Sesamoid Fractures: Email Advice

Dear Dr Blake, 

I have had broken sesamoid bones in both feet for over a year! I've had a bone stimulator since December (4 months) and the pain comes and goes. I am trying not to have surgery but I have just had it at this point. I've had heel spurs and they treat me as if I am avn (avascular necrosis). I have been to 2 different doctors at this point and I just don't know what to do.

Dr Blake's comment:

     Thank you so very much for your email. I have had several patients in your situation who have opted to try to avoid surgery. Classic orthopedic logic would have you have the sesamoids removed and move on with your life. And, no one would blame you for that. Surgery on the feet is difficult with many decisions to make (for example, one foot or both feet at the same time with surgery, will you have permanent disability post op, how much physical therapy will your insurance allow, etc??) Personally, I try to avoid surgery on these important bones, but it is hard for you if you do not have a partner in healthcare to team up with you in this process. Typically, you need to continue twice daily using your bone stimulator, eat healthy with Calcium and Vit D supplements if necessary, get a baseline MRI and CT scans if possible. The CT scans are better at deciding on AVN (dead bone) or not. Ice twice daily and every other day do a full contrast bath for deep flushing. Get foot inserts and shoes that make your walk comfortable, pain level 0-2 max, which will allow you to do much needed protected weight bearing. Without good weight bearing daily, even in a removable boot, the joints freeze up, the ligaments can tight, the muscles weak, and the bones demineralize. Every day that passes without flareup means your sesamoids are getting healthier. The fact that the pain comes and goes is a good sign. Email with other aspects of your history. I hope this helps some. Rich

I have tried to email back on your blog, but it is not working? I have now been to a 3^rd doctor and he had me just take a CAT scan. My question is if I do have AVN, how will the bone stimulator still help me? Also I do have orthotics, but I have flat shoes from the podiatrist, what do you feel is better to wear? This all started by running 3-5 miles a day on the concrete. I ran literally almost every single day. I have very arched feet I guess, or so I have been told. I at this point feel my feet will never be the same.  I appreciate your time very much, thank you.

Dr Blake's response:

If you want to send me the CD of the CT I would be happy to look at it. Bone Stimulators are perfect for AVNs that have not fragmented. If the CT Scan shows the bone in multiple pieces, then surgery is your best choice. Orthotics in some sort of shoe that seems to protect the sesamoid area would always be the best bet. With flat soles shoes, if you can not wear orthotics in them or some sort of accommodation, there is too much pressure on the sesamoid area. Rich

Plantar Fasciitis Video Playlist

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Dr Roy Corbin, father, friend, and podiatrist extraordinaire just passed away

I need to honor my dear friend Dr Roy Corbin who passed away last night (4-10-14) in Bangor, Maine. Roy was a great podiatrist, but would want you to know how much he loved his two boys more than anything else in the universe. Roy was kind, soft spoken, easy to laugh, generous, and always taking care of you. I met Roy when we both served on the Board of the American Academy of Podiatric Sports Medicine together 1987 to 1993. He loved his University of Maine that he showed me so proudly. A New Yorker by birth, but a true native of Maine by desire. He was a gifted dedicated Podiatrist that would do anything for his patients and staff. His staff was his family. He spoke of them (when I used to make his orthotics) with love. Few people have touched me as much as Roy. He was gentle and humble, and quietly went along his business with great passion. Thank you Roy, I am only one of thousands who did not get a chance to tell you enough what you meant to us. My great sorrow for your family and friends. You will be sorely missed. We all loved you. Dr Rich Blake

Arch Taping with Kinesiotape (KT)

You need to watch how to apply kt tape. They give great tips! I'm a massage therapy student and we use kinesiology tape, but I've been using it a few years. Have tried it the way you've shown and the way kt tells you how and kt tapes tips seem to work better. Also this tape is not waterproof, it is like fabric it absorbs water but dries fairly fast; however the adhesive cannot be removed with just water (needs oil based product to remove). Not trying to be a snob just trying to help. Love the one strip taping technique, saves a little money and makes a great and simple support!

Dr Blake's reply:

No snobbery noted and thank you. I will try to find the KT tape video. Thank you so very much. It will help so many people. Rich Blake

Here is my original video that sparked this comment.



Here is one version of KT for arch pain. I sure hope it helps some of you guys. 

Tuesday's Patient Question of the Week: How to deal with Bunion Surgery Complications?

Dear Dr. Blake,

I imagine you must get many of these emails.  I stumbled upon your blog by reference of an enthusiastic patient of yours.  Coincidentally, I live in the Bay Area.

I have a series of complications which has led from flare-up to constant chronic pain and immobility.  I have eliminated all exercise except swimming and lifting weights.  Walking and standing are hard; I used to be very active.  I have a slight build so my weight is not an issue.  I am just wondering how to proceed, how to find an expert, whether surgery is appropriate (I am scared of this as I have had 6 in all but I do not want this current condition to be my new norm).  My summary, if I may indulge you, is as follows:

Image of a bunion patient whose previous surgery had failed and the toe collapses towards the 2nd toe and off the big toe joint causing arthritic pain. 

After no luck with orthotics for painful bunions, in March 2002, I had my left foot worked on ( a bunionectomy).  In June, 2002, I had my right foot bunionectomy-same doctor- an orthopedic surgeon.  One outcome of that surgery is that the big toe bone has become shortened and my first metatarsal head is misaligned with the second and third.

The bunions came back five years later; in August 2007 and December 2007, I had my left then right foot done respectively, by different surgeons.   The surgery, shaving rather than cutting the bones, was much easier to recover from.

Dr Blake's comment: Bunion surgeries vary immensely, and typically the longer the post op course, and the more bone work done, the longer the bunion correction will hold. There are also so many factors like severity of pronation, width of foot, general ligamentous looseness, and bone structure to name a few that can help determine the longevity of these surgeries. Surgeons have their preference, but in discussing with them, see if you can determine why they choose a particular type for you. Definitely get a second opinion and do not mention what the first surgeon plans on doing. See if they are on the same page or miles apart. 

In 2011, I developed bone spurs and was diagnosed with hallus ridigus which amounted to a 40% loss of mobility in my foot due to arthritis so I had surgery on the bone spurs (by my big toe).  My left foot was worked on in August 2011. 

Dr Blake's comment: Surgery on any joint weakens the joint leading to gradual onset of potential problems in the future. This is typically very slow process, so it is unusual that arthritis set in after your second surgery. I am assuming that there was no mention of arthritis in the first and second surgeries. Something does not make sense, but you have what you have right now. Bone spur surgery on the big toe joint, AKA joint cleanout, AKA joint arthroplasty, AKA cheilectomy is definitely a very skilled procedure and needs some luck in going to work. I highly recommend this surgery over implant or fusion for Hallux Limitus since it works well normally (at least for many years). 

 The doctor also removed screws in my feet from the previous surgery and he shaved a “bunionette” off the right side of my left foot, so in August I had two parts of my foot worked on.  I was healing okay until I tripped about six weeks later and broke my middle toe on that same foot.  This set me back immensely.

My second bone spur surgery was in March, 2012 on my right foot.I was healing well, in general, and was running by fall of 2012 just a little.  I did lots of yoga until I injured my left foot in January 2013.  I took time off and by March, got a cortisone shot in my left foot.  I had had one in 2012 at some point for swelling.  I began physical therapy in March/April of 2013 and had been seeing my PT currently once every two weeks. I'm now upping it to once a week.

Current problems since June:  Metatarsalgia, sesamoiditis, arthritis, poor flexion in the ankle due to tight calves (and on my feet all day due to teaching), thin padding on the bottom of the feet and stressed metatarsal heads, minor pain from Taylor's bunion on right foot.  Left foot, overall, is much worse than right.  I tried a chiropractor this summer with no positive outcome.  I sometimes get acupuncture and massage.  I'm also wearing a metatarsal pad, mainly on my left foot (Jill's Gels) and am now trying toe stretchers.  I have rocker-bottom shoes and have been unsuccessful with new orthotics.

Another orthopod is recommending surgery to align the metatarsal heads.  I have a second opinion upcoming with another orthopod.  I am also considering a visit to the Mayo Foot/Ankle Clinic in Arizona.  I will do anything to  get my mobility back.  If you have any advice as to who to see or how to proceed, I would be so grateful.  I am very lost on this journey.

Best Regards and thank you for what you do.

Sara (name changed)

Dr Blake's response:

     Hey Sara, thank you so very much for your email. I will try to help you. Your journey is not unusual unfortunately for many patients that have bunions and probably some underlying arthritis. But, it has been alot of surgery for you. I would be cautious about more surgery at this point, since something must be amiss. Someone has to explain how you got to this point in so much pain. And then explain what can be done for it. Since your pain is so widespread across your left foot, you should be in a removable boot for 3 months to place that foot in the Immobilization Phase of Rehab. During that 3 months, get MRIs (if affordable) on both feet to see what is wrong. Have someone into orthotics figure out how to off weight sore areas. Daily ice both feet 3 times daily for 10-15 minutes to cool them down, and take NSAIDs. Try to analyze the % of pain from each area. When you present to the medical profession with these issues, it is overwhelming. Focus on one problem (the most problematic) if possible and get that well, then move on to lesser problems. See a pain specialist if you are having trouble with day to day activities, or if the present docs can not help with the pain. Pain causes more pain, and you can get into vicious cycles. Check the information on this blog on handling nerve pain. I hope this helps somewhat. Rich