because this was what the orthopedist recommended. But I’m still not sure how that can help me right now, considering that I feel quite immobilized for the time being.

This also leads me to what you said about the different aspects of treatment – e.g. dancer’s padding and orthotics, but also activity modification and foot strengthening. I guess I’ve been doing quite a lot of activity modification for the last months – namely going from being active to being inactive. However, since I get very restless from not being able to do much physical activity, I’ve done a lot of exercises at home (e.g. push-ups on the knees), focusing on not doing anything that puts weight on the left foot. Maybe the physical therapist can help me find even more appropriate alternative exercises?

I’m not entirely sure about what you mean with foot strenghtening, although I can understand why it might be needed. After I began the contrast baths, I’ve tried to wriggle my great toe in a non-painful manner when in the warm water – and I’m quite shocked to see how stiff and difficult to move it has become! Therefore, I would really appreciate more advice on the different aspects of treatment – especially foot strengthening. If you have the time to do that in separate posts, as you mentioned, that would be really great.

Finally, having read about sesamoid fractures in medical journals, it worries me a bit that avascular necrosis is said to be a potential complication of sesamoid fractures. When having a sesamoid fracture for months (and potentially 1-2 years, in my case), do I run a risk of avascular necrosis? Is the risk higher the longer one has a sesamoid fracture?

Again, thank you so much for helping me! I’m looking forward to your next post. If you need other MRI images than the ones I sent, just let me know and I will try to pick some better images.

Best,


Sunday, November 20, 2016

Lisfranc's Injury: Email Advice (a lot we don't know)

Hello, first of June, I injured my foot at work. Xrays were clear. After 3 months of pain and decreased function, I was given a CT -bone scan- 3D imaging. I was sent to an Ortho Surgeon. It showed a major mid foot fracture.
Dr Blake's comment: Tell me what happened. A misstep off a ladder? Or what? If you can send any image that shows the injury that would be helpful. Were you all swollen? Black and blue? This area is called Lisfranc's and it is known for not showing on x-ray. 

 I was immobilized and informed a block fusion will probably be the end result because I had been walking on it for 3 months. Cast removed in October and still in boot cast. 
Dr Blake's comment: The secret is to keep the pain level between 0-2 as you begin to wean out of the boot. Typically, you need crutches, orthotics, taping, gait instruction, etc. You need to work on the inflammation with ice pack twice daily, and contrast bathes each evening. Where is the fracture? Half healed? They need a new CT scan. 

Then yesterday, my x-rays were clear ( no MRI or CT done) I am unable to kneel or get up from kneeling, and unable to walk down stairs. Also, my foot wont roll properly upon walking and has pinpoint pain and occasionally snaps above the 3-4 metatarsal. Its extreme pain when I do these activities. 
Dr Blake's comment: That is okay, these activities can take longer than running to feel right. Forget the stairs, and it sounds like you need to progress to long walking in the boot for now while they get another CT scan, design some orthotics, teach you several ways of taping, and help you get the inflammation under control.

Well, at my appt ortho surgeon yesterday, suddenly surgery is back burned and cortisone shots are being scheduled. In your opinion, is these shots used post fracture with possible damage to tens and ligs?
Dr Blake's comment: Yes, stay away from the shots for your cartilage and ligaments may be trying to heal. I would get alot of more info with CT and MRI if possible. I hope this helps some. The list below is an excerpt from my book entitled "Secrets to Keep Moving: Guide from a Podiatrist". 



    The top 10 conservative treatments for Lisfranc’s sprain/injuries (without complete rupture of the Lisfranc’s Ligament):

  1. Arch supports (typically custom) with as high of a medial arch as possible/comfortable.
  2. MRI for ligament testing. Also make sure patient can do a one sided toe raise. This can be impossible with complete ligament tear.
  3.  Kinesio taping in a circumferential wrap around the entire foot for 2 months longer than you think you need to.
  4. Avoid activities that lift the heel off the ground initially.
  5. Ice Pack 2 times daily for 20 minutes to reduce the inflammation.
  6. Create a pain free environment with crutches, removable boots, and other assistive aids.
  7. Pain over 5 in the area of the Lisfranc’s Joint should be over protected until you are certain it is not a ligament rupture.
  8. Begin metatarsal doming, 2 positional inversion/eversion Therabands, and Single Leg Balancing. Go to YouTube and type drblakeshealingsole foot strengthening exercise playlist. Remember no exercise should hurt.
  9. There is really no stretching for this injury that helps directly. However, massaging the arch to move the swelling that collects there can be very helpful.
  10. Stretching the achilles tendon indirectly takes the tension off the arch. When done, do both gastrocnemius and soleus stretchs but only with the heel firmly on the ground. Go to YouTube and type drblakeshealingsole achilles stretches.

Fractured Tibial Sesamoid: Email Advice

Hi, I'm so pleased to have found your blog and I'm wondering if you might give me some advice. I am looking for a second opinion on treatment for a fractured sesamoid (the one on the outside of my foot).

Here's the story: I trained for a marathon all summer and the week before hit my pinky toe on the leg of the bed and broke it. I stopped running for 2 months to let it heal and then started back up a couple weeks ago. My foot felt good but I did have a little discomfort in the ball of my foot by my big toe and figured maybe I was overcompensating unintentionally and stressing it a little. 

Dr Blake's comment: I have seen patients one or two years later after an injury still limping and not knowing they were doing it. 
Last Monday night I woke in the middle of the night to severe pain in the outside bottom of my foot when I flexed my toe. The next day I was limping a little and everyday the pain got worse and it was harder to walk. On Thursday night the pain was almost unbearable even when lying down. I went to my doctor and they did an x-ray and only saw the fracture in my toe. He prescribed me pain meds and suggested I ice it and rest it. I wasn't satisfied so I made an appt. with a podiatrist and saw him on Wednesday (this is 5 days before answering this on the blog). After telling him my story he thought it could be my slight bunion bothering me, but I insisted the pain was intense when I touched the area though I could walk better by then. He did a physical examination of my sesamoid bones (very painful!!) and looked at the x-ray and said I could have broken it. 

For treatment he said I should use insoles with a hole cut out to reduce pressure and try to rest my foot as much as possible, but he also said if I would have come in the day of or after he would have put me in crutches for 8 weeks. He said I was too far out from the injury for that to help now. 

Dr Blake's comment: I would definitely not agree. You just need to go for 3 months into a removable boot with an accommodation to float the sesamoid and give it some time to heal. You are putting yourself in the Immobilization Phase. This blog will have tons of information for you on this injury.


Sorry it is so blurry, but does show the accommodation


After reading you blog I feel like you advise an aircast or some kind of non-wieght bearing treatment for the first 6-8 weeks. I'm just concerned that I should be doing something more than just using an insole with a cutout circle so this doesn't become a long term issue as I continue to walk on it. And of course I want to run again someday!

What would you suggest? Thanks for listening.


Dr Blake's comment: Here is an excerpt from my book Secrets to Keep Moving. And good luck. You should get an MRI to document that it is broken. Rich

The top 10 initial treatments for sesamoid fractures are:

  1. Exogen bone stimulator for 6 to 9 months
  2. Removable boot for 3 months to create a consistent pain free (0-2 pain level) healing environment.
  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.
  6. Learn how to spica tape for post boot action
  7. When you are not wearing the boot, avoid barefoot.
  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

Saturday, November 19, 2016

Video of Healthy Foods to Eat

As the title of my book goes: Secrets to Keep Moving, you have to start with eating healthy. If you are new to this good healthy diet game, you will have a life changing time ahead of you. Even if you already have a healthy diet, a little reminder is never bad. This video emphasizes some of the best food out there. These include:
  • Fatty Fish
  • Broccoli
  • Low Fat Diary Products
  • Olive Oil
  • Beans (my mom reminds me Dr Oz loves this)
  • Garlic
  • Cherries
  • Ginger
  • Oranges
  • Papayas
  • Carrots


https://youtu.be/dDVpsyFIE4M

Dr Charles Price: Wonderful Lecture on Common Nutrition for Fracture Healing

Have you ever wondered why patients with a right hip replacement need the opposite side done with 2-4 years? Do you know at my age of 62 that my diet most likely will not allow a fracture to heal quickly or at all? Dr Price's wonderful lecture should help us all. If you break a bone, along with the mechanical aspects of treatment (cast, boot, brace, orthotics), and the anti-inflammatory aspects of icing, elevation, compression, and contrast bathing, you should also take your bone health very seriously. Dr Price's helps us know some of the science involved. 


https://youtu.be/LW4nEMk-kcQ

Dr Susan Brown on the Complexity of Bone Healing

http://www.betterbones.com/bonefracture/speedhealing.pdf

And this is a nice chart on what we need.


TEAM: Together Everyone Achieves More


When I learned in college psychology what a great team was, I did not realize in life how difficult it would be to get on a great team. What does this have to do with my photo, well the Golden State Warriors are a great team. and I am a loyal fan. And I wanted some of you to be jealous!!LOL
What defines a great team, the Together Everyone Achieves More mantra, is the willingness of everyone to sacrifice for that team. Yes, from Iggy being willing to come off the bench, to Curry getting less shots, to Green not worrying about his points. The sacrifice one or two people make initially becomes infectious, and spreads throughout the team.
In my real life as a health care provider, I try to team up with my patients to achieve great results. Some want to be part of that team, others just want an opinion or quick fix. Members of my team not only include the patient, but the trainer, coach, physical therapist, consulting docs, etc. I am honored to be on some pretty good teams in this regard. 
I am frustrated some with how the patient must do this alone many times. Providers give an opinion, and nothing more. If the patient selects that provider, and something goes wrong, there is no Plan B, C, or D. The patient must fend for themselves. 
So, even though I have little impact on other docs, I hope those reading this can get into a team atmosphere for their injury. Everyone wins, but you as the patient must do what you are told if it makes sense. I had a patient on Wednesday this week who is getting better, and I know I gave her too much to do, but several of the treatment aspects she is not doing at all. So, the treatment will be stalled, or just go very very slowly. Typically if I need someone to stretch 5 times a day, it is for a reason, and once a day does not do it. Look at your programs, at what you are doing, and see if you can be a better team player. At least get the pompoms!!

Bone Stimulators for Fracture Healing: Common Questions

Hi Dr. Blake,

I heard from the rep about the bone stimulator.  He said my part of the cost would be $500.  I think you said that, but I thought that was what they charged the insurance company.  So, I’m a little sticker shocked.

I called him back to find out what kind it was, so I could do a little research to see if they really work.  He got kind of defensive, and warned me not to buy a used one online.  He is a salesperson, not a caregiver.  He said it is an ultrasound device made by Exogen.

My googling revealed that there are not great studies, but some people got good results.  The devices are for one person to use and then toss.  They are programmed to die after a given number of uses.  The wholesale cost is $1500, they ask $4000, and my insurance company pays $2500.  There are certain things about our medical system that I find disturbing, and this is one of them.

That said, I trust you and I am grateful for your care.  If you recommend it, I’ll go for it. My PT said I should ask you what % bone healing I currently have.

Since the rep gave me the idea, I looked up the Exogen on Craigslist, and they go for $60 - $250 (used).  Is this an option?

Thanks

This patient has fractures in the first metatarsal and first cuneiform bones with a major amount of bone demineralization from resting the area in removable boots. Most of his pain may be coming from some arthritis in the first metatarsal cuneiform joint, and not from a healing fracture! Too difficult to tell right now. 

Dr Blake's response: 

     Thanks for doing some research on bone stim. The bone stim is a 9 month experiment. You are healing, but still have more pain then I would like. People do stop healing, or the pain can be from the arthritis and nothing to do with the bone fx. It is all educated guesses. I think the chance of the stimulator helping  you is 20%, but if we don't do it, it could come back to bite us. And, if it does work, we won't know really if it was the bone stim! Such is life, but I would still have you pay the money for the stim, then an elaborate holiday gift to your favorite podiatrist!!LOL. Rich