CRPS following foot injury: Email Advice

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


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

App for Chronic Pain Sufferers: Curable

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




https://www.painnewsnetwork.org/stories/2018/6/25/wear-tear-care-the-curable-app

Chronic Pain and Possible Surgery: Email Advice

Dr. Blake,

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

The report on both MRI's say:

1) Mild scarring of the anterior talofibular and calcaneofibular ligaments, remote inversion injury.

2) Dengeneration of the deltoid ligament complex deep fibers

3) No acute osseous injury or arthritic changes of the ankle

4) Small tibiotalar joint effusion.
Dr. Blake's comment: This is typical for anyone over 40 years old, and really not meaningful. It is the normal wear and tear of an ankle, injury or just life related and the march of time.

Upon seeing the new Podiatrist, he reviewed this with me. He said this was due to a childhood sprain and meaningless. (I don't recall ever spraining my ankles in adulthood or childhood)

Dr. Blake's comment: It does not have to be an acute injury. If you are over 40, it can just be wear and tear on the ligaments with some breakdown or repair with scarring. These problems can lead to some ankle instability and pain. You treat with braces, taping, or muscle strengthening, depends on the stage of Rehabilitation you are. 

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

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

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

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

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

Thank you for your time.

Take Care,

Fifth Metatarsal Fracture Post Sprain: Email Advice

Hi Dr. Blake,

My mom, a long time supporter of yours, sent me your blog after I learned last week that I fractured my 5th metatarsal on my left foot. For a quick background, I am a 30 y/o female. I have not exercised regularly since October thanks to grad school applications, but otherwise lead an active lifestyle; until recently, public transport and walking were major components of my daily life.

I fractured my foot one month ago...walking down the staircase. It was that simple. I've sprained my right ankle many times and the situation felt very similar to previous falls but my actual foot took the brunt of the fall, and my ankle remained unscathed. After ~48 hours of being unable to bear weight, I visited two NPs, one at a general immediate care facility and one at ortho-specific immediate care. Both took xrays, and both confirmed no fracture. Ortho NP put me in a walking boot and said I should be fine in 2 weeks. I did have some pain initially bearing weight in the boot but it was an otherwise overnight transformation: my swelling went down immediately and I was able to bear weight w/o the boot (though limping) pain free the next morning. I thought I would back to normal in no time!
Dr. Blake's comment: This is always a dilemma since it can take up to a month for a small stress fracture to show up on x-ray. It will be hot on a bone scan and MRI in a few days, but these are more expensive tests and not used in the screening process.

Three weeks went by, however, and my healing had plateaued. I made it into a podiatrist one week ago who ordered new xrays (weight bearing this time) and immediately found the fracture. His diagnosis was "5th metatarsal base fracture" but I never recall him mentioning "Jones." He told me that I'll need to be in boot 6-8 more weeks and my injury was a bit tricky because the specific area receives little bloody supply.
Dr. Blake's comment: This is the area of a Jones fracture just in front (towards the toes) of where the 4th and 5th metatarsals join together.


Told me to stay off my feet as much as possible and make some lifestyle modifications (note to work from home as much as I need) but never mentioned complete non-weight bearing nor suggested anything like crutches. Wasn't super interested in the prospect of surgery and said the next step will be a bone simulator if it comes to that. Follow up apt in 3 weeks.
Dr. Blake's comment: Many insurance companies require 3 months of treatment for fractures before they approve a bone stimulator, however the doctor should start the process on Jones fractures, sesamoid fractures, and navicular fractures, since they are the slowest to heal and surgery potential is high.
 

Of course, I googled 5th metatarsal fractures and immediately Jones fractures met his description of my injury, but the standard treatment (NWB for at least 6 weeks) was a different than his. I am now working from home 2-3 days a week, Ubering to work (as opposed to metro), getting groceries delivered, etc. Prior to my diagnosis, I was much less conservative and was actually walking up to as much as 2 miles some days of the week (it's so hard not to do this living in a city) in my boot.
Dr. Blake's comment: There is a protocol for Jones of non weight bearing for sure. You can have someone non weight bearing in a boot by floating the fifth metatarsal with adhesive felt padding. Therefore they can walk, and still off load the bone. The secret is creating 0-2 pain level for healing, and what it requires to accomplish that. If it is a Jones fracture, we definitely off weight for a while, but we want the weight bearing for bone mineralization and swelling reduction. It is a fine line. Maybe he does not think it is unstable, which is how it sounds, if it was only picked up on the 3rd set of xrays. Maybe there is no gap, just changes in the bone reflecting healing. If you can take a photo, and email mail of the xray images, I can let you know what I think.

You aren't able to view my xrays or examine me, so I know your insights are limited. Still, I am wondering if my doc's treatment plan sounds potentially reasonable assuming a Jones' fracture or if I need to second guess him and go down a far more conservative route and eliminate all weight bearing. I've read a few academic journals and the consensus about treatments seem to be...all over the place. For what it's worth, my symptoms are probably improving, at least in terms of swelling and bruising, and certainly not deteriorating. Some days I am a little more tender and swollen than others, but compression socks and a session with frozen vegetables always do the trick and get me back to my "baseline." I'm not taking any pain meds (especially not NSAIDs) nor am I a smoker. Taking calcium, D3, and magnesium supplements and trying to up my calorie intake. I also assume that, in terms of WB, it can't hurt that I weigh less than 110 lbs. 

Any insight you have would be so appreciated.

Best,
Dr. Blake's comment: Send me the images, have the doctor float the bone in the boot, use crutches with the boot if you can not achieve 0-2 pain level. Start doing contrast bathing twice daily to flush out pain from the swelling. This is a must since you want to make decisions on the fracture pain, not on the pain from swelling. Push for the bone stimulator process to begin, even if you do not need it in the end.



Since I had been on vacation, she tried to contact me again:

Hi again Dr. Blake,

I got a hold of my medical chart online so I have a few more pieces of info. My diagnosis on the chart is "L 5th metatarsal styloid process fracture" and he also noted that it is nondisplaced. From my understanding (which could be completely flawed), styloid fractures fall in the same group as zone1/tuberosity/avulsion/pseudo Jones fractures, aka the GOOD type of fracture to have. I'm wondering why, then, he said I was dealing a stubborn fracture that receives little blood flow and there is a chance I could have delayed or nonunion--these seem like hallmark Jones characteristics.

Thanks,
Dr. Blake's comment: Yes, that is good news and the styloid process fractures tend to heal just fine. Still, take a photo and send. You can ask the office to take a photo of each of the xrays and email to you. Maybe they will do it.


Then the patient responded with good news!!

Thanks so much for your reply on your blog! I decided to just call my podiatrist and I have good news: I do NOT have a Jones fracture. It didn't occur at the very base of the 5th metatarsal, but it was not distal enough to be a Jones fracture; therefore it is still in zone 1 and he confirmed that it's still receiving adequate blood supply. He told me that if it had been a Jones fracture, he would have put me in a hard cast and would not have let me leave his office without crutches. 

Here's what's interesting: he said it was not an avulsion fracture, either (or a pseudo Jones). I've been hard pressed to find any online sources that do not classify styloid process fractures (my official diagnosis) as avulsion fractures, but I suppose that was not the mechanism of action that caused the injury. I'll ask him to clarify this on Friday during my follow up. I am also curious to hear more about his mentioning of poor blood supply. I suppose he meant that feet in general receive less blood supply compared to the rest of the body. His treatment plan (8-12 weeks in walking boot) also seems to be more aggressive than those of other avulsion fractures (or anything in zone 1), but I read in one of your earlier posts that you think these types of fractures tend to be undertreated; perhaps his philosophy aligns with yours.

In any event, I hit the 6 week mark last week, and since then, my foot has started to feel much better. Best way I can describe it is that it feels more like a regular foot that can do its job again. I feel like I could walk more normally on it when my cast is off (he gave me permission to do a little walking around my apartment w/o the cast so long as I concentrated my weight in my heal) but I'll wait until my appointment before I get clearance. To the naked untrained eye, it does not look like my foot is injured. However, if you look closely, I have a bump where the fracture is. I am not sure if that is the callus and/or residual inflammation.  

The only thing bothering me now is my walking boot, whose front straps occasionally press against the area of the fracture and cause tenderness (just depends on the day). He said that had he come to me first, he would have put me a different type of walking cast with air pockets, so maybe that one would be a bit better. Also, the muscle atrophy, which is all the way up my thigh, is pretty bad, and my pants are baggier. I'm starting to do some NWB floor exercises, and will probably ask for a physical therapy order.

I will ask for both sets of x-rays next visit and will be sure to share. As for the old ones, I took them sitting down on a large x-ray table. My x-rays at his office were taken in a completely different manner (standing up, bearing weight) which he explained was key. I gave him my old x-rays but they were taken at awkward angles and were incompatible with his computer.

My own images are attached. Don't be alarmed by the fact that my right ankle is bigger than left--that's old scar tissue from a previous injury. 

If you end up sharing this on your blog, feel feel to abbreviate for brevity :)

Thanks again,

Sesamoid Pain with Fragmentation: Email advice

Hi Dr. Blake,

I came across your website when researching sesamoids. Apologies in advanced for the long email but i hope you can read through it and provide me some guidance.

I have been dealing with my sesamoiditis since May of 2018. It started with improper Cycling equipment (tight shoes, wrong cleat positions and wedges/shims). The pain came and i removed the wedges, got proper shoes and proper cleat fit and continued cycling for the most part pain free just inflammation of the toe and pain during walking or bending of the toe.

After sometime i went to the first of 2 doctors and we did the dancers pad and a small sandal/boot for 2 weeks with dancers pad without cycling, i then convinced him i wanted to bike because of the carbon shoe in cycling and high arch support insole, cycling would not be an issue. He agreed and i was back on the bike training as usual, -  i do it competitively so its around 2 hours a day almost every day and longer on weekends (4-5 hours). Also some gym workouts usually focusing on leg strength. It didn't get any better and we tried an injection of cortisone on the foot and continued as is, cycling almost daily and using the dancers pads.
Dr. Blake's comment: There must be a better way to train so you can have more recovery time for your body, even when you are not injured. Without recovery time in sports, you always run the risk of tissue fatigue and resulting injury. It is a fine line. Do you have a cycling coach? What is his philosophy?

I got an x-ray and an MRI and all it showed at the time was inflammation no fractures. After some time i decided to see a new doctor recommended by a friend who put me on Hokas and  an Atrex orthotic for my work shoes (office job). He also got me a more serious walking boot (one you would get for fractures) up to the knee and i got completely off the bike for about a month due to an accident, during this time i only wore this boot and did some aggressive Epson salt baths and daily icing.
Dr. Blake's comment: Hopefully this is the start of your healing!!

Going back to the doctor, we did an Xray and it showed again the sesamoid bones were good no fractures but there was still swelling, so he took me off the boot gave me a lot of confidence that cycling was not an issue and to continue cycling at full strength and use orthotics and good shoes when I was not on the bike so i did. The inflammation never went away but i was pain free on the bike so i continued cycling and wearing the shoes as advised and attempted some nighttime walks on the Hokas.
Dr. Blake's comment: For those who do not know Hokas, they have a roll in the forefoot so you do not have to bend the metatarsals. There are various types of Hokas, and some have the roll in a good place for an injury, but some do not. Some experimentation with various Hokas may be needed. Typically, I would also allow you to cycle if you are keeping the pain between 0-2, and really work hard on protecting the sesamoid area and controlling the inflammation. Were you pain free, or at least 0-2 in the boot, that is the goal?

A couple of weeks ago after a day of walking at Universal Studios park my feet were in some serious pain, i also started cycling in dirt/off road about a month ago which caused more stress and i would feel it more on the bottom of the foot. 

Due to the higher than normal pain during universal i went back to the doctor where the xray showed now a fragmentation of the inner sesamoid. And this is where i am at now.
Dr. Blake's comment: Wow, that is very disappointing. I am surprised nothing showed on previous xrays. When you said the MRI did not show sesamoid fracture, but did show swelling, was any of that swelling in the sesamoid (a possible sign of a stress fracture)?

At this point i am dealing with some neck/lower back issues and i am off the bike again while i figure out that situation. So again i can get off cycling and let the foot relax heal a bit but its not looking good for me. I am now considering surgery due to this new development of the fracture. The doctor described is no blood flow in the area causing it to fragment. From your experience since my main focus is cycling and on the bike i don't really have pain should i continue trying conservative treatments while returning to bike competitively.
Dr. Blake's comment: I have never found that if you are damaging something you have no pain, unless you have masked the pain with pain killers or cortisone shots. Definitely stay away from cortisone injections. Next time you see the doc ask them to show you the MRI images that show that most swelling so you can email me. Also take a photo of every x-ray image, first to now, and email so I can appreciate the progression. My gut level is cycle, boot rest of the time in creating 0-2 pain level, Exogen bone stimulator for 9 months, contrast bathing every night for circulation, and acupuncture for circulation if you can get it. Also get Vitamin D levels, and if you are low, bone density.
What is your experience mainly around cycling and this injury, if i were a runner things would be different but how much damage am i causing by cycling on it and at this point with the fracture of the bone and the lack of blood flow causing it to fragment am i doing or have i already done permanent damage down there? I know without imaging it will be hard for you to assist me but any insight you can provide will be helpful.

Thank you so much
Dr. Blake's comment: You are welcome. All was okay in your story until the fragmentation. If insurance is okay, get a CT scan of your foot which shows the bone so much better. Again, cycling should be fine if you can keep the pain level between 0-2, and you do not have any increase in pain afterwards. Hope this helps some.


And then the patient responded with an Important Decision!!


Thank you so much for taking the time to write back to me and for your recommendation. This injury is frustrating to say the least, it's beaten me and I have decided on surgery to remove the lateral sesamoid. Surgery is scheduled for March, hope to have a successful surgery and recovery.


And my response!!


Good luck! If you want to write in 6 months about your surgery experience, it will help many patients! Remember after one sesamoid is removed, you always have to protect the other one. Rich

Sometimes Heel Pain is Not Plantar Fasciitis: A Case of Wrong Self Diagnosis

Rich, 

Thank you again for lifting my spirits today. Honestly can’t express in words how much the appointment meant to me. 

AND - I forgot to tell you!  You fixed my mother-in-law’s foot!  Basically she was having heel pain that she had labeled plantar fasciitis. I hadn’t seen her in a while, and wasn’t sure if that was the right dx. So, I sent her one of your plantar fasciitis summary pages from the blog (it has a video of you doing a heel pain exam/eval), and this is what I got back a few days ago:

https://youtu.be/plbBvPASXwM

“Thank you so much for sending me that video.  I watched it and decided I didn't have the typical symptoms of plantar fasciitis.  I pushed at the places he pointed out and the pain was wrong.  I saw my physician today.  She decided that it was not plantar fasciitis but a thickening of the skin on the heel.  In one spot because of a wart and in the other spot probably some foreign object.  She scraped and scraped and miracle of miracles----no more pain.  I can't believe it!  I have been off my feet for almost two months eschewing hiking and walking.  I gained more weight.  I feel like a fool not to have researched it myself or at least made an appointment much earlier.“

Amazing!  

Morton's Neuroma: Email Advice

Dear Dr. Blake,

I am very excited to have found your blog. I am super impressed with all the information you offer. I've been suffering from a Morton's neuroma on my left foot for the past 7 months per the diagnosis of my Podiatrist upon physical examination. In the past 7 months I have tried multiple treatments. I had completed 3 months of physical therapy prior to seeing my podiatrist where I had been getting treated for a form of tendonitis. I have tried four treatments of acupuncture, which only worked for a day or two. I wore a shoe my orthopedic  doctor gave me for six weeks, his diagnosis being Metatarsalgia. For the past 8 weeks I have wore a pad my Podiatrist gave me and an insert I had  purchased upon her recommendation. Also, I have been wearing shoes with a wide toe box  since mid-September. I ice daily and use essential oils such as lavender, peppermint and rosemary every night. I stopped going to the gym which was very difficult as I enjoy martial arts which involves a lot of pivoting ( down and in) and weight bearing on my left foot. Although  the super intense pain  has improved somewhat, still alot of pain is present. I will be completing an MRI on Monday, January 21st. Hopefully, I will be receiving my first cortisone shot on January 28th. Do you administer alcohol injections for Morton's neuromas with or without guided ultrasound? I'm just trying to think of my next step if the cortisone shot or shots do not help me. Thank you in advance for your time. Is truly appreciated.


Dr. Blake's comment: I was trained way before ultrasound and have had no trouble finding the nerve without. But, some doctors prefer it, so it is a personal call with the one responsible for your health. Today is the 21st of January so send me the report and any observations made and I will attach to this same post as a continuation. Morton's neuroma pain is in essence nerve pain. It is the L5 nerve coming off your low back. I mention this because evaluation should always consider if the pain is only local to the foot, or coming from higher up, or both (called Double Crush Syndrome). Also the treatment should always be mechanical, anti-inflammatory, and neurological. The metatarsal pads, shoes, wide toe boxes, orthotic devices are all mechanical changes. This blog is full of things that sometimes help any individual. Cortisone shots are anti-inflammatory along with the icing. Nerve treatments which help are acupuncture, TENS, topicals like Neuro-Eze or Neuro-One, compounding prescription meds, neural flossing, alcohol shots, oral nerve meds, and possibly low back treatments. Make sure you are always addressing your problem using these 3 treatment areas. Good luck. Rich

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I have been reading your book and blog.  Thank you so much for the information!!!  I have been to 3 doctors in the last month (2 orthopedic surgeons and 1 podiatrist).  I have xrays from September 2018 and an MRI from December 2018.  2 of the 3 doctors believe that I have a fractured fibular sesamoid and their recommendation is to have it removed.  The third doctor, an orthopedic surgeon, says that the xrays look like the sesamoid is multipartite and that the MRI just shows inflammation in the bone and surrounding tissue.  I am waiting for approval from insurance to get a CT Fusion.  I am a healthy, active 47 year old female and had some blood work to check Vitamin D, magnesium, calcium, etc.  Everything was normal. 
Dr. Blake's comment: The CT scan is a better test for fracture vs bipartite (2 or more pieces congenital) so I am glad you are having it. The bipartite sesamoids I think are weaker bones since they are not completely united, so they can more easily fracture along the junction. The junction of these multi-piece sesamoids are fibrosis (syndesmosis) like ligaments, cartilaginous or partial bone bridges. The cartilage (synchondrosis) or boney (synostosis) can fracture and should be treated like a fracture. So, at the end of the day, if the MRI is positive for bone inflammation, treating the sesamoid as a stress fracture is the safest way to go. 

I am not sure when I first noticed some pain in the ball of my foot.  I believe it was around November 2017.  I am a pilates instructor and I do recall coming home one evening and noticed the ball of my foot felt sore.  I went from teaching bare foot to wearing my normal minimal shoes (LEMS) and things settled down.   Over time, I would occasionally have a flare up (mild inflammation after doing loaded exercises/stretches in dorsiflexion of the big toe), but it would quickly go away.
Dr. Blake's comment: This is definitely the symptoms of sesamoiditis where you are bruising the bone and not enough passes to let it totally heal. It is not the history of something who has broken the bone.


In June 2018, my husband and I started swing dancing.  I don’t remember it bothering me too much until August when we started a style called “Charleston” swing dance.  It is a lot of bouncing on the ball of the foot and turning on the ball of the foot.  Our fourth week into it, last week of August 2018, I was having a flare up and remember thinking I shouldn’t go to the last class.  I went anyway and after that evening, it was uncomfortable to walk for a few days.  The week after that we were in Santa Barbara and I had a hard time walking there as well.  When I got home, I got xrays because I was concerned.


The radiology report indicated “1. Mild osteophytes first MTPJ. 2. Multipartite or fractured lateral hallux sesamoid.”  By the time I got the xray, it wasn’t really bothering me anymore, so I had a hard time believing that it was fractured.  I changed to Altra running shoes and started building up to wearing correct toes and using a metatarsal pad.  Things calmed down and in December, I did some jumpboard work on the reformer (jumping while lying down with springs attached to the carriage) and I had started pushing it a bit with stretching the big toe/metatarsal area.  I had another mild flare up (no more than a 2 or 3 pain) and my acupuncturist insisted that I go to a specialist to get it checked.

Dr. Blake's comment: The xrays indicate some wear and tear in the big toe joint. The MRI typically tells us how bad. But your symptoms are not bad, mainly very short lived, and not consistent with a stress fracture or full fracture. As of now, I would side with the bone bruise people. You will have to figure out if Dr. Jill's 1/8 th inch or 1/4 inch gel dancer's pads can help when you are barefoot (usually needs some tape to hold in place).  If you have a prominent ball of the foot, you may need 1/4 inch. Has anyone commented on your foot structure? Do you have a high arched foot which definitely will put more pressure on the big toe joint/sesamoid?

In late December, my foot felt ok when I went to the first doctor.  There was no pain upon palpation and ROM was normal.  He suggested surgery based on looking at my xrays.  When I said no, he suggested a carbon fiber insert and sesamoid pad be added to my shoe and wrote a diagnosis of sesamoiditis.  I asked for an MRI and he prescribed it.  I got it a couple of days later (December 21, 2018).  The radiology report is as follows:

“TECHNIQUE: Sagittal T1, sagittal and coronal fat-suppressed T2, axial T1 and T2 fat-suppressed, coronal PD, T2, T2 fat-suppressed.

COMPARISON: Radiographs dated 9/13/2018.

FINDINGS: Linear decreased signal intensity extends across the midportion of the fibular sesamoid on axial image 15. There is diffuse bone marrow edema within the sesamoid. There is also linear decreased signal intensity extending across the medial margin of the tibial sesamoid on axial image 15 and there is mild edema in the tibial sesamoid. 3 mm focus of chondromalacia with underlying subchondral edema at the plantar margin of the first metatarsal head. No effusion at the first MTP joint.

Flexor tendons and extensor tendons are normal in signal intensity and caliber. Musculature is normal in appearance.
Dr. Blake's comment: The linear decreased signal intensity is typically normal from the ligaments and tendons wrapping around the sesamoid and distorting the image. The chondromalacia part is wear and tear on the first metatarsal or mild arthritis. This may be the only reason you hurt and means that the joint has been beat up for a long time, even much before you started having symptoms. The symptoms you are having is of mechanical bruising and then inflammation that collects. Work real hard at protecting with dancer's padding and orthotics and changes in some routines that really pick on the big toe joints (like some Pilates routines with the weight on your arch and not the ball of the foot). These restrictions hopefully will be temporary, but I am talking about the next year.

IMPRESSION:

1. The fibular sesamoid does not appear fragmented as it did on the radiographs dated 9/13/2018. There appears to be a transversely oriented band of decreased signal intensity with surrounding bone marrow edema at the fibular

sesamoid worrisome for a nondisplaced fracture. There is also mild edema in the tibial sesamoid compatible with sesamoid stress reaction or sesamoiditis. 2. Chondromalacia with subchondral edema at the plantar articular surface of the first metatarsal head.”
Dr. Blake's comment: When there is chondromalacia, basically softening of the underlying cartilage, I think it is imperative to try to reverse with an Exogen bone stimulator for 9 months, and it will also help if you do have a stress fracture.

Approximately 3 weeks ago, I started wearing the carbon fiber insert and sesamoid pad.  I also started following the advice in your book/blog and have been doing contrast baths 2x/day (4 hot/1 cold for 20 minutes), icing 1-2x per day, and spica taping.  I am also getting acupuncture 1x/week.  Before all of this, my pain levels were typically 0-2.  I feel like where I messed up is that I didn’t keep that 0-2 pain level long enough.  The icing and contrast baths feel great.  The carbon fiber insert made things feel worse.
Dr. Blake's comment: Yes, the carbon fiber inserts are the opposite of off weighting that dancer's padding does.


I tried the Hoka shoes with the sesamoid pad and metatarsal pad, but could feel sensation in the sesamoid when I walk.
Dr. Blake's comment: Hoka shoes are wonderful, but each shoe has a slightly different place for the rocker. If the rocker is in the wrong place, it may put too much weight on the sesamoid. Try on 3 different types of Hoka and see if there is any difference to how you feel before giving up on this shoe.


Now, after 3 weeks of this, my foot feels worse.  Now things are stiff and I start to feel more discomfort later in the day.  At night when I wake up, I feel a warm sensation in my foot and mild discomfort (around a 2 level pain).  It does not hurt at all to press on the sesamoids. Dr. Blake's comment: You need to use a removable boot with the same off weighting inside to rest the foot. Hopefully it will only be for a few weeks, but we have to put you in the Immobilization Phase to calm things back to 0-2 pain levels. I know you can get there.

The second doctor does not believe that it is fractured based on his review of the imaging, his exam, and my story.  Again, palpation did not cause any pain and ROM was normal.  He said to “let pain be my guide”, to use the sesamoid pad/metatarsal pad, and stiff shoes, icing, contrast baths, and to remember that I need to be patient for a long time (he said 3-6 months and then slowly start to introduce activities that have previously irritated it).
Dr. Blake's comment: He sounds smart and wise.

Today I went to a third doctor and he said that it is broken and that it needs to be removed because lack of blood flow to bone, fracture, etc.  He did his exam and again no pain.  He didn’t have me immobilize my foot.  He said to wait until we get the CT done. 

I am feeling very frustrated and scared.  If you have the time, would you be willing to review the imaging.
Dr. Blake's comment: I would be happy to. Please mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109.


 For now, I have the following questions:

1. My pain has always felt more like inflammation (hot and a dull ache) and the pain (other than the one week after swing dancing) has generally never been above a 2.  The week after swing dancing was about a 3 or 4 and calmed down within a the week.  Is it possible to have a fracture and have minimal to no pain? Dr. Blake's comment: Very unlikely
2. Should I be immobilizing in a boot (until I get the CT and results) just in case even though my pain levels stay in the 0-2 range with my current setup? Dr. Blake's comment: You should have in your possession a removable boot to put on and minimize the days of your flare ups.
3. Any other advice/input based on my email? Dr. Blake's comment: Just to continue to learn about what is it about your foot that caused this. Is there any biomechanical explanation that inserts can help. My wife takes Pilates twice a week for 15 years and plenty of times the injured teachers have to change what they are doing for awhile to let something heal. Good luck. Rich

Thank you so much for reviewing!!! 

Plantar Fasciitis:General Principles of Treatment

 Plantar Fasciitis is one of the most common problems facing podiatrists. 

Several Golden Rules of Foot are common.

Golden Rule of Foot: Plantar Fasciitis begins gradually over weeks and months before effecting athletic performance. It does not come on suddenly.

Golden Rule of Foot: Even bad cases of plantar fasciitis have no swelling. Heel swelling typically is a sign of something worse like an actual tear in the fascia or a stress fracture in the heel bone. 

This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery for this since there are so many options for treatment. 30 years ago 1 in 10 patients required surgery, now surgery is less than 1%. The treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week there should be improvement once active treatment begins. If improvement plateaus, a change in treatment options should be made, but not the basic conservative treatment protocol. Analyzing what is working and what is not working should be part of that process.

The patient and health care provider deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanics (one being the transference of pressure from the painful areas to non-painful areas). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some of the more stubborn cases of plantar fasciitis need all of the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, cortisone shots if a bursitis under the heel bone is found, and many other options.

In resistant cases, 3 months in a removable cast can help calm down the inflammation. I presently would not recommend this unless I got an MRI. The MRI typically will show you why a case of stubborn plantar fasciitis is not improving. The moral of the story with plantar fasciitis is to never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical changes. Good luck. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, and plantar fascial tears all head the list in the differential diagnosis. I hope this helps and gives you encouragement. Dr Rich Blake

Here is a video on the stretches to do and not do when you have plantar fasciitis.



When I talk about mechanical changes that effect plantar fasciitis, there are many Golden Rules of Foot and come into play.

Golden Rule of Foot: When designing an orthotic device, or using an OTC arch support, the patient must feel that the weight is being transferred into the arch (even borderline obnoxiously) and the heel is feeling protected. The patient should never feel that the majority of the pressure is in the heel. 



Golden Rule of Foot: The most stress on the plantar fascia and achilles is when the heel just comes off the ground. Treatment of plantar fasciitis therefore typically involves staying in elevated shoes, orthotic devices, clogs, and remaining flat footed in some exercises like the elliptical, and sometimes not getting off the seat in cycling. 

Golden Rule of Foot: A negative heel stretch (where the heel drops below the ball of the foot) can irritate the plantar fascia with all of the body weight suspended at its attachment. This is in stark contrast with the same position of the Downward Dog in Yoga which never seems to bother the plantar fascia as the body weight well in front of the plantar fascial attachment into the heel.

Golden Rule of Foot: Plantar Fasciitis patients hurt less walking on their heels than flat footed. If you think you have plantar fasciitis, try to walk barefoot normally, on the balls of your feet, and then on your heels. If you hurt the most on your heels, you probably do not have primary plantar fasciitis, and more bursitis, plantar fascial tears, or heel stress fractures. All three of these are diagnosed by MRI. 

The video below discusses heel evaluation.



My initial visit for plantar fasciitis typically includes:

1. Teaching the patient Support the Foot taping (www.supportthefoot.com) and giving them a few extra strips. Every podiatrist and PT will have some version of taping. 
2. Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
3. Plantar fascial and achilles stretches (see video above) 3-5 times a day. Typically, gastroc and soleus stretches 1-2 times per day, and plantar fascial stretch 5 times. Nothing should hurt when you stretch however.
4. Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical. 
5. Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc, or getting an MRI if a tear or stress fracture is suspected. 

I sure hope this helps. Rich

Free Ebook to the first One Hundred who Email

22 sent, 10 received, 78 to go!!! (updated 1-12-19) If you ordered, you should have received. One patient found it in the Spam folder. I have more to send, so please ask. I want to help!!

     I would love to offer a free ebook (500 plus pages) to the first one hundred who send their email me at drblakeshealingsole@gmail.com as a form of celebration to start the new year. I am so happy I have been able to help some of you, and I so appreciate the warm support of this book. The book can also be a gift from you to a loved one who you think will benefit. Please be patient with my mailing through Amazon website, as I will be handling the requests over the next month. As you read the book, please free feel to email me comments on your experiences, or questions that come up, as I want this to spur conservation, and I want us all to be healthier. Thank you and Happy New Year. Rich



Sesamoid Pain and Trying to Avoid Surgery: Email Advice

Dear Dr. Blake, 

I work in the US but my home is Brazil. 

I just came back from vacation in Brazil with disturbing news: the podiatrist there told me I need to get surgery on my right foot, as my two sesamoids in my right foot are compromised. One of them is split in the middle and the other one is worse, fragmented (see below). 

After looking for doctors over the Internet I came across your name and website. I have also noticed that you are able to treat patients with less invasive treatments, avoiding surgery. The prospect of a surgery is really difficult for me for different reasons: (i) my family does not reside in the US, so it would be difficult to recover and work at the same time; (ii) my work involves a lot of travelling; (iii) any invasive approach scares me.

If you believe there are any chances of curing my condition without surgery, I would like to talk to you. Could you please look at the CT scan results below? I would truly be grateful for any inputs and/or ideas you might have. 

After researching online I found that a vitamin D level exam and a bone density level exam should ideally have been carried. Neither of them were requested to me. 

Below please find the CT scan results (translated by myself from Portuguese). The exam was undertaken at Albert Einstein Hospital (considered the best hospital in the southern hemisphere)  

 
A study carried out using the fast spin-echo technique, in heavy multiplanar cuts in T1 and T2, pre and post-paramagnetic contrast, showed:

·         Attitude in hallux valgus.

·         Lateral sesamoid with fragmented appearance, with irregularities and bone sclerosis.

·         Medial hallux sesamoid with bipartite morphology with bone marrow edema suggestive of overload.

·         Other bone structures with normal spinal morphology and sign.

·         Minimal metatarsophalangeal joint effusion of the hallux.

·         Lack of significant joint effusion in the other joints.

·         Tendons without significant changes.

·         Fluid distention of the intermetatarsal bursae between the 2nd and 3rd spaces.

·         Obliteration of the plantar adipose cushion underlying the heads of the first, second and fifth metatarsals, indicating load points.

Thank you so much for your help and support. I truly appreciate it! 

Best regards,

Dr. Blake's comment: Thank you so very much for writing. As I write this, I know it must be late on the East Coast of the US. It probably does not matter at this point how you did this, but you have injured the sesamoids. Okay. Some doctors take them out after 3 months of treatment, and others like myself drag their feet delaying and hopefully preventing surgery. It is a whole spectrum. You really have to treat the injury as if you just got it. Depending on your insurance, an exogen bone stimulator distributed through Bioventus works well most of the time. This is a 9 month assignment to get the bone strong. Contrast bathes 4-7 nights a week will act like a deep flush to the tissue. Order Dr. Jill's dancer's pads to protect the sesamoids yourself, along with learning how to do spica taping, and cluffy wedges. Make sure your winter shoes are stiff to help immobilize the tissue as many hours a day as possible as you are trying to create a 0-2 pain level environment for healing. See my buddy Dr. Steve Pribut (link below) in DC for local hands on. Keep me in the loop. Good luck. Rich

I know there are some good articles supporting shockwave therapy as a noninvasive treatment for sesamoid problems, but it may be just too costly.

https://www.vitals.com/podiatrists/1zwb65/stephen-pribut

Sesamoid Fracture: Email Advice

Dr. Blake,

Happy Holidays! Thank you so much for all the time you’ve put into this blog! I’ve read through many posts regarding sesamoid injuries, and there's more info here than anywhere else.
My 15 year old daughter fractured her sesamoid and her podiatrist hasn't known what to do, so I was wondering if you could help her out.

This is what she said:
In october, I felt a pop in my foot during cross country practice, and ended up in a lot of pain. I ran one final 5k a few days after, and went to homecoming in heels that night. Horrible idea. My foot was bruised and my pain level was about an 8 (10 being the most painful).

I went to the podiatrist, who said I just had sesamoiditis and could run again in a week. I took an entire month off just to be safe, and when I went back to the podiatrist because I was still in pain, he said it turns out that I had a fracture. I wasn't given a boot to immobilize it.

A few weeks later I felt another painful pop in my foot, went back to the podiatrist, asked for a boot, and here I am. I’ve been wearing the boot to immobilize my foot for the past 2 weeks and my pain level is at a 0, but it is very visibly swollen. I've been icing 3x a day and am going to start contrast baths as you recommended. I bought calcium supplements and am taking vitamins as well.
Dr. Blake's comment: So you are now starting about 3 months of immobilization with 10 weeks to go. Now until Feb 15th, the boot should be your friend in creating a consistent 0-2 pain level. The icing twice a day, and the contrast baths each evening are important. Gentle massaging the area with your palms 2-3 minutes three times a day with arnica, mineral ice, hand lotion, just to desensitize the area. Make sure you bike a lot of leg strength. Unfortunately 30 minutes of running is equivalent to 2 hours of biking outdoors, but probably one hour on a stationary bike.
     This part is the easy part. Soon, the podiatrist must make a good pair of custom orthotics to protect the sesamoid. These should be ready for you at 8 weeks into the immobilization, the earliest time to start transitioning into orthotics and athletic shoes. It is imperative you keep the pain level to 0-2 during this whole process. Sometimes, as you wean from the boot, you need to wear Hoka One One shoes or Bike Shoes with embedded cleats.
     Remember also to have your Vitamin D level tested as this is a frequent cause of stress fractures. If the normal range is 30-80, I want my athletes around 55. Also, a good healthy diet is crucial to get the building blocks for fracture healing.

I am just wondering if there's anything i'm missing. Also, how would I get an exogen bone stimulator? I assume I would need a prescription. I can also send you my MRI if you would like to see it. The radiologist confirmed that I have a fracture.

Dr. Blake's comment: Yes, you can send it to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. The podiatrist or your pediatrician can start the Rx process for the bone stim from Bioventus called Exogen. Hope all this helps. Rich
Here's the MRI report:

Technique: Routine MRI images of the right foot
Findings:
A marker has been placed beneath the medial forefoot and great toe to indicate the site of clinical concern. There is confluent marrow edema within the medial sesamoid bone indicating a nondisplaced vertical fracture or stress fracture and edema in the underlying soft tissues. The lateral sesamoid bone of the the great toe appears normal. No metatarsal stress fracture or suspicious lesion is identified. Normal signal is present within the muscles. No Morton's neuroma or ganglion cyst is evident. The flexor and extensor tendons are intact. There is no plantar plate tear.
Conclusion:
1. Nondisplaced fracture or stress fracture of the medial sesamoid bone of the great toe and edema in the plantar soft tissues.


Again, thank you so much for the blog!

Happy Holidays!!

The patient's mom sent me the MRIs for review. Here is my response:

 I had a chance to look at the MRIs. So, clearly there is a nondisplaced stable fracture of the medial (also called tibial) sesamoid which needs some protection going forward. You can protect it in different ways as you blend the Immobilization phase into the Return to Activity. The protection can come from Dr. Jill's dancer's pads, cluffy wedges, spica taping, custom orthotics, and removable boots. The boot is to prevent her from stirring it up and some of the patients only use while walking great distances (probably 4 hours a day to rest the tissue and trying to decide which 4 hours are the most meaningful. With return to sports, you have to see if sometimes she can wear an orthotic, say in her conditioning, and sometimes Dr. Jill's padding with cluffy wedges with or without spica taping. If patients feel good, they first stop taping. I would experiment as you place her on a 6 week return to full activity program. Each week she adds more and more stressful ball of the foot activities until she is at full speed and full activity at 6 weeks. It is the push off of most concern, so speak to the coach and see how this can be arranged.

     The difference between the 2 MRIs are minimal, which is to be expected. After the first MRI, I wait 6 months to repeat and go solely on the patients feel, and if they have to limp at all (a big no no!) It is usually a mistake to remove the sesamoid protection for the next several years. Part of me saying that is because I do not know her foot mechanics (some patients have 3-4 reasons that their sesamoids can be stressed) and part of that because I know sesamoid padding will not inhibit her ability to perform at the highest level.

     Contrast bathing remains the best home treatment to flush out the sesamoid of swelling that can cut off the circulation. Try to average 3-4 nights per week, and simple ice pack after workouts. Hope all this helps. Continue to listen to the pain, even if she is competing again. Rich

Chronic Plantar Plate Injury: Email Advice

Hi Dr. Blake,

I got your email from your blog and I am hoping you can spare a minute to offer me some advice. I have read online that you have been very helpful to people suffering from this condition and I would greatly appreciate your advice.  I am a 31 year old teacher who lives in Canada and I have been suffering from pain around the second mtp joint in my right foot for about 10 years, ever since a single traumatic misstep while running barefoot. At the time of my original injury I was put in an air boot and a bone scan rules out stress fracture or necrosis etc. But the culprit for the continued pain was not found.
Dr. Blake's comment: At least bone was ruled out, could be soft tissue ligaments or nerve pain.
 Other the next 10 years the pain persisted most notably in and above the second mtp joint, while underneath the joint remained tender, it wasn’t as sore as the joint itself. I had about 5 cortisone injections into the area over the years with little improvement.
Dr. Blake's comment: Unless the doctor is injecting Morton's neuroma pain, have them limit it to short acting cortisone. Long acting cortisone can possibly hurt the ligaments.
 Finally, a podiatrist diagnosed the injury as plantar plate dysfunction about 2 years ago (ultrasound confirmed this (fluid under joint) though a recent mri showed no abnormalities of the plantar plate) and I was gaining some relief through taping and custom orthotics (though the pain in the second mtp joint was never fully alleviated, the pain under my foot had improved a lot after wearing insoles for the last year). I was also using diclo cream. My toe slightly migrated away from the big toe but it is not very noticeable.
Dr. Blake's comment: The MRI and ultrasound should have got the same results. Interesting, what was the Lachman test like?

Recently, Because I was still having pain, and a joint drawer test (same as the Lachman test) indicates my second mtp was not stable, I was offered a second mtp osteotomy by an orthopedist surgeon but he thought I should try prp beforehand, just to see if the joint would respond. The doctor who administered the prp injected it into the top of my second mtp and also directly into the plantar plate, this is where my current dismay began.
Dr. Blake's comment: The surgeon must have been going to due something else to repair the ligament.

Since the prp injection 3 weeks ago, my plantar plate feels as sore as it did when I was initially injured 10 years ago. Experiencing this renewed pain on the bottom of my foot makes me realize how much it had improved with taping and orthotics over the last year and how all of my pain was actually coming from the joint itself (and notably felt on the top of the foot rather than the bottom). Now I am worried that the trauma of the prp needle and the injection of the fluid may have made my injury on the bottom of my foot worse. It has been 3 weeks and the area can still not bare weight .

Can you offer any advice regarding my current predicament ? Do you think prp could cause more damage ? Should I expect the prp to take longer to heal due to the  rigid nature of the plantar plate ligament and it’s lack of blood supply? . Should I treat the site as a new rupture (and try and immobilize for 6-8 weeks) or follow prp post-procedure guidelines and keep using the area as normal in a stiff soles shoe? Also, if/when this pain on the bottom of my foot is alleviated, should I consider the second mtp osteotomy to address the original issue of second mtp joint pain ?

Thank you very much for your time - I hope to hear from you!
Dr. Blake's comment: The PRP from the bottom was hitting all the nerves in the area and is very painful in general. Yes, if you can not bear wear, go into a removable boot for the next month or so, and ice now. I know you are not supposed to ice with PRP as it is trying to make a new injury and mount an immune response. Get this calmed down, and you hopefully will have found this helpful to you. In one month, if you are not much better, I would seek an MRI to see what the tissue looks like. Too early to talk about surgery. I hope this helps some. Rich


The patient then responded:

Thank you for getting back to me so quickly! I will begin icing my plantar plate and get into a boot for the next month. Do you think the pain is likely causes by inflammation or upset nerves rather than additional tears in the ligament due to the needle? Dr. Blake's comment: Yes.

I realize a needle point is a fairly small implement so I’m scratching my head as to how much pain I am in 3 weeks later. I spoke to my brother-in-law who is a physiatrist and he says it is rather unlikely a needle could do any real damage.... I have a follow up with the orthopaedic surgeon in two days so I’m wondering if you have any advice on things to mention to or ask him ? Dr. Blake's comment: Yes, talk to him about another MRI in a few months, PT to calm the joint down, ask him if he does just ligament repair of the joint (not osteotomy). I guess if the second metatarsal is very long, an osteotomy should be in the discussion, but many surgeons just sew the ligament  where it is torn and place the patient on Budin Splints for a year to hold the toe from moving. You can also not fix the tear, but sew the joint on top tight for the least rehabilitation. I had a podiatry surgeon tell me they did that on some professional basketball players to get them back faster. You can talk about a arthrogram where they inject dye into the joint to see if there still is a tear. If the dye leaks from the joint, the tear is still present. Ask his or her advice on calming the nerves down quicker. Should you be using topicals like Neuro Eze or Lidoderm patches. They have compounding medications for nerves by RX. Does he/she believe it is nerves or inflammation or both. What about a 6-8 day course of oral cortisone to calm it down?

 As I know that it will be too early to make a decision on a procedure due to the post-prp pain but I figure I’ll keep the appointment so he can at least take a look at the area and I can bring him up to speed. Also, I purchased a portable TENS machine and I am wondering if you think this would be suitable to use on the area ? Dr. Blake's comment: If you know how to use it. You may need a PT to instruct you the best way, especially how low to start so you do not irritate things more.

Thanks again for your help! It seems like it is nearly impossible to find information on this topic online so I truly appreciate your time and effort .

Best,