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Saturday, February 8, 2020

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

I came across your blog and since sesamoid injuries are so tricky, I thought I would reach out to you. It looks like you have been in the field for awhile and hopefully, you can give me the best course of action.

I was diagnosed with a medial sesamoid fracture on my right foot 7 months ago, about two months after running 1/2 marathon. I’ve been a runner all my life and have done a number of races. Im aware not to overdue things and had a running schedule designed by my PT to do a mix of runs and cross training so I was surprised to have sustained a stress fracture. I’m 39years old. 

I went into a boot for 5 weeks, and then slowly weaned out of the boot for a few more weeks. I was still having pain with walking, so  got another scan that showed delayed union, some healing but not fully healed. I went back into the boot for 3-4 weeks, and then has been walking in sneakers with orthotics. I was doing great until 2 weeks ago when the pain came back. An MRI showed edema, persistent fracture, a cystic intraosseus cyst  (which was on prior imaging as well), chondral loss, and partial ligamental tear of MCL. Full results below.

I saw a surgeon who has had good results with sesamoidectomies although I’ve heard that surgery could lead to further complications. I also have hallux valgus on my right greater than my left foot. Does surgery sound reasonable at this stage? If so, what should that entail, removal of the sesamoid only? Or would you recommend more immobilization? Drain the cyst? Steroid injections? I am desperate and would really appreciate any thoughts you have. I can send photos of MRI if that is helpful. I also had CT done back in Nov. Thank you so, so much.

1. Undisplaced fracture of the medial sesamoid bone with persistent
diffuse bone marrow oedema appears similar to the previous study.
Fracture line is still visible on MRI but the degree of fracture
healing would be best assessed by CT if clinically indicated.
2. Cystic intraosseous lesion within the medial first metatarsal head
likely represents an intraosseous ganglion cyst related to the
proximal medial collateral ligament origin. This has decreased in
size due to bony ingrowth proximally but there is persistent
moderate bone marrow oedema within the medial head of the first
metatarsal similar to the previous study.
3. Persistent increased T2 signal and thickening of the proximal
fibres of the medial collateral ligament likely due to a partial
4. Unchanged full-thickness chondral loss first metatarsal-medial
sesamoid articulation.
5. Full-thickness chondral loss medial aspect of the first metatarsal
head at the first MTP joint.

Dr. Blake's comment:  thanks for reaching out. You had quite the injury involving at least 3 structures. If you can send me the images, I can get a better read than the report alone or some random images. My mailing address is Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. There is never a charge for this service, just part of running this blog. What I would recommend if this was me to rest the toe bend this next year. I know that sound alot, and of course you have to evaluate things monthly. You have alot to try to heal, and I think you should give yourself the time to try to heal. You abnormally loaded the big toe joint at some point injuring the medial sesamoid, first metatarsal head, and medial collateral ligament. If surgery was to be done, they would remove the medial sesamoid, perform microfracture surgery on the first met head, and sew up the medial collateral ligament. You would be off your foot for months on crutches and scooters, and this would be bad for the ligament should needs motion. And you would still need the shoe, orthotic, dancer's pads, spica taping, etc to protect the joint for a year post surgery. 
     So, my suggestion, start using Exogen 5000 bone stimulator twice daily, get into some bike shoes with the embedded cleats or other stiff soled shoes, learn to spica tape, and design dancer's padding. Massage with oils or gels the area twice daily to de-sensitize. Do icing for 5 minutes twice daily and contrast bathing for deep bone flush each evening. All of this work is within the blog at various parts. The spica taping is actually very helpful when the ligaments are involved. 
     As the year goes on, you may be on the fast side of healing, and the restriction of shoes can be lessened. Make sure you have good bone health by getting a Vitamin D blood test, and a bone density scan. There has been many surprises on these. Hope this helps. Rich

Friday, February 7, 2020

Hallux Varus: Splinting Possibility

Dear Dr. Blake,

I came across an article from Podiatry today regarding non surgical solutions for patients who had a failed hallux valgus surgery in the past, this is my situation - I am a 55 year old woman - that is active and busy at work.  I live in NYC, otherwise I would make an appointment to see you. I am suffering from this condition  after my bunions surgery went wrong. I am really looking for some kind of orthotics to help me with basic things as walking - since my big toe is always going to the outside - is there something else than taping it together that you can recommend?

Please I really appreciate your help and will be really thankful with any ideas/tips about it.

Thank you!

Dr. Blake's comment: For walking, get 1/4 inch adhesive felt from Alimed and place it along the medial side of the big toe to gently push towards the 2nd toe.

A local brace shop should be able to use multiform, also from Alimed, to fashion a sleeping brace. Depending on how tight your tissues are, they can slowly move the first and 2nd toes closer. A sheet is cut out about 8 inches long and 4 inches wide. My little video here shows the way they would wrap the multiform. A sock will have to be worn with it.

You also need to strengthen the right muscles. So, metatarsal doming must be done with the toes taped together along with single leg balancing. Hope this helps. Rich
PS you can always go to PT and have them make sure you are do the right exercises, but also increase the mobility of the lateral and medial capsules of the joint to allow it to be pulled back. 

Saturday, January 25, 2020

Midfoot Arthritis: Email Advice

My 88 year old mother was recently diagnosed with midfoot arthritis in both 
feet.  The orthopedic surgeon said she was not a good candidate for 
surgery. Besides ice and heat therapy, would taping, orthodics or rock 
shoes help reduce the pain?

Dr. Blake's comment: you are asking all the right questions. Yes, for midfoot arthritis most patients, even much younger then your mom do well with activity modifications to keep the pain at 0-2, orthotic devices to support the tissue, occasional taping for more support with increase stressful activities, and rocker shoes like New Balance 928. Weight can be a big issue at her age, so she made have to get by with lighter shoes but good stable orthotic devices. Way to be the running of son of the year!! Good luck my friend. Rich
Make sure she ices the top of the foot for 10 minutes twice a day until it begins to feel a lot better.

The following is an excerpt from a previous post:

3. Midfoot Arthritis/Arthralgias

     So many of my patients develop midfoot arthritis as they age. Golden Rule of Foot: Pain and swelling in the middle of your foot if you are over 60 or have had previous injuries to this area is midfoot arthritis until ruled out by MRI, CT Scan, or bone scan. Like any arthritis situation, it has both a conservative treatment side and a surgical fusion side. I have only had to recommend fusions to a handful of all my patients over the years.  

    The top 10 treatments for midfoot arthritis/arthralgias:

1. Ice Pack for 10 minutes twice daily to the top of the foot
2. Contrast Bath each evening home for 20 minutes total as a deep flush
3. NSAIDs only when needed to sleep or when the pain over 4 consistently
4. Learn a daily form of tape from or Kinesiotape circumferential arch wrap. Daily until symptoms improve, then as needed, like with long hikes.
5. Removable boot, hiking boot, bike and hike shoe, or post op shoe  when need to limit motion more.
6. Custom made functional foot orthotic devices with high arch support as a cast initially full time, and then just with activities more stressful.
7. Daily Foot and Ankle Strengthening forever. Go to Youtube and type drblakeshealingsole foot and ankle strengthening playlist.
8. Activity Modifications to create pain free environment, and build core strength and get cardio.
9. Physical Therapy or Acupuncture to reduce inflammation.
10. Occasional cortisone shots to reduce inflammation (the least as possible).

Monday, January 13, 2020

Monday, January 6, 2020

When the Pain is Superficial, Think Deep

When the Pain is Superficial, Think Deep

In medical school and residency training we are taught that superficial pain in a muscle/tendon/ligament may be secondary to deeper, more serious problems. The superficial structures may be sore for many reasons, including deep swelling that has surfaced (like after an ankle sprain), or muscle soreness from strain as they compensate to protect the deeper tissues. Hundreds of examples abound, including the diagnosis of Achilles tendinitis, only to later find out that there was a chip fracture in the back of the ankle requiring surgery. The diagnosis of Achilles tendinitis may have been followed with months of physical therapy, casts, orthotics, braces, and medications. A sports medicine practitioner works hard when superficial structures are identified as the cause of pain to at least consider deeper evaluation if the symptoms do not respond. This is where the patient can greatly help their own cause by asking questions about possible deeper structures involved.

Golden Rule of Foot: When the treatment is not progressing, think about deeper structures as the cause of the pain.

Another common scenario (of the reverse) happens all the time, and I will use Judy's story to describe it. In this case, Judy actually developed a superficial tendinitis on the outside of her knee called Ilio-Tibial Band Syndrome. The smart clinician looked deeper with an MRI and found arthritis in the knee. The decision was made, without proof, and not following KISS principles, that the arthritis must be causing the tendinitis, and that the knee required a knee replacement. The patient wisely chose the KISS principle and treated the tendinitis first (on advice from other physicians) to see if the pain would go away, and it did. I have had three major injuries in my life, and all three had a surgical option. Good people recommended good surgeries for me. But I chose to try rehabilitation first, and so far, I am fully functional and have avoided surgery. We owe it to ourselves to try rehabilitation first. In Judy's case, her pain was superficial, and surgery on her deeper arthritis was unnecessary.

The photo above shows the complexity of the knee joint and how soreness in one area may be caused by deeper problems, but perhaps not. So, deep injuries can be mistreated when the care is only directed at the secondary, more superficial soreness. And, superficial injuries with concurrent deeper, non-painful abnormalities can be mistreated when the doctor, therapist, and/or patient mistakenly blames the pain on the wrong structure.

Golden Rule of Foot: Allow time for rehabilitation to succeed or fail, so that you can possibly avoid unnecessary surgery or have the surgery you need with a firm conviction. 

The above has been an excerpt from my book: Secrets to Keep Moving

Retrocalcaneal Bursitis can be Improved with Shock Wave Therapy

Saturday, January 4, 2020

Painful Feet with Heat Exposure: Opinions Needed!!!

Hello, this is Dr. Blake and I need your help. The following are photos from a patient with extreme foot pain at the areas of redness primarily I believe when she is exposed to heat. This can be normal walking more than a mile, or triggered by hot tubs and hot weather. One suggestion is erythromelalgia from a dermatologist friend. She will be getting a biopsy soon. 

Hi Dr. Blake, 
Attached are the photos we talked about today. 

To summarize the issue: 
~ These episodes seem to be triggered by heat (hot weather, hot tubs) and/or moderate amounts of walking/standing - most of these photos were taken while I was on vacation. 
~ 10/10 pain, which can be described as achy, hot, burning, stabbing, and like a "bruised sunburn" on the soles of the feet
~ Extremely painful to walk or put weight on affected feet/foot (resulting in limping and hobbling) 
~ Feet feel warm to the touch most of the time, but especially during these episodes 
~ Usually feels better after a day or two of rest and air conditioning or moving to a cooler climate, but if air conditioning or moving to a cooler climate is impossible, it can stay like this for days/weeks

Please keep me updated on any interesting possible diagnoses! 

Oh, and here's the foot pain forum that I told you about today (full of other people who have something similar going on):

Thanks for your help,

Here is a response from one of my patients/friends:

I know you can research anything but here's one:

Dr. Steve Pribut wonderful post:

Wednesday, January 1, 2020

My Shoes Must be Short: The Tips of my Toes Hurt

This is a patient who complained about pain at the tip of her second toe. She had bought one pair of half size bigger shoes, which even felt too big, yet her second toe remained sore. She brought in 3 pairs of shoes at her visit and, after removing the shoe insert, I could definitely tell her that the 2nd toe had plenty of room. She had a hammertoe on the 2nd toe and a large callus at the end of the second toe. I felt the 2nd toe was not painful for running into the end of the shoe, but gripping the floor. I fit her for a small right toe crest to lift the tip of the toes off the ground and she felt instantaneously better.

Tuesday, December 31, 2019

Calcaneal Stress Fracture: Last Patient of 2019

     My last official patient of 2019 was the 95 year old mother of a wonderful patient of mine. He brought her into the treatment room in a wheelchair with acute one day pain in her right heel. There was no incident of trauma. She has been struggling with pain in her left knee for a long time and perhaps is favoring her right foot. I went right to an MRI which they were able to get within the hour at our hospital fearing broken bone with this age and history until proven otherwise. Xrays can take weeks show subtle signs of a stress fracture, but the MRI images below (both T1 and T2) dramatically show the stress fracture non-displaced. I will keep her off her foot for the next month and start an Exogen bone stimulator if I can get approval for. Interestingly, her son fractured his heel bone doing ball room dancing 10 years ago in the same place. Genetic do give us weak spots. You can tell by the MRIs that the stress fracture was not due to weight bearing compression forces, but to the pull of the achilles tendon similar to many cases of Severs. Look how strong the achilles looks and the overall bone density seen on T2 throughout the area looks fine and not demineralized like in disuse atrophy. 

On a side note: This is my 2000th Blog Post since my start of blogging in March 2010! No one cares but me, but that will not stop me from raising a glass of champagne or bubbly tonight! Happy New Years. 

Sunday, December 29, 2019

The Role of Second Opinions

Second Opinions

After over 40 years practicing the science and art of podiatry, I fully appreciate the role of second opinions for treatment of injuries. I am fortunate to work at an institution (Saint Francis Memorial Hospital in San Francisco) where second opinions are almost second nature. But, this is not the norm. I believe getting a second opinion for orthopedic/podiatric surgery is really a no-brainer, unless you are stuck in an emergency situation. But for most cases of elective foot and ankle surgery or difficult to treat non-surgical pain syndromes, getting at least two opinions can be helpful. It is ideal that a non-surgeon (podiatrist, therapist, primary care physician, sports medicine physician) helps you decipher the recommendations of two surgeons before you go under the knife. This is the ideal world, but hopefully, you can get this type of ideal treatment. For most patients and doctors, that is way too much work to do. But, you cannot go back and reverse a surgery. Even when the two surgical opinions are identical, you will develop a feel for which surgeon you want to do the surgery. Find out how their surgical approaches are different, and what differences there are in the postoperative treatment. Second opinions for complicated non-surgical problems are less commonly done. But, the approaches of physicians can be so different that they should be done when improvement is stymied. If a doctor/therapist ever implies that you will not get better because of your age, definitely get another opinion. Age can be a factor, but normally only a small part of a slow healing process. Take an active role in your own care; at least you and your family will have fewer surprises in the process. And, never tell one surgeon what the other one says. You want an independent opinion. I tell most of my patients that really we are getting a second opinion on what should be done next. I am surprised when orthopedists and podiatrists that I am using for second opinions recommend another direction in the conservative treatment that I had not thought about. These opinions are worth their weight in gold. 

Golden Rule of Foot: It is best to have a non-surgeon say, “You really need elective foot or ankle surgery,” since surgeons tend to be so selective on who they cut on.

This is an excerpt from my book: Secrets to Keep Moving

Flare Up Pain Post Examination: Nerve Related?

Dr. Blake,

I hope you're well. I have spent some time reading through you blog as well as various reviews. It seems you are a leading expert in sessamoid injuries. My story is I'm a 35 year old competitive runner. I never had sessamoid issues until recently. I went for a hike/run in the mountains and had the indicative stiff toe shortly thereafter. I was able to get around well and saw improvement through the week. I tested my foot 7 days later and had mild soreness after the run. Although I was able to walk without issue I was unable to run and wanted to rule out any sort of fracture. I went to see a sports medicine doctor three days after the light run. Before the doctor came in a resident physician on rotation examined me twisting my foot in various positions as well as pushing my big toe up to the highest point my body would allow. The pain was not immediately debilitating but on the way home from the hospital I began to feel pain on the top of my first metatarsal as well as pain in the ball of my foot for the first time. The pain got progressively worse over the next 24 hours.
Dr. Blake's comment: Sorry for that. I have inadvertently done that to a few patients over the years. Residents do not have experience yet, actually you are their experience. I was a resident once so I feel for you. It normally lasts a day or so. 

 I wasn't able to sleep that night and was unable to walk or weight bear the next day. It's been three weeks since that examination and I still cannot bear weight. I knew something was wrong and had an MRI done two days after my initial visit to the doctor. The MRI results did not show a sesamoid fracture just some metatarsal edema and "sesamoiditis". I have been taking prescription anti-inflammatory meds and limping around in a post op shoe putting my weight on the outside of the heal (i find the cam walker to be too uncomfortable). I use a scooter around the house. When I do limp in the post op shoe I try to put a ballet pad on my foot to offload some of the pressure from the sesamoid. I live in the Carolinas so literally across the country. Is it possible to schedule a remote consultation with you or do you only see patients in the office? I have been reading the horror stories and like most I have seen no improvement over the past month. I'd also like to have a second opinion since the doctor who initially diagnosed me as not having a fracture was the attending physician when I was injured by the resident.....which makes me question his familiarity with this injury. He recommended a graphite insert which I can't even imagine walking on anytime soon. 
Dr. Blake's comment: So sorry for your problem. I can review the xrays and MRI. You can have them mailed to Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. Look up my friend at the Barry University in Florida Dr. James Losito. He also may have a local recommendation. You need to get back in the removable boot with a cut out for the sesamoid. Some times I need 1/2 inch sesamoid accommodations to protect the sesamoid. Anti-inflammatories slow bone healing so try to change to ice and contrast bathing. With contrast bathing start with 1 minute hot and 1 minute cold for 10 minutes and see if it makes it feel better. I would rather you do that. This is very unusual to hurt like this after an examination, so if you forget about the diagnosis for awhile, the goal has to be weight bearing with 0-2 pain levels. Typically podiatrists are great at that, but if you have to also work with a pain specialist. The 3 sources of your pain are mechanical injury documented by the MRI, inflammation, and nerve hypersensitivity. So many patients with pain like this actually have nerve pain. If you float the sesamoid 1/2 inch off the ground and you still have major pain, then you have some nerve pain. And, nerve pain has to be treated differently than mechanical produced pain or inflammation produced pain. I hope this makes sense. Rich I also love Pat Nunan in one of those Carolinas!!


Saturday, December 28, 2019

Failed Neuroma Surgery: What Next?

Hi Dr. Blake,

I had stump neuroma surgery ( plantar approach) in November 2018.  For the first 6-7 months post surgery I was able to bike without pain, and hike and walk 5-6 miles with slight pain.  When I got to month 8 things started changing.  I could bike without pain, but with walking the pain increased.  I will also say in month 7 and 8 I was diagnosed with uterine cancer and doing some type of exercise was needed for my mental health.  It ended up they got the cancer through surgery and I did not need further treatments.  Yeah! 
Dr. Blake's comment: I am so happy for you!! 

During months 4-7, I did have some physical therapy and continued to check in with my doctor.  At month 8, I went to another doctor for a second opinion and he suggested that I need softer cushioning under my forefront.  I did this and what he prescribed did not work well with my orthotic. 

Fast forward to month 11, and I return to my foot doctor telling him I am in pain almost all the time and that I feel a lump to the right of the scar on the bottom of foot.  I suggest we do an MRI so he orders it.  Now I know it probably should have been done with contrast...  but it wasn’t.  It showed postoperative scarring within the third web space and within sub adjacent plantar subcutaneous fat and adjacent to the fourth flexor tendon related to the neuroma excision.  They also found a small ovoid T2 hyper intense mass along the plantar margin of the second MTP joint consistent with a small ganglion cyst. 3 by 7 by 3mm.
Dr. Blake's comment: Is this where you hurt? They probably need some diagnostic injections with local anesthesia only. Does it feel like the same pain as before? Hyper-sensitive nerves from double crush (like coming from your back) can involve neuromas, but removing the neuromas does not help always. 

Both doctors did not think anything of the cyst.  And they said the best way to break up scar tissue was with steroids.  My doctor would only give me 1 shot because of my history of steroids in that foot.  I am 5 weeks out from that shot, and have noticed no improvement.
Dr. Blake's comment: I am assuming that you never respond to steroids. Are you some one who scars alot? Do they think you kept entrapping the nerve in more scar tissue. That makes sense from the timing of feeling good for awhile which normally happens in scar entrapment but not double crush. These of course are general rules with exceptions. What happened with the first surgery? Same symptom development months after the surgery?

At this point, my doctor has given me my records and said there is nothing more he can do.  Wow... I was not ready for that.  The other doctor I am seeing  is pretty non responsive.   So in one weeks time, I am discharged from a doctor and then learn they found some more cancer cells on my check up.  It’s been quite a week.... but I am strong and I will tackle this!  My CT scan showed it was contained... so I think a few zaps of radiation will kill those nasty demons....
Dr. Blake's comment: You are inspirational to me!! Go Girl!! You got this!! I have had a patient once similar where the pain was double crush and coming from Stage 4 prostate cancer pressing on the L5 nerve roots in his back. The foot pain made the diagnosis since it made us look at his back that did not hurt. 
     What about alcohol shots to de-sensitize the nerves? This is a very successful treatment. I have a recent post on my protocol. 

So now I am back to foot searching for the answer.  Before having stump neuroma surgery, I had done RFA and PRP with some success.  I reached out to them and they said most likely there are some nerves caught up in that scar tissue that are causing me the pain.  At this point, I can’t do PRP because of active cancer.

I am doing some massage and stretching exercises. I have also ordered a new orthotic with metatarsal support.   Can you think of anything else?  Should I get more tests done.... mri with contrast...ultrasound?  No one seems concerned about the cyst... I guess that is ok?  I am just discouraged about the level of care I have received.  I would have never thought I would be worse off post surgery...
Dr. Blake's comment: 

  1. Make sure no feels this is double crush from the uterine cancer or low back issues
  2. Yes, get an MRI with contrasts which is standard of care for this issue
  3. Be considered for alcohol injections (typically one or two series of 5 injections which each injection one week apart). 
  4. Do the typical nerve treatments which I have not heard you mention: Lidoderm patches, TENS home use 2-3 times daily, neuro-eze or neuro-one topical gel massaged in, other ketamine based compounding medicines, and neural flossing.
  5. Find the local PT member of the Neurology Academy. They look at PT from nerve standpoint. You need to be at least on a Sciatic Nerve protocol as you can be tweaking the nerve by sleeping, sitting, standing, lifting all day long.
  6. There are other treatments I have some experience with like Quell for pain control. 
  7. There are tons of oral medications like Lyrica and Gabapentin. These are to drive the nerve sensitivity down, and then maintained with whatever dose achieves that, and then we attempt to wean off.
  8. The goal with all these treatments is to get you fully functional at level 2 pain and hold you there for a year.
  9. New orthotics with perfect metatarsal support is crucial. That task alone can take awhile to do with a good orthotic person who wants to experiment.     

Any advice is welcome.

Injured or Treating Someone Injured: Fight Inertia and Get Going

Golden Rule of Foot: When injured in one sport, find another one or two to keep healthy. 

     These Golden Rules which are all over this blog are rules never to be broken. However, this article speaks of how we become so addicted to one method of exercise, that when we can not do that exercise, we also have the inability to do something else. Inertia wins (and in this case it is psychological inertia). As health care providers, it is a good reminder as we talk to our athletes, that we help them understand the significance of cross training. Do not say "I think you should do something else for awhile". Say "we really need you to spend 30 minutes every other day on a bike and 30 minutes on the elliptical. Also, on your off days start hitting the weight room for your core, upper extremity and stretching." Be more proactice!! Your athletes will rehab better.

Golden Rule of Foot: When injured in one sport, start cross training the next day.

Arch Adjustments on Custom Orthotic Devices

Arch Adjustments are Necessary for Good Orthotic Devices

     My patient yesterday needed several arch adjustments to her custom orthotic devices which took me 30 minutes (between adjustments, gait evaluation, and patient's feedback), and another patient needed adjustments to her arch for the third visit in a row. Why is this needed after I took the appropriate impression cast and wrote a great prescription (in my humble estimation)? I will focus on the medial arch in this post. It is by far the most talked about aspect of any orthotic device, yet sometimes the least important in terms of what an orthotic device is supposed to do. 
     I always tell my patients when they receive their new orthosis that there is a period of breaking in as the body gets used to the new positioning. Even if a patient has been a long time orthotic wearer, a new orthotic device should always be treated with this respect. It will make changes, hopefully all positive, but those changes may pull and push and compress and stretch tissues that complain some.
That being said, the breaking in process should never be painful. The 0-2 range of mild ache or discomfort is fine. If there is pain, the patient is advised not to wear the device until I have time to analyze why.
     The 4 typical reasons that patients need their medial arch adjusted are:
  1. Nerve sensitivity from low back, tarsal tunnel, or another cause. These patients do not want any orthotic pressure on the sensitive arch structures. They need nerve treatment much more than the mechanical treatment of arch support.
  2. Plantar fascial bow stringing at heel lift. A small groove needs to be placed along the plantar prominent medial slip of the plantar fascia.
  3. When the pronation is still excessive with the orthotic devices, so the medial column collapses into the medial arch causing pain. This is not related to fit as the orthotic device can seem like a perfect fit onto the relaxed foot. When the patient walks or runs, you can see that the foot still pronates excessively on the device. Temporarily you must lower the arch, unless it is simply that they need more stable shoes. Permanently, if the powerful pronation force needs more control, a higher arch with or without an inversion force at the heel is needed. I know, to the patient, it is counter intuitive.
  4. The arch fill makes it too rigid. Many labs make orthotic devices where the medial arch is filled from the ground up with material. It can be rather soft material but this fill removes the flex of the arch. This flex can be crucial for comfort. When this seems to be the case, I remove half of the arch fill at first telling the patient that I can always put it back. 


Friday, December 27, 2019

Alcohol Shots for Morton's Neuromas Instead of Surgery

     This article documents the positive results for 20% alcohol injections to help Morton's Neuroma Pain. My present protocol is one series of 5 weekly injections starting at 10% and ending at 18%. I then wait one to two months, and if there has been a positive help, and less then 80% success, I then do a second series at 20% only. If patients have a bad reaction, it is one in five patients on the first shot at 10%. They will have more pain for 4 days to 2 weeks. I do not give them another shot until this has calmed down. They do not experience more pain with any other injection even with the higher doses. Rich

Sesamoid Injury: Surgery in a Few Days Scheduled

Hello Dr. Richard Blake,

     I stumbled across your blog and am hoping to get your opinion on some sesamoid issues I’ve been having over the past 12 months. Your input and advice would be greatly appreciated as it seems you are very well versed with these injuries. Here is my story

     I’m a 24-year-old male and I have a sesamoidectomy scheduled one week from today (at the time of this blog post). My issues first began in January 2019 after skateboarding on a concrete boardwalk for about an hour and the next day my left foot was very sore. Within about a week the big toe joint became very inflamed and I could hardly put any weight on the foot. I went in to get an x ray and suspected I may have fractured my sesamoid bone but the x ray came back negative only showing bone marrow edema in the MTP joint. I was already aware of these sesamoid bones because I fractured my right one when I was 17 and after over a year of failed treatments I ended up having my medial sesamoid bone removed in that foot. I’m relatively pain free in that foot now but I definitely can’t do the things I used to athletically speaking.

     I spent about a month wearing a boot on this new injury and was eventually able to transition to a running shoe with a steel plate in it about two months after it first flared up. I was later on given some plastic orthotics which restricted the motion of the MTP joint. Fast forward to August 2019 and I was still having pain and could not walk long distances and my gait was still altered. I ended up getting an MRI and the diagnosis was bone marrow edema within both partitions of medial bipartite sesamoid. They knew I had a bipartite sesamoid because they had x rays from years ago. I saw an orthopedic surgeon shortly after and he recommended surgery. He showed me the MRI and how there was a jagged edge on the medial sesamoid and fluid in the bone which apparently indicated degenerative changes. At that point I schedule surgery and decided I was going to try to attempt to transition out of orthotics and would cancel if my foot felt better by surgery time.

My foot has definitely improved but the pain is still there. I can walk alright but I am not living the very active lifestyle I desire. Some days are worse than others but there always seems to be at least some pain and redness in the injured foot. I avoid impact activities and I believe I am definitely walking with an altered gait to compensate for the pain. I feel like this is negatively affecting the health of the rest of my body including knee, hip, and low back.

My question is do you think I should just continue to wait this out and hope the pain in my foot eventually goes away? Or has it been so long that its unlikely to completely get better at this point? Is there anything else I should try before getting the surgery? I’ve diligently iced and avoided activities that cause pain over the past 12 months and I’m getting so emotionally drained dealing with this. At the same time I am so worried that I’m jumping to the surgery too soon when it there’s still a chance the foot could get better on its own. However, my surgeon doesn’t think that’s very likely at this point and is a proponent of the surgery.
Dr. Blake's comment: Thanks for the email. After 6 months of dealing with sesamoid fractures, the standard of care is to remove the sesamoid. But, as you said with the sesamoid removal in the past, you have had some permanent changes. There is no sign of bone fragmentation or sclerosis of avascular necrosis, so there is hope you can heal. I feel the sesamoids break by accident, as in your case of overloading against cement (where the cement won), but do not heal in young healing individuals like you when something is missed. That can be your biomechanics that put too much weight on the sesamoids. It can be Vit D deficiencies, which I am always dealing with in the winter months with my athletes. It can be that you have not been treating it correctly, so I will list the top things you need to do for the next 6 months. They are:

  1. Exogen Bone Stimulator twice daily
  2. Contrast Bathing for 5-7 days per week for a deep flush
  3. Vit D Blood Test and correct if low
  4. Biomechanical treatment to off weight the sesamoid 24/7
  5. Keeping the Pain levels between 0-2 (must stay here while being physically active)
  6. Avoid Cortisone shots and the use of NSAIDs
  7. If swelling persists, get PT
  8. Cross Train with cycling, swimming, and the elliptical flatfooted
  9. Massage painlessly twice daily for 2 minutes to desensitize.
  10. See a sports doctor who is not a surgeon for an opinion, or, without telling someone about this list find a doc who mentions at least 6 of the above.
  11. Go to the AAPSM to find a local sports podiatrist
Then get another MRI at the same location and see what the comparison. No healing, surgery is your best option. No regrets. Some healing, keep going for another 6 months. A strong sesamoid will help you for years and years be active, but with your history, I would always protect it. Good luck! Rich

I greatly appreciate your input.

Kind regards,

Thursday, December 26, 2019

Always Have Plan B

 Always Have Plan B

When treating athletic injuries, it is always important to know various ways to help people with their problems. I was lucky to have great instruction in podiatry school that taught me to have a Plan B when Plan A did not work for a patient. Patients also had to be educated that if Plan A did not help them, come back, and we will see if Plan B works better.
In 1981, I joined Dr. James Garrick, orthopedic surgeon, and an orthopedic rebel if there ever was one. Dr. Garrick wanted many skilled docs and physical therapists surrounding him, helping his patients, so that he could spend his time in research, writing books, and doing surgery on patients who really needed it. He was the first doctor I ever heard say that you don't need to fix every torn ankle ligament, every achilles tendon complete rupture, and every knee meniscal tear. These injuries  could be treated conservatively, and that many foot and ankle fractures would heal fine with the right rehabilitation without surgery. What a mentor for my first days in practice! For most sports medicine injuries, Dr. Garrick had a Plan B different from what podiatrists and orthopedists were taught. Needless to say, he helped me develop many Plan Bs for my injured athletes over the 33 years we worked together.
As our practice grew, we hired more physical therapists, dance medicine specialists, athletic trainers, sports medicine MDs, other podiatrists, physiatrists, adolescent medicine specialists, and they all were trained differently. The blacks and whites of training became the grays of the art of medicine, which became the rainbows of a true sports medicine holistic approach. Plan A was carefully selected, and if not helping totally, Plan B, and C, and D could be called into play.
                                                                  In the last 30 years, this approach has been further molded by chiropractors, acupuncturists, body workers, personal trainers, nutritionists, and other healers. I clearly see that there are many ways to  help my patients get well. Any time I get tunnel vision on a problem, and the patient is not responding, a second opinion from a colleague can wake my creative side up, and a new Plan B can be developed. If I can impart anything on this topic it is that if you have a difficult problem that is not responding to treatment, see if a new Plan B can be found through the role for second opinions.

Golden Rule of Foot: When rehabilitating an injury, always have a Plan B.

The above is an excerpt from my book: Secrets to Keep Moving