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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. As of 10/22/16, $95 has been given in October 2016. I am very grateful. Dr Rich Blake


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About Me

San Francisco, CA, United States
I have been a podiatrist for 34 years now and I am excited about sharing what I have learned on this blog. I love to exercise, especially basketball and hiking. I love to travel. I am very happily married to Patty, and have 2 wonderful sons Steve and Chris, a great daughter in law Clare, my new grandson Henry, and a grand dog Felix.

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Sunday, October 16, 2016

Common Running Injuries and Their Treatment

This hour long video could help many runners with some self help ideas. Dr Kevin Kirby is a podiatrist in Sacramento, California, always known for his brilliant ideas and innovations. 

Wednesday, October 12, 2016

Lecture on Shoes and Socks at California School of Podiatric Medicine

Shoes and Socks Lecture
October 12th, 2016
Samuel Merritt University
California School of Podiatric Medicine
My partner Dr Jane Denton examining shoes

This lecture is mainly for self study, since the blog posts and videos can take a long while to study. Yet, Dr Blake would like to spend the next 2 hours giving the students a glance at the ever-changing topic. Dr Blake will skip some of the videos during class time for time concerns. 

What are the objectives?
  1. Introduce the anatomy of an athletic and dress shoe (what is a vamp, etc.?)
  2. Explain the 3 types of socks used in a podiatry practice (athletic, compression, speciality).
  3. Explain how to modify shoes for fit and stability (What is skip lacing, or power lacing, or dancer's padding, etc.?)
  4. Introduce podiatry students to various shoes specific for certain sports (what are the 3 traditional types of running shoes?)

1.   Introduction---Shoes and socks are some of the great Podiatry tools that are used in helping patients. The individualization of these factors can greatly benefit your patients. To start out, let us look at a video of the anatomy of the running shoe. Some of the red questions will be used in developing your midterm quizzes. Some of the links are for self study alone.

                      What can go wrong with flex grooves in the wrong place?
               What is more dense--outer-sole or mid-sole?

And now, even more on the anatomy of the shoe.

                                   What popular shoe company has a narrow last?
                        What part of the shoe is the Vamp?
                        Where is the saddle of the shoe?
                         How many irons equal one inch?
                         What is a toe spring?  
                         What are 3 common tests done to shoes?

I think another crucial TEAM effort is the marriage of podiatry and the shoe store. In San Francisco, I am lucky to have the extraordinary help in fitting from 3 stores: Shoes and Feet, Fleet Feet, and On The Run. I have also heard wonderful recommendations on A Runner's Mind and See Jane Run. However, it can get a little too easy just recommending a store, when the doctor should also be giving some direction. 

2.   Socks---A) athletic (know about Merino Wool and NuWool)

     There has been an explosion in the world of socks and shoes. Podiatrists need to have several recommendations for their patients since they get incredible benefit from this knowledge.
                        What socks advertised have Merino wool?
                 What socks have left and right requirements?
                  What socks have embedded arch support (name 3)?
                  What socks from Heat Holders are 7x warmer than                           most?
                  What socks have silver embedded (for anti-bacterial)?
                             What are the two best wools for Hiking?
                    What is the sock with the 5 separate toes?

                    B) compression  (look into 110% and Juzo)

I love Juzo for the thigh high and open toe. Juzo comes 12-20 mmHg pressure in OTC, but also medical grade (20-30 and 30-40).

This following video talks about putting on support hose.

             What is the pressure in typical medical grade support hose?
What is the Juzo slippee used for?

Athletes are using compression socks to their advantage. Check out 110%.

Why are compression and ice used together in controlling swelling?

                    C) particular purpose---arch support

                                                           heel or metatarsal cushion 

(BeyondSock from Thorlo)
See the nice video attached.
                                                           plantar fasciitis
What is the name of 4 plantar fasciitis socks?

3. General Shoe Modifications in Podiatry

What are 2 ways to stop heel slippage?
What eyelet is skipped in power lacing?
Why is Sole easier to work with then Superfeet?
What can you do to make a full length lift more flexible?
When designing lifts, why does Dr Blake prefer full length over heel lifts?
4. General Rule on Shoes---Always Think Bio-mechanics 
                                             Always Think Injury (or history of injuries)

     A) Stable (everybody, pronators, supinators)
     B) Cushion  (where??)
     C) Flexibility
     D) Rocker
     E) Stiffness (usually talking about forefoot)

     F) Width
     G) Toe Box Room (can there be too much?)
     H) Durability?
     I)   Price?
     H) What do we put into Shoes?
     I)   How much do people's feet grow?
            What is the length change from 20 to 70 yo?
     J)   Power Lacing (another name is "Runner's Lacing")
What are two other names for Power Lacing from the video?

     K)   General Shoe Buying Rules
            Buy within 2 hours of the store closing
            Thumb width longer than longest toe
            Fit for the longer foot
            Go to a Speciality store whenever possible for fitting
            If the shoe is uncomfortable in the store, then it probably                          will never break in
            Buy with the socks you will be wearing.
            You should feel low in the shoe.
            If you wear orthotic devices, bring them to try.
            The shoe should always fit snug around the midfoot

5. Types of Shoes  (that have a removable shoe bed)
     A)   Running

What are the 3 general types of running shoes?
What has a straighter last--cushion or stability shoes?
     B)   Court
What are the 3 crucial components of the good basketball shoe mentioned in this video?

What is the phrase "feeling low in the shoe"?
     C)   Ballet
What are 3 ballet shoe companies?

     D)    Dress
As Podiatrists, we are interested in dress shoes with removable inserts to remove and put our orthotic devices. 

     E)   Walking (I love to have patients walk in running shoes)--more cushion and stability than walking shoes
     F)   Hiking
What are the 2 parts of a hiking shoe that helps in stability?
     G)     Soccer
What would have the longest cleats: Indoor or soft ground?
     H)     Ski Boots

What boot line is for narrow feet?

What is the best time to fit a ski boot?
When putting on a ski boot, what is buckled first?

And finally, the last word on what is in!!

What shoe line has the distinctive yellow stitching?
What shoe line started mainly as a skate boarding shoe?
What shoe line had the "Pump Shoe"?

Monday, October 10, 2016

Inverted Orthotic Technique: Email Questions

Dear Dr. Blake,

sorry for my bad english,
 I'm an Italian podiatrist; I very interested about inverted technique. I have some questions to ask:
- Is it right to think Fettig modification only with inverted technique? and then, is it only used to correct a forefoot valgus associated with rearfoot varus? if no, when and how?
- Denton and Feehery modification are similar, when apply one or the other?
- In your daily treatment, do you often use these modification?
Thanks for your patience!

Dr Blake's response:

     Thank you for the kind email. I am happy to teach you. Please feel free to take the information I give you and ask any more. I will combine with this posting.  My wife and I hopefully will go to Rome next year on vacation. The Fettig Modification is a modification of the Inverted Technique only and used for the many patients with both a pronation tendency and a supination tendency. The Fettig can only be used in forefoot valgus (everted) feet, as it uses the forefoot valgus correction to be an anti-supination instrument. When the inverted technique controls rear foot pronation, the Fettig can grab that lateral column and slow down or stop mid stance to propulsive phase supination. The supination tendency can come from many causes one of which is rear foot varus, another unstable lateral column, or weak peroneals, or chronic ankle sprains, etc. The Denton modification, her sister lives in Rome, is an extrinsic lateral arch fill that wonderfully fills up the lateral arch  and helps block a supination tendency. The Feehery is an intrinsic raising of the cuboid and lateral anterior calcaneus that does the same, but you cut into the cast. Like the Kirby skive laterally, you have to learn when to violate the cast and when not to. I make orthotic devices as a process typically only violating the cast on the second modification when needed. This is the same general principle I typically use for the Kirby skive.
     Let us say that you have a patient with pronation and supination tendencies. They pronate mainly at contact, but due to chronic ankle instability, love to misstep and supinate at times (typically also at contact). For the pronation, you estimate they need a 30 degree inverted correction. For the supination tendency, they have a forefoot valgus/plantar flexed first ray we can use. So, you order a Fettig. You can also typically add a high lateral heel cup and lateral phalange, a Denton modification, and a full topcover to a forefoot valgus extension under the 4th and 5th metatarsal heads. 
     Let us say that you suspect initially, or you see at dispense, that the patient is not as controlled laterally as you would like. Your next orthotic device will be a lateral Kirby skive to the above cast, a Feehery cuboid skive, or both. And you  can also add more height to the lateral heel cup, and more height to the lateral phalange, along with a bigger forefoot valgus forefoot extension. The possibilities are endless. Please ask other questions. Rich

PS I use the Denton routinely (almost daily) and the Fettig modification 1-2 times per year. I probably use the Feehery once every other month. I relie a lot on stable shoes, lateral phalanges, forefoot valgus extensions.

Sunday, October 9, 2016

Recovery from Sesamoid Avascular Necrosis:Can he avoid surgery?

Hi Rich

I hope fall's arrival is treating you and your family well.  I noticed that on a video or two you are wearing cornell gear.  I graduated from cornell in 1984 and my daughter graduated with both her BA and MS. 
Dr Blake's comment: What a wonderful school!! I actually went to Cal Berkeley, but my oldest son Steve went to Cornell. He loved it, and really blossomed as a young man.  

wanted to give you and update.  It has been 6.5 months since my injury and Since labor day, I have resumed partial weight bearing, after 12 weeks NWB (bc of avascular necrosis).  Have had PT since july and ongoing.  Progress has been slow, prob 75 to 80% weight bearing, but can't seem to do more than that without getting pain beyond (0-2) and getting some swelling on the big toe joint.  Feel stalled for past 2 weeks.  Still in walking boot 80% of the time and using crutches to control weight bearing 100 percent  of time.
Dr Blake's comment: Of course, the daily routine of pain level is fine. You can not push it. You should be bone stimulator daily, ice pack twice daily, contrast bathing in evening, massage 2 minutes 3 times a day with the palm of your hand, 1500 mg calcium, 400 units or more Vit D, 1/2 inch adhesive felt in boot as dancer's padding off weight, and a soft orthotic with 1/2 to 1 size larger shoe in the wings. 

  Since injury, I Have seen 2 ortho foot and ankle MD's who counsel patience and slow rehab, and the diagnosing podiatrist (Ivan Herstik, MD, do you know him?  affiliated with NY School do Pediatric Medicine, says he has done over 100 of  these  with many good outcomes ) who feels I have maxed out on conservative measures and recommends surgery.  He feels risk of arthritis and other factors could limit my mobility in the  future even more if I do not get the medial sesamoid excised as I am only 54.
Dr Blake's comment: No, I don't. I would see one of the podiatrists in New York for their opinion that I know: Dr Karen Langone, Dr David Davidson, Dr Robert Conenello, and Dr Joseph D'Amico. Arthritis can be watched for as joint limitation and plantar changes of the first metatarsal. With all the followup MRIs, typically every 6 months, it is hard to imagine missing the development of arthritis. It is still with you in the discussion of "preventative surgery" and I do not have a great feel of those 2 words used together. 

I am going to get custom orthotics from a well regarded pedorhist next week or so. I may also try aqua therapy at Burke Rehab.  Still getting once a week acupuncture and exogen (5-10 min 3-5 times a week, cannot tolerate more as it sometimes causes more swelling and pain if I do too much) and contrast foot bathing 1-2 times a day.   My thinking is that if I cannot walk with minimal assistance (cane) and keep pain level manageable by Thanksgiving (only 6 weeks away), then I will likely get surgery.  My QOL has been low to nonexistent since april.  thanks goodness I have supportive family to help.

Any advice or reflections would be helpful
Dr Blake's comment: I try to tell the patients I am treating to give me a year. If their quality of life is still too hampered, and usually we have now 2-3 MRIs by then which do not show enough improvement, then surgery is needed. But, it is rare to have the surgery, but only 1 out of 20 get significant AVN. If you haven't gotten, please get a CT Scan in the next month, because it is the best test for AVN and for arthritis. The protocol for sesamoids that alot of docs use is 3-4 months to heal, and if not, remove. I have many patients that healed fine in that time, and some taking several years. Vital to the surgery is the manufacture of good off weight bearing orthotics for the year post op. It is also vital to the avoidance of surgery. 

By the way, for my Left foot sesamoiditis, I am finding zero drop or low drop sneakers helpful.  Altra shoes in particular.  Tried Hoka Bondi but the early stage rocker design was too much (although super max cushion ) and seemed to aggravate the sesamoiditis , maybe because toe was curved toward in that early stage rocker design?  they recommended constant 2 which has later stage rocker and is a more stable cushioned shoe, but I will wait to try until I see how I am doing over ext 1.5 months
Dr Blake's comment: I love the Hokas for sesamoids, and typically the Hokas with orthotic with dancer's pads with spica taping can work. But not for everyone, and the subtle differences in Hokas can make a difference for sure. Good luck and thank you for your kind words. 

Your blog is great and dedication to help others is admirable.  making another donation today


Saturday, October 8, 2016

Orthotic Arch Height

Dr Huppin discusses a simple, but very important, concept in arch height. I am amazed at how many times I find not correction in this area. However, it is not that simple, since many corrections for supination tend to correct laterally (outside of the foot) and not medially. You should never feel that the shoe and ortho combination makes you unstable to the outside. If your dealing with metatarsal or heel pain, you desperately need weight transfer to the arch. Very crucial say with plantar fasciitis or sesamoid injuries.

Friday, September 30, 2016

Sesamoids and Shoes

(if this is not the correct way to submit blog questions, please let me know!) 

Hi Dr. Blake,

I’m a 47 year old male, fairly active (and aspiring to be more so). In April/May of this year, I developed pain in the sesamoid area in both feet, which started out much worse in the left foot and a mere annoyance in the right, but over time the right has been catching up with the left.  A few Pod visits led to a diagnoses of Sesamoiditis. MRI w/ contrast showed no fracture. I believe I developed this due to (very stupidly) trying to do heavy squat exercises in the gym in bare feet, which I’ve obviously stopped doing forever.

A few things I’m doing to try in order to facilitate healing which is a combination of advice from local podiatrists here in NYC as well as your blog and a few others: ice (work in a very busy corporate office and can’t do nearly as much as I should), contrast bath 4-5 times a week in evening, KT taping as per your advice and the videos you’ve put on youtube, trying different OTC orthotics and cutting pressure relief holes in the sesamoid area which seems to be very helpful but can also be tricky depending on the shoe, wearing gel dancer’s pads, MAJOR activity modification which is depressing beyond belief and consists mostly of just 30 minutes a day of light stationary when I used to do a ton of walking/city hiking/weights. I’ve got some shoulder issues so a lot of upper body weights are difficult at time. Swimming isn’t practical for me in the city. I’ve been hesitant to go down the road of expensive custom orthotics (though I do need some arch support) because so many people I know have found them unhelpful , and also because I have been stuck on and struggling on one gear for a while: SHOES. I have tried so many different shoes over the last few months, keeping the shoe companies, Amazon, and Zappos very busy with my purchases and returns, I have spend way too long in all the major shoe stores in Manhattan, with lots of returns. I will say that it is EXTREMELY difficult to find a good quality shoe that meets the desired criteria: very stiff/rigid sole, some degree of rocker bottom, deep and wide toe box (I also have some minor great toe bunion action going on in the left foot which makes it more fun), low drop from heel to forefoot. It’s actually really amazing how difficult it is to find all this in men’s shoes, and equally amazing how very little most podiatrists seem to know about specific shoe recommendations.
Dr Blake's comment: Try also a roll of 1/8th inch adhesive felt from moore medical company to make your individualized dancer's pads and arch re-enforcement strips. You want as much dancer's pad as you can take without falling into the hole initially, and you can also back it down later. Sometimes you can take more dancer's padding if you equally balance with good arch support. Many of my patients on top of the OTC arch support add a thinned out small longitudinal medial arch pad from Hapad. They will play with the balance. Also, the more protection you can get into the shoe insert, and less  you will need from the shoe except forefoot cushion, overall stable, and a good roomy toebox. You can place a Otto Bock carbon graphite plate under the orthotic if you need stiffness.

The biggest challenge is the stiffness. It’s virtually impossible to find, and when I do, it’s in a $900 Brooks Brothers dress shoe made for men with narrow bird feet. I’ve tried Dansko clogs (forget the non-clogs when it comes to stiffness) and I’m surprised these are so heavily recommended because even with that strap in the back, they still forces my toes to grip and work to stay in the shoe which I thought was counter-productive to what we need for this injury. I’ve tried all the major “medical” shoe companies like Drew, Apex, etc. but even though they have a lot of deep/wide options, all those shoes have very flexible soles. I’ve tried (and spent way too much money on) the carbon fiber inserts. I don’t know how anyone really gets these to work. You need a totally flat footbed(hard to find, believe me I’ve tried) otherwise you bounce up and down where the plate doesn’t meet the footbed, and getting them to fit in a shoe with assorted inserts and padding is like stuffing your foot in a vice. 
Dr Blake's comment: First of all, make sure the carbon plate is flat, firm, and goes the length of the shoe, and the width of the shoe.

The stiffness is to be used when you are trying to completely immobilize the area. At your disposal are carbon plates, stiff soled shoes, shoe repairs stores adding forefoot stiffness, spica taping, removable boots, and orthotics designed with forefoot stiffness. Ask if you need the stiffness, and when, because you eventually want to go in the top direction. 

So here is what I have so far:
MBTs: I finally caved and got a pair even though I hate the way they look, and they are very difficult to find in wide. I do think these help. I finally understand the concept of keeping the forefoot stiff along with the rocker motion. I used these to walk around the city a lot but they are also very unstable and make for dangerous treks up and down subway stations. I also can’t wear them in the rain which is a problem.
Dr Blake's comment: In this category are the very popular Hokas. They may do the trick. Hokas run narrow overall, but you can find one style wide. Check them out if you like the MBTs.

New Balance 928: I am not sure why I see these are recommended so often for these kinds of foot issues. I like the shoe itself, the footbed and inside feel good, but they simply aren’t that stiff. I’ve held many, many pairs in my hand and I can always bend the forefoot upwards. New Balance tells me they are designed to bend. They are not designed to be stiff. But they keep popping up on all the blogs as the Go To for foot problems in need of stiff soles. It’s a mystery to me, because they aren’t. But since I like the way the overall shoe feels despite the bend, I brought my pair to a Pedorthist and spent too much money having a steel plate and rocker bottom installed. I haven’t had a chance to wear them since I just picked them up, but I have hope they will help with walking around the city and such.
Dr Blake's comment: I agree, the 928 has a rocker, but is not stiff. I am glad you have a Pedorthist. He/she can slide a 1/16th poly plate 1 inch by 1 inch into the mid sole right under the big toe joint to make that stable. We have done it for years in the arch of shoes that needed arch stiffness. My dad as a teenager would have that done for arch support. 

So I am getting desperate for two kinds of shoes: a good pair MEN’S DRESS SHOES, that can be worn in an office with a suit,  as well as a some type of HIKING/RAIN/WINTER BOOT that will work well on the sidewalks of NYC. I used to live in that amazing town you call home, San Francisco, and miss it greatly but now I am in the sometimes wintry wet environs of New York City. Winter is coming and this is a major concern.  MBT makes some Men’s Dress Shoes, but they are extremely narrow, not well suited for extra padding and orthotics and they look really strange in an office setting. They also make boots I think, but I wouldn’t dream of that extreme rocker in the snow and ice, up and down subway station stairs, and again the issue of no Wides. I know Hoka makes some Hiking Boots but again those don’t come in Wide sizes yet.
Dr Blake's comment: A boot that is wide in the toe box for us foot people to put things in is the Lems Boulder Boot. Definitely give me your feedback. The pedorthist could add a front stiffener. I have told patients to try the Hoka Hiking, the New Balance 1069, and the Zamberlan boots to see what fits. All, with the Lems, have different qualities.

For the Dress Shoe, something like an Alden might work, in spite of the major cost. They will be stiff but they won’t come in Rocker Bottoms and it is my understanding that the stiffness isn’t very helpful if you aren’t also rocking. I’ve looked at some Clarks, and Ecco’s, all have flexible soles and even the rigid ones are not rigid by Sesamoiditis standards. I think with the Dress Shoe, I may be forced to find something wide and deep and good quality, and have that modified with a still sole and rocker by a Pedorthist. I could go back to one of the diabetic Apex, Drew, etc. and have the sole done, but I'm hesitant to spend that much money on modifications to a shoe that might not last very long.
Dr Blake's comment: Personally, I have not placed too many rockers into shoes. I take what the shoe has and go with it. There are so many factors: stiffness, rocker, cushion, heel height, toe box room, along with all the things you can put into the shoe. So, for my patients, I try to get at least 3 of these features, especially toe box room, and then I play. 

As far as the Hiking Shoe, I would be surprised ifhere weren’t a good quality hiking shoe that would be good for the city, can be worn in snowy conditions, and is very stiff and rocker bottomed, comes in wide with a roomy deep toe box. Don’t these exist?
Dr Blake's comment: I hope Hoka will come out with one. Can you tell me in an email if you are getting better? Sesamoiditis needs to be treated by these mechanical factors, and some anti-inflammatory measures, and then should get better and better. As it gets better, the restrictions of rocker, and stiffness, etc, are removed slowly. Where are you in this realm? Should you go into a removable boot at least 4 hours a day to rest the sesamoid?

So my entire novel here is a longwinded way of including some background in my pleading with you to see if you might guide me towards some specific HIKING SHOES and some specific DRESS SHOES that are good for people trying to get their foot in a healing position for Sesamoiditis. Might you or your Colleagues there in the office have a few recommendations for shoes? It’s truly overwhelming trying to find these on one’s own and the ironic thing is, especially in a place like NY, I spend a lot of time on our feet running around trying to find them. I am convinced I would have healed better and sooner if I had gotten into proper footwear earlier.
Dr Blake's comment: I will ask the podiatrists about the general shoes and sesamoiditis. For now, consider my thoughts on temporary removable boots, and better dancer's padding. See Joseph D'Amico at the New York College of Podiatric Medicine. Also, call the owners of Richey and Company in Virginia, give them my name, and see what they recommend. Any feedback on the above, positive or negative, is great. We are all just trying to help. Good luck.
P.S.  There are a million podiatrists here in NYC, and from what I’ve been able to tell, not many really seem to understand Sesamoiditis or the shoe situation. I wish we had a YOU here.

I greatly appreciate any suggestions you can make, and thank you very much for your blog and your commitment to helping patients heal.

Thank you kind sir!

Exercise Benefits for the Elderly (and I am in the category)

Monday, September 26, 2016

Sesamoid Injury: Email Advice

Hi Dr Blake,

I found your blog about 6 months back and read through much of the guidance you have provided for healing sesamoids. It was very helpful in terms of level-setting us on how long this type of injury can take to heal.  My (now) 11 year old daughter was diagnosed approximately 1 year ago via an MRI with a stress fracture in her left foot tibial sesamoid. She wore a boot for 4 months, going to PT weekly for massage and some range of motion exercises. We purchased an Exogen in November and used it consistently for 4 months. In January she transitioned out of the boot into running shoes, with a carbon fiber plate under a Type-3 (High Arches) orthotic from FootScientific. A second MRI in February showed that the stress fracture was not healed ("no significant change as compared to the prior MRI"). The MRI also showed "multiple small ganglion cysts arising from the plantar aspect of the second and third TMT joints." So we PE, no sports, other than some swimming.
Dr Blake's comment: The bone stimulator definitely clouds the picture since it will increase the bone metabolism for healing, making the stress fracture bone reaction seem unchanged. So, as long as you can keep the pain level between 0-2 you try to increase activity gradually at this point. I typically love the bone stimulator for 6-9 months, well after someone is back to full activity. 

In May, an office xray at our Pediatric Ortho showed partial healing. Finally some good news! We added ART massage to our regime. Our ART has found a lot of tension and stress in her hip/lower back area and feels like this could be contributing to the inflammation and pain that she still has. She would typically be pain free for 2-3 days after seeing the ART. So, we were encouraged. (Btw, when the stress fracture occurred she had just gone through a big growth spurt and with a fairly tall muscular build, had lost a lot of range of motion in her feet due we think to tight muscles and Achilles not keeping pace with bone growth.) So she did summer swim team, I held my breath every time she went off the blocks and this went fine - no increase in pain. We dropped PT at this point since she was doing ART and swimming 3x/week.

July rolls around and we decide that with school and her soccer season approaching it was time to test the foot a little bit. She went to a 3.5 day indoor volleyball camp, but with the restriction of no jumping/low impact activity only. (At this age, there isn't a lot of 'volleying' that goes on anyway.) This went fine and she was encouraged. So a couple of weeks later she tried some soccer - a half day workshop at an indoor soccer facility. She came home in tears convinced that she had reinjured the foot. That was 2 weeks ago. My hope was that it was sore and maybe inflamed, but hopefully not injured. The pain has lessened, but still higher than prior to trying the soccer.
Dr Blake's comment: I am so sorry for this problem. She is definitely in the Return to Activity Phase, although flareups are common, and some need 4-7 days of return to boot occasionally. I hope you have been icing after each practice, at least once a day, continuing to do a daily flush of the bone swelling with contrast bathing (minimum 3 evenings a week), and maximizing dancer's padding and cluffy wedges in the shoes she is participating in sports.

Adding to all of this - is that she regularly has pain on the tops of both feet at the base of her toes and in the right sesamoid as well as the left. Even during the May/June months when ART seemed to be helping, within a few days, she would have pain. Some days sesamoids, but more often on the tops of her feet. Her pain level is not high, she tolerates it and doesn't complain with regular activities unless she is on her feet for a long period. So, I'd say 2-3 levels.
Dr Blake's comment: This whole immobilization and body compensations process makes other areas hurt. This is why no limping is allowed in Return to Activity Phase. Also, this is why you ice and contrast bath, get some arch supports, and sometimes tape. You could try the contrasts and suppport the foot taping to see how that works.

Prior to all this happening, she had a lot of ankle pain and we put her in a stabilizer running shoe which helped significantly with that pain. So this has been about a 2.5 year journey so far, trying to understand why at such a young age she has persistent ankle/foot pain and how to address. I kind of feel like her stride/gait may be completely out of whack after all this - she favors her feet in different ways on different days and that moves the pain around? But I have no real evidence of this - watching her stride there is nothing obvious to the untrained eye.
Dr Blake's comment: Tell her that it is the sesamoid pain we want to avoid, and protect with dancer's pads, and the other pain we need her to work through. Unless the pain is consistent, you almost have to ignore it. Her nervous system is on such high alert for any pain whatsoever, that pain is now magnified. Children always have a problem differentiating between good and bad pain, and in this scenario, any pain can seem bad, which triggers inflammation and compensatory gait and muscle activities. Some physical therapists are just wonderful in this world. 

We see our Dr. next week and should get a read on how the fracture looks. But I have had a hard time getting him to look at the big picture. I am considering a running expert, or maybe even a chiropractor at this point... We also have a prescription for a gait/running analysis from PT that we haven't done because she isn't supposed to run...
Dr Blake's comment: You are definitely thinking along the same lines as I, although I tend to work more with PTs knowledgeable in biomechanics. 

I know I crammed a lot of info into this note, but if you have any guidance on what to ask next, what to try, etc., it would help us greatly to have that input. Her soccer season started this week, but she has not gone. Sitting out PE again is really going to be hard for her as she starts middle school.
Dr Blake's comment: As long as she has some inserts and sesamoid padding to off weight the fracture, she should start on a walk run program. It takes a minimum of one month to get up to thirty minutes of running straight, but at this stage, it is better than an xray to tell us where she is at. I sure hope this helps. Rich

Thank You!

And the patient response 7 weeks later.

Hi Dr. Blake, 

I'm following up on your August 6, blog post to my email. It has taken me a while to reply, partly because of the craziness of school starting, but also because things took a little bit of an unexpected turn with my daughter's recovery. At our 8/11 appointment, our Dr. was pleased with the xrays - he didn't go as far as to say the fracture was healed, but ordered custom orthotics and told us that if her pain levels were improved after several weeks of wearing them to start to gradually ramp her activity. She has high arches, so his objective was to take some of the pressure off the ball of her foot and base of her toes and add some extra support with a met pad (at least that is what I can make out in the prescription).

We had the orthotics made and she has had them for 1 month tomorrow. They have helped significantly with her pain, especially the pain she had been consistently having at the base of her 2-4th metatarsals. Some occasional pain in the sesamoids, but usually easily correlated to a day or activity where she "did more." So to me this is goodness and orthotics doing the job. So far, so good. She is doing PE at school daily, sitting out high impact activity and playing some volleyball 2x/week (no jumping).

In the meantime, our ART therapist had noticed tightness in her left hip and concern that those muscles weren't 'engaging.' Various range of motion tests he did also illustrated that her right hip did not have the same range of motion as the left. So we decided to see a chiropractor who my husband has used with success. Based on his xrays, her bottom four vertebrae are 40 degrees off center and her right hip is out of alignment. He wants to see her 2-3x/week for 6-8 weeks. Our ART is more of the opinion that this should be addressed muscularly vs. skeletal. She was in a boot for 4 months at a time when she was growing (wondering now if that was the best approach).
Dr. Blake's comment: The curve in the spine should be treated by an MD specializing in scoliosis. He/She will direct the right PT and chiro. 

Our Dr. also gave us a prescription for PT for 'Gait Training" and progression to running. I'm a little uncertain of the best next steps. I'm not a big fan of chiropractic care, and from what I've read its not often recommended for patients under 13. I'm planning to call our Pediatrician tomorrow and get the x-rays transferred to him for his opinion on the overall situation. My inclination is to start with PT, but things seem a lot more serious now that her back/hip are involved. Any guidance you might have is greatly appreciated!


P.S. Wrt dances padding - do you still recommend it in the ortho? We haven't been using it since the orthotic was custom made to her foot and there truthfully isn't a lot of extra room in the shoe.

Sunday, September 25, 2016

Runners Be Smart when Going to Minimalist Shoes

This article clearly shows it is the transition process from one thing to another in runners that causes injuries, not the thing itself (whether it is hill running, speed work, minimalist shoes, long distances, etc.)

Saturday, September 17, 2016

Sesamoid Fracture: Email Advice


I’m so glad to have come across your blog. The world of sesamoid injuries is quite daunting and your blog and insight offer wonderful information. I wrote to you in August, but I’m writing again in hopes that I will reach you. Many thanks in advance. 

I am a 21-year-old female with a history of pain and injuries in my right leg. For 5+ years I’ve experienced pain in various parts of my right leg, and have never gotten to the bottom of it. While my primary pain is currently in my right foot, and I have been diagnosed with a stress fracture of the lateral hallux sesamoid (see MRI report summary from 06/27/2016), I find it pertinent to mention my history, as I believe it is at the root of my sesamoid and foot problems. In May 2014, after severe foot pain that prevented me from walking, I was diagnosed with a stress fracture in the 2nd metatarsal bone in my foot. From May-August of 2014 I spent in a boot and refrained from weight-bearing physical activity. In Sept 2014 I attempted to begin to run again, trying change my running form, shifting from heel strike to toe strike, and after experiencing pain, I was then diagnosed with a stress fracture in my 3rd metatarsal.
   Dr Blake's comment: Definitely, mechanics and possibly bone density are problems. Have a nutritionist and a bone density doc review this with you. 

At this point, I gave up on returning to running. I embraced all forms of non-weight-bearing exercise, such as Pilates, yoga, core strength workouts, and swimming. I did not run at all from late 2014-to the present. I even limited long walks (although, as a college student, my daily routine includes a moderate amount of walking--2-3 miles a day or so). In March of 2016, even with limited weight- bearing exercise I was experiencing significant pain in the ball of my foot. By May, the pain was too much to even walk comfortably. (I believe it may have been this way for a while and I was altering my gait so as to not put pressure on the ball of my foot/sesamoids.) In June, I had an MRI, which revealed edema.  Here is the radiology report (I would be happy to get the images to you if that would be helpful.): 
Dr Blake's comment: Yes, I am happy to look at them and the bone density test you mentioned below. Please send to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

1. Imaging findings likely representative of stress change within the lateral hallux sesamoid with suggestion of cortical disruption. Osteonecrosis could have a similar imaging appearance. Correlation with plain radiograph to evaluate degree of sclerosis and/or fracture line may be helpful.
2. Additional edema like signal within the medial aspect of the first metatarsal head is nonspecific but may also be related to stress change. No discrete fracture line is identified.

My orthopedic doctor (in Charlottesville, VA) believes I have a sesamoid stress fracture. He prescribed a pneumatic walking aircast boot (weight bearing) with crutches for 8 weeks. I got a dexa bone density scan as well, with normal results.  
   Dr Blake's comment: Thanks for getting the bone density test. I lectured at the U of V in Charlottesvile in 2007. What a beautiful and historic place! 

After 8 weeks on crutches and the boot with a significant amount of pain, I went to see a foot and ankle specialist in at University of Virginia. He looked at my MRI, and said that AVN was occurring and I needed to have the bone excised.
   Dr Blake's comment: The avascular necrosis of the sesamoid should be first treated with an Exogen Bone Stimulator, dancer's padding, and 0-2 pain levels with appropriate boots and restrictions for the next 9 months. There are stages to the AVN progression, so we want to stop it in its tracks. And, if it does progress, and there is boney fragmentation then possibly surgery is needed. I say possible because we just do not know. I have seen many patients with bone fragmentation, the classic end stage of AVN, just follow along the rehab program and do fine. I personally think it takes 2 years  to know you need surgery, but no one would blame you if you had it now. This is for so many problems I deal with. 

Knowing the risks of surgery, I sought out a second opinion in Baltimore, MD. After 10 weeks on boot and crutches, he said I did not need crutches. He immediately requested that I get my Vitamin D, calcium, and thyroid tested as well as a general physical. Everything was normal, but my vitamin D levels came back as 40, which he said was on the low range of normal. He has me on Vitamin D supplements for 2-3 weeks, and says if I don’t see some improvement then I should consider surgery. He also has me schedule to have a full endocrine workup just to be safe.
   Dr Blake's comment: That does not make any sense. Get the D to 55 or higher, and get a full workup, but that should not influence surgery at this point.  

Again, I am very hesitant to go through with excision, for many reasons including my age, the fact that there could be pain in both sesamoids, and the dangers of the surgery with the nerve in that area, toe drifting after surgery. etc.

At this point, I was on crutches/boot for 10 weeks, and boot only for another 2 weeks (3 months total of immobilization). I am still in the same level of pain as when I first started immobilizing. The pain is intense and debilitating.
   Dr Blake's comment: That does not make sense also. How is the pain walking in the boot? It should be 0-2 after the first 4 weeks. Does anyone know about your other fractures? Have you ever had a Vit D below 30? How is your diet? Your periods? Family history of osteoporosis? 

A few specific questions:
Is the boot the best healing device for me right now? Are there any alternatives?
   Dr Blake's comment: Based on your answers above, we need some weight bearing for bone mineralization, while we keep the pain between 0-2. This could be Hokas with their rocker bottoms and cushion. You need orthotics with dancer's padding. You need an MRI 6 months after the first.  

What can I do to alleviate the pain? You say on your blog a level of 0-2 is necessary to begin healing. I am wondering how to reach this level.
   Dr Blake's comment: There are 3 types of pain: mechanical (which should be addressed with shoe, orthotics and dancer's padding), inflammatory (which is helped with icing twice daily and contrasts bathing each evening), and neurological (treated with topical nerve meds, oral nerve meds like Lyrica, keeping it warm, gentle pain free massage, neural gliding, etc--since this is unusual, probably see a pain specialist for a consult.  

Is it worth using an Exogen bone stimulator since it has been 3 months? 
Dr Blake's comment: With AVN threat, you are probably looking at at least one year. 

Should I be spica taping?
Dr Blake's comment: You need to use all you can to fight this. Spica Taping and/or cluffy wedges may be important to you.

Should I continue taking Vitamin D? And calcium? Any other supplements?
Dr Blake's comment: Eat healthy, including some red meat weekly (two 7 ounce servings). We need to know if you need anti-inflammation, or anti-nerve meds or diet. I do not know.  

Should I get any more imaging done to see what is going on? I have not had imaging since an MRI in late June. 
Dr Blake's comment: Another MRI in November or December for comparison. You could get a CT scan now to see if you really have AVN. 

What exercises and stretches do you recommend to keep up strength and flexibility while I am in the boot?
Dr Blake's comment: Since you have not gotten to the 0-2 pain level, you have to do bike with the sesamoid off the pedal, swimming okay but no pushing off, tons of gym activities just avoid impact and pushoff.  

Should I be getting fit for an orthotic? I have very high arches.
Dr Blake's comment: For sure, the high arch means that they probably will have to be full length. That is typical for the dancer's pad application. 

I live in Central Virginia (Charlottesville) but I am wondering if it is worth it to try to travel to see you. I am very desperate to get my life back!
Dr Blake's comment: Here is the link to the AAPSM members in Virginia. I personally know Furman and Rubenstein. They can at least tell you where to go. Good luck. I hope this was helpful somewhat.  I am happy to look at your images.

And the patient responded:

Dear Dr. Blake,

I cannot thank you enough for all of this valuable information. Truly, I’ve been feeling very lost with what my next step should be and I appreciate your response immensely.

I will absolutely send my MRI and bone density and blood work to you. To answer your questions, pain walking the boot I am currently in is 0-2. I have been in this boot for 2-3 weeks. While on crutches and in my other boot for 8 weeks, around 4 weeks I began experiencing a fair amount of pain (pain level of 4 or so) while in the boot. So while I have been in the boot/immobilized for 3 months, the total duration of that has not been completely pain free. All the doctors I’ve seen know about my other fractures. It was concerning to the doctor in Baltimore, and that was why he recommended Vit D/other testing to see if something was going on with bone healing abilities. No one has really linked how these three stress fractures are related though. I have never had Vit D below 30 (two years ago it was 42, so it has stayed fairly constant). My diet is very good, mostly vegetarian in the past month but I eat appropriate servings of vegetables, fruit, and protein. Regular periods, and no family history of osteoporosis.

I have a few follow up questions if you wouldn’t mind taking a look!

-Do I need a prescription for an exogen bone stimulator? I am completely on board with being patient to solve this injury, but I am a bit concerned about the cost. From what I can find on their website, it seems like they are around $3,000. Is this how much they cost? Is it generally covered by insurance?
Dr Blake's comment: Exogen does have a self pay program much much cheaper, but I would always try the insurance via RX. Have the doc treating you now, or your primary, start by contacting the Exogen rep. It is relatively easy from the doc's side.

-I appreciate your information about the 3 types of pain. You say that we need to know if I need anti-inflammation or anti-nerve meds or diet. How might I figure this out? At this point, would you recommend seeing a pain specialist for information about what might possibly be nerve pain? Related question: do you recommend Quell for me? I’ve read about it on your blog and am curious to know whether it may help my pain, not in my foot but in my leg as I have general aches and pains in my right leg for 5+ years.
Dr Blake's comment: I am just beginning to experiment with Quell, but one of many patients wore it for a month and when it did not help, got a full refund. So, nothing to lose. I am glad you are now consistently at 0-2 pain. So, you can hold off on the pain specialist, and wear the boot for 10 more weeks. It should be a weight bearing boot, and you should slowly and surely increase your walking. Get an EvenUp for the other side.

-You mention meeting with a nutritionist. After reading my whole case, would you recommend that I meet with someone? A related question, how much Vitamin D should I be taking to get to 55?
Dr Blake's comment: That area also sounds good. Typically you take 1000 units per day and retest in 2 months.

-I’m wondering what my plan for now should be. Would you recommend: 

*Staying in the boot or trying to transition into a shoe such as the Hoka? Mainly, it is crucial to already have orthotics for the Hokas? (in which case I would stay in the boot until the orthotics were made and then transition into a Hoka?) 
Dr Blake's comment: Boot for now, and once orthotics with dancer's pads made and adjusted let me know how you are feeling. I figure that is a month or 6 weeks for now.

*Regardless of what boot/shoe I am in, should I start learning to spica tape now?
Dr Blake's comment: Yes, it takes about 10 times to be good spica taping. Also, see if Cluffy wedges help. Do you have some accommodation in the boot to off weight the sesamoid? You can experiment with that at this time. The problem with Hoka One One brand is the narrowest at the front. You may want to get an extra wide (for you) New Balance 928 also at the time orthotics are being made.

*Should I be doing the daily foot and ankle strengthening exercises on your website?
Dr Blake's comment: Yes, some will have to be modified for the sesamoid pressure with a float made of books with the sesamoid in the middle.

*Should I ice 2x daily and contrast bath in the evening?
Dr Blake's comment: Yes, you want to continually control the swelling in the bone.

*Is there anything else I should start doing, today? (other than keeping up physical fitness through swimming, biking off the sesamoid, core/upper body strength)
Dr Blake's comment: Not that I can think. You are welcome and good luck.

Again, I cannot thank you enough for your help. I will send you my images this week. I am so grateful!