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Thursday, March 21, 2019

More on Minimalistic Shoes: Great Video

     I love shoes period. I think shoes protect our feet and give us support and cushion when we need it. And, as a podiatrist, I treat injuries or patients who are biomechanically stressed. By that I mean, some patients (whether they are runners, hikers, cyclists, etc) need a correction in their gait or structure, just to be aligned right to avoid injury. The video above is very well done and fun to watch. My problem is that their thinking is too narrow. They should come out and say that some people may get injured going without cushion and without support, and that those patients should be able to wear shoegear that corrects. It is up to the health care provider, athlete, and shoe stores to figure out what they need. I certainly could not walk as much if I did not have cushion and support. Some people do just fine with a minimalistic approach. But, my waiting room is filled with patients who can not walk without aids, and cushioned shoes, and who may be trying to slow down their knee arthritis from needing a replacement. I think a healthy runner should have traditional, maximalistic and minimalistic shoes in their closet. Alternating is very very healthy. Staying in the same enviroment is unhealthy. We all have to learn from each other. Everyone should do more strengthening and flexibility work. Everyone should do various forms of exercises. Everyone should try to find out how to do these things safely and with no pain. I have no idea why 30 years of sports medicine knowledge is being completely thrown away for the potential gains from minimalistic shoegear. Rich

Wednesday, March 20, 2019

Big Toe Joint Arthritis: Email Advice

Hi Dr. Blake, 
I recently found your videos on YouTube.

I was wondering if you do any Skype evaluations. 
Dr. Blake's comment: I am sorry, right now I do not. I will in the future however. 

I have a problem with my right big toe lacking full ROM. I jammed it really hard about 7 years ago going from a headstand into chaturanga (low push up position) intentionally in a yoga class.

I guess I did not have my right foot flexed enough. It really hurt my big toe which felt sore to walk on for several weeks. It never had full ROM after that when I flexed my foot. But I kept working that range of motion until my toe would not bend anymore thinking I needed to work the ROM so I would not lose it.

Six months ago I went to a physical therapist and asked him to work on my big toe. He held my big toe and extended it and moved it around. He said he felt increased ROM when he was moving my big toe but I did not feel anything. However after I left my foot really hurt around my 4th metatarsal which turns out had a stress fracture that I discovered after I finally went to a podiatrist for an x-ray. 
This really made me pay a lot of attention to my foot. I attached the x-rays. It looks to me like the sesamoid bones are out of alignment. But I am not sure - the podiatrist did not say anything about that.

This x-ray shows lateral compartment arthritis in the big toe joint

Do you do Skype consultations? Does it look like the sesamoid bone is out of place and if so is there a way to heal that without surgery?
My posterior right arch collapses a bit when weight bearing.

I live in Asheville, NC and do not really know of anyone who is really good at helping me from a holistic point of view.
Dr. Blake's comment: Look at the AAPSM directory list. This is the sports medicine aspect of podiatry. See who is near you in North Carolina. I think your treatment is for Hallux Rigidus, or just arthritis of the big toe joint. Rich

I would appreciate any advice. I really want to address this problem and find a good solution. I am willing to do the work to make changes.

Thank you. 

Monday, March 18, 2019

For Podiatrists: The Significance of Heel Bisections

This is the second of many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

     For me, I need to be able to draw a line on the back of the heel that represents the bisection of the heel. I am sure my measurement is only accurate within a few degrees. I am trying to have a line represent an entire heel bone and I try to do this the best as I can. I should be able to draw the same line with the patient prone or standing. It is one of the basic skills taught podiatrists. 
I use the heel bisection to see how my orthotic devices are helping, or if more correction is needed. 

The ruler is just a reference line as the orthotic device on the right foot straightens up the everted heel below

This right foot is everted to the ground . I use a bisection line that I was taught in Podiatry School, to represent whether the heel bone is everted to the ground, vertical, or inverted to the ground. Then I can check (be honest) if my orthotic device is helping make the foot more stable. You should first look at the back of the heel and decide if it is everted, vertical or inverted. Then draw your line and see if you captured this heel position. If you are performing this at orthotic dispense, then this should correlate to what you see in gait. Or, you just keep learning.

Here a goniometer is being used to measure the degrees at the heel.

Of course, when we are designing orthotic devices, we try to make everted heels generally less everted, vertical heels inverted when the foot is pronated, and inverted heels generally less inverted unless there is significant rearfoot varus conditions. 

Friday, March 15, 2019

For Podiatrists: Biomechanical Discussion Points #1

This is the first of hopefully many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

Bio-mechanical Point #1: In what position of the heel are the patients most stable: is it heel vertical, heel inverted, or heel everted?  

     The best heel position for stability depends on several factors. One concept was first introduced by the ballet world in the 1700's that the most stable position of the heel is when it is stacked directly under the talus, and the talus is stacked directly under the tibia. I have always found that patients, and especially dancers (who are very attuned to their bodies), can feel this inherent stability. This has been termed the neutral position of the subtalar joint (neither inverted or everted) from that position, much as the neutral position for stability of the ankle joint is where the tibia is at a right angle to the foot (in which the ankle is neither dorsiflexed or plantar flexed from that position). 
     That stable subtalar joint neutral position is inverted to the ground when we have tibial varum and other forms of rear foot varus. That stable subtalar joint neutral position is everted to the ground when we have tibial valgum or other forms of rear foot valgus to treat. Therefore one person can be in their most stable heel position to the ground 5 degrees inverted and another person 5 degrees everted. The most common will be tibial or rear foot varus that will set the ideal heel position to the ground somewhat inverted. Too often orthotics are set at vertical for these patients meaning that the orthotic holds them pronated or everted from their most stable position, which means makes them more unstable. If we measure these positions, or at least recognize these deformities by observing the patient in angle and base of gait, we can be more thoughtful in prescribing an orthotic device's heel position. 
     When does this thought process get thrown out the window? All the time. Patients present with certain needs that may have higher priority than simple Root Bio mechanics (not that there is anything simple about Root Bio mechanics). This need may be permanent or temporary, but must be addressed. What are some examples? A patient presents with terrible pronation due to a high degree of tibial varum (bowlegged) mechanics, but they have had 3 ankle sprains and are trying to avoid ankle reconstruction. Root Bio mechanics would have them Inverted due to a high rear foot varus, but their injury with lateral instability requires a vertical heel pour or even slightly everted if they have the range of motion. The goal of the orthotic device, which may change down the line, is for elimination of the supination forces, not correcting the abnormal pronation. This is so common in a sports practice. 
     Another example which is very common in my practice, almost daily, concerns lateral wedging for medial meniscal at the knee problems. If you pronate the foot for a period of time, and open up the medial knee joint line, you can let an injured meniscus have time to heal. You are not concerned about the ideal heel position for stability, but only to generate enough pronatory force to off weight the medial compartment of the knee. This can be extremely important in documented medial knee compartment issues 50% of the time. The other 50% actually want more stability, and you may be inverting the heel to give them that. Inverting the heel 3-5 degrees in general, stabilizes the medial knee compartment, places more weight on the medial knee compartment, helping so many soft tissue medial knee torque or instability problems. 
     I hope to keep the thinking going. Thanks for reading. Rich

Monday, March 11, 2019

Chronic Pain: Curable App with Graph

I would love to have any patient with chronic pain from all different sources download Curable App and see how it works for one month. I am so hopeful it can help reduce your pain. 
This wonderful chart is reprinted courtesy of Curable App. 

Saturday, March 9, 2019

Use Code to help Dr. Blake's Travels. Why not?

Hi Richard,

Have a great trip! Why not make it even better by earning a reward for you and your friends?
All your friends have to do is book using your referral link. When they get back from their trip, they’ll get a US$25 reward, and you’ll get US$25, too!

To All my Blog Friends, if you travel, you know is a great site. If you use the code above, both you and I get $25 each. Good deal right? Thank you in advance. I love Rich

Start Standing: A help for Back Pain

We all know we must stand more to help our bodies, especially the low back. I hope this website helps in your journey toward better health. Rich

Sesamoid Fracture Treatment: A hope to avoid Surgery

Hello Dr.Blake!

I am happy I found your blog post about fracture seasmoids. I’m hoping to get some advice or maybe just some encouragement!

So here goes! I am pretty active and enjoying hiking, running and workout classes. I suffered from turf toe back in 2016...after therapy and taping it got better. A few months later similar pain returned and it was diagnosed as sesamoiditis. Last year we found I had a complete fracture of my medial seasmoid. I was put in a walking boot for 6 weeks and the pain went away but fracture didn’t heal. The podiatrist told me to leave it alone if it didn’t hurt. Fast forward to a few weeks ago when I finally got a second opinion and I am now non weight bearing and using a bone stimulator twice a day. My biggest question is this, do you really think that after a year this fracture could heal without surgery? I’m pretty skeptical.
Dr. Blake's comment: Depends on the gapping or the fragments, the amount of avascular necrosis that has sent in, the biomechanics of your foot and activities placing stress or little stress on the fracture area, the overall fragmentation, the bone density and Vitamin D levels, eating habits, etc. You want to do the contrast bathing as a deep flush. A CT scan would give us the best imaging at this point.
     I have many patients that the sesamoid does not look great on any imaging, but do fine, and as long as we can keep the pain between 0-2, and they are happy with activity levels, I just follow them.

The pain wasnt unbearable I just wanted the second opinion because I am 32 and work a pretty physical job (PT assistant in an inpatient setting) so on my feet many hours a day.  I also enjoy running and hiking. Those are things I wasn’t able to do the past year so I have substituted with using a stationary bike and weight lifting. I have been using a dancer pad and started wearing hokas which I love but the pain still lingered. I feel like I’m too young to just give up but I am really hesitant to get surgery for this. My podiatrist said if this doesn’t heal she would like to do a bone graft and use it to pack in between the non healing fracture. It seems like more trauma to my foot than I’d like to deal with. I know I should be more positive because maybe this can heal with NWB and bone stimulation but again I’m skeptical. I should also mention I started taking a vitamin supplement to help bone healing.

I’m sorry for the long email I just thought you should have all the info.
Dr. Blake's comment: Unfortunately, I have had no experience the results of bone grafting. If you find any articles, please send my way. I just want to know if you have surgery, they are just not experimenting with you. I am not a surgeon, so I have to leave final decisions to surgeons, but send me one or two images of the fracture from a CT scan and I will give you some thoughts. Have your Vitamin D level measured. Go 6 months on this course, although at some time you will have to switch from NWB to a weight bearing boot for 4 weeks and then back into your Hokas. The bone stimulation should be 9 months period. Hope this helps. Rich

Thank you in advance for even reading this and thank you for what you do!

Wednesday, March 6, 2019

Nerve Pain after Long Distance Bike Ride

Hello Dr Blake,

I found your email address after reading your blog and an article written by you in "Podiatry Today" on Morton's neuroma. I am writing to you from Australia seeking your medical opinion after seeing many specialists in Australia on my foot issue, with no real success. First a little background on my issue.

My problem started back in September 2018 whilst working overseas. I first hurt my right foot after training for a long distance bicycle ride. The initial symptoms were tightness in my calf, sole of foot and some heel pain. The heel pain would be shooting pain on the inside of heel whenever my foot was dorsiflexed. Over the following three weeks, whilst standing in my job, my condition worsened with the onset of pins/needles throughout the sole of my foot. At the end of a typical work shift my whole right foot would be completely numb and tingling. The GP's that I first saw thought it was plantar fasciitis and prescribed me anti- inflammatories which provided some relief.  I also saw a podiatrist who moulded me a set of orthotics with little improvement noticed.  After three weeks I returned to Australia in October and sought further investigation.
Dr. Blake's comment: There are 3 sources of pain: mechanical, inflammatory, and neurological. The cause of your pain was mechanical (the long distance bike ride), but the symptoms are all neurological. This is like overstretching the calf, and pulling too long on the sciatica nerve, and having the calf pain intensify. You have to treat this neurologically at first with treatments that help nerves. then work on the mechanics, and any inflammation that has set into the tissues.

Since I have been back in Australia I have seen the following specialists:
  • Neurologist (Nov) - performed a nerve conduction test, which was inconclusive, apparently quite often this happens with people over the age of 40.  Had an MRI (report attached below) which showed a thickening of the medial planter nerve throughout the mid-foot course involving up to 8 cm in length.  The Neurologist concluded that I had Tarsal Tunnel syndrome, informed me that surgery was my only option and referred me to an Orthopaedic surgeon.
          Dr. Blake's comment: Yes, there is 1-5% of almost any injury that has a surgical solution, but
          that is not where you start. Hopefully, you never have to go down that route.
  • Orthopaedic Foot Surgeon (Nov) - the orthopaedic surgeon said that I did not have tarsal tunnel syndrome as the thickened nerve was not in the tunnel.  He was reluctant to operate and advised me to take three months of rest and see if my condition improves.
  • Podiatrist (Dec) - visited a podiatrist who concluded that I may have medial calcaneal nerve entrapment and/or Baxter's nerve entrapment.  Advised me to keep wearing my orthotics.
  • Orthopaedic Foot Surgeon (Feb) - condition had improved after three months of rest, but still only limited function. Surgeon would not operate and referred me to a Anaesthetist/Pain Specialist.
       Dr. Blake's comment: When you irritate nerves, they can take a long time to relax, so most of this
       advice is good. It is using only rest as the number one treatment for nerve pain, but not bad
       advice. Glad that they sent you to a nerve guy (called pain specialists).
I am now awaiting an appointment with the Pain Specialist on March 27th.  My current symptoms are the following:
  • Can walk okay, but after one mile or so start to experience pain in the sole of my foot 4/10 (feels like a stone in my shoe). The pain extends from where the heel ends, along the mid-foot section. Dr. Blake' comment: Do not push through this pain. Do you guys have Uber down there?
  • Tightness in calf has disappeared. Dr. Blake's comment: Great, that means some of the neural tension is improving. Has the heel also resolved?
  • Cannot walk down stairs properly as the dorsiflexion of my right foot causes a shooting pain on the inside of my heel. Dr. Blake's comment: Just answered the above question. Remember the sciatic nerve, branches of the big nerve are irritated on you, is pulled too much right now with ankle dorsiflexion, straightening the knee, and bending over at the waist. Try to go downstairs leading with the bad side, and then lowering the good side to the same level. That is usually the best. Down with the bad, up with the good is the mantra.
  • Flat surfaces are okay for a mile or so, but inclines uphill or downhill really take a toll on my foot quite quickly. Dr. Blake's comment: Stay on flats right now as the neural tension resolves. It is never a fast process. Sorry.
  • Sometimes when I stand in one spot for an extended period my foot turns red.  Podiatrist was initially concerned that I may have the beginning of CRPS and encouraged me to keep walking. Dr. Blake's comment: This is called vasomotor insufficiency where the skin and soft tissue are influenced with nerve spasticity. This is part of the neural tension also. Nerves love motion, and not prolonged stretching. They do not like certain positions, so keep moving is a good thing, or at least finding comfortable sitting or laying positions when you can not move.
  • Still wearing orthotics which help a little.
  • Currently on Lyrica 150mg to ease pain on the days I walk more. Dr. Blake's comment: Typically I wonderful nerve treatment if you can tolerate.
Am I a candidate for Radio Frequency Ablation, cortisone injections, or alcohol injections?
Dr. Blake's comment: Unless someone can tell you that a neuroma, or entrapped nerve, is a constant trigger for the pain, it is best to not risk irritating it for now. As your symptoms get better, and one spot on a nerve remains super sensitive, then some discussion is in order. I doubt you will need these, but I am of course not sure. I would not do anything invasive to speed up the treatment. With nerves, that course of action tends to irritate more than help.
  Is there any value in having a diagnostic injection around the medial calcaneal nerve or Baxter's nerve to see if the shooting inside heel pain is relieved when foot dorsiflexed?
Dr. Blake's comment: Local anesthetic on an inflamed nerve could help, and you may need to do several over 3-4 weeks. That being said, it goes against my better judgement. Do this for me. Have you knee straight and then dorsiflex the foot, you should get nerve pain. Now, bend the knee to ninety degrees and then dorsiflex the foot. If there is no pain now with that change in position, it is most likely an irritated nerve, not an entrapped nerve (which should hurt both ways). It is another finding and for sure not conclusive. What I have not had you say is that the MRI showed a possible nerve entrapment in the heel with intense swelling, etc. I have also not heard you say anything about a low back MRI since this can be all coming from your back.

 Could I have a nerve entrapment that might be relieved with Radio Frequency Ablation?
Dr. Blake's comment: This is not a procedure I have any experience in. Start doing traditional treatments: neural flossing, Neuro-Eze or like products, get the Lyrica dose up to normal amount, add Cymbalta if you can tolerate, avoid positions that irritate the sciatic nerve, see a physical therapist skilled in nerve problems, try topical compounding meds that have Ketamine, get your low back pain eval, look into foods that irritate the nervous system, and get supplements that calm it down. Most of this is in my blog also. I hope I have been somewhat helpful. Rich
Be kind to yourself, and do not rush into treatments, meditate daily, acupuncture can be of great help.

I have researched a lot online and there is very little information about enlarged nerves, besides Morton's Neuroma.  I really don't wan't to be on painkillers the rest of my life and refuse to believe that this is the end of the road for me.  I recognise that I may never get full function back, but am searching for a procedure that could improve my condition a little. In Australia there does not seem to be any podiatrist surgeons that specialise in my condition, or at least I don't know who they are.  The Pain Specialist is currently my next avenue for help.  Any feedback you could provide would be greatly appreciated.


The Patient then responded:

Hi Dr Blake,

Hello from Down Under. Thank you so much for your quick and detailed reply.  I have already actioned a number of your suggestions, like taking supplements to calm down the nerve (Vitamin B12) and ordering Neuro-Eze to apply to the sole of my foot.  I will also explore acupuncture and physical therapy.

To answer some of your questions:

  • Heel Pain - For over a month now I have been going down the stairs by leading with the bad side and lowering the good side second, just like you suggested.  Then today I decided to try and walk down the stairs normally, so I could report back to you on my progress.  Good news, I managed to walk down the stairs with only minor discomfort which was a big improvement from a month ago. Still have tenderness around the inside of heel and the arch of foot though.
  • Dorsiflexion Test - I performed the straight leg and bent knee dorsiflexion test like you suggested.  In the straight leg position I felt no pain, however I have lost about 20% range of motion when compared to the other foot. I'm pretty confident that if someone pushed on my foot it would have elicited some pain as it did before. Dorsiflexion in the bent knee position hurt.  Is nerve entrapment still a possibility? Dr. Blake's comment: Yes.
  • Explore lower back possibility - When I see my specialist next week I will ask him for some imaging on my lower back, as you indicated it may be the source of the pain.

What I didn't mention in my first email was some other symptoms that presented when I first hurt my foot 5 months ago after the bike ride. The tightness in the calf was predominantly in the top outer side portion, combined with big toe tingling and sensitivity.  In fact, whenever I experienced the shooting pains through the sole of my foot, the big toe would end up throbbing.  After researching quite a lot I believe my initial injury may have been a sprain of the Flexor Hallicus Longus muscle, apparently a common injury amongst ballet dancers and bike riders. If the FHL was inflamed throughout the foot, could this have led to the medial plantar nerve enlargement ? Dr. Blake's comment: For sure, and that should be calming down. 

Thank you again and look forward to your reply.

P.S. We do have Uber down here! 

Every Single Street: Rickey Gates Runs San Francisco

Rickey Gates runs Every Single Street in San Francisco, very motivational, we can do perhaps smaller projects, but as mindful.

Friday, March 1, 2019

Sesamoiditis turning into Fracture: Email advice

Good evening Dr. Blake,

I am currently a student at a university. I suffered sesamoiditis in February of 2018. I visited the doctor and they took an MRI and Xray, and he said it was sesamoiditis. They gave a steel toe plate to insert in my shoe so I don't bend my toe too much and it did help for a little bit. A couple of months went by and I got used to the pain.
Dr. Blake's comment: I hope you understand that we must get the pain to 0-2, not just be helped, or you will not heal potentially. This is especially true with sesamoids that are slow healers in the first place.

I did try to ice as much as I can and the pain went away. I am a pretty active person, and just couldn't sit out during the summer while I trained. I didn't think much of the injury since it was a busy summer for me and didn't know that it is that big of an injury. I trained and ran with it and played basketball with it all of 2018. I adjusted my gait so I don't put pressure on it and that lead to other problems such as calf tightness and knee pain and hip pain.
Dr. Blake's comment: Thanks for being honest. I know we all try to just live with it with the eternal hope that it will eventually get better. At your age, I would have been doing the same thing, so no guilt allowed.

I stopped playing around a couple of months ago since I knew it wasn't really healing so I didn't want to risk it (Which I already did by running on it that whole summer.) I visited the doctor on 1/30/2019 and he took an X-ray where it was found that I completely broke it. The doctor said I have to get a procedure to take out the bone ASAP and referred me to a surgeon. I talked to the surgeon and he basically just told me about the recovery time and things of such and I told him that I read some people never return to 100% and he agreed and told me to just sleep on the option of surgery. He also said it has no chance of healing since there is no blood supply to this area. It doesn't look like it is a huge break, but is there a chance of it healing without surgery and could it union? I attached the X-ray picture to this email. I came across your blog because I was desperate and it has been so helpful. Please get back to me. 

Thank you so much

Even though this is alittle blurry one can see the obvious crack with jagged edges

Dr. Blake's comment: Okay, you got yourself in a bind. Please understand that there is no gap between the fragments, so the bone contact is good for healing. Yes, these heal slowly so the rest of this year will be dealing with your sesamoid in one way or the other. I am sorry when some of my patients need surgery after a long battle, but since the majority heal fine, the battle is always worth it. Plus, even if you need surgery, you will have the orthotics and dancer's padding that will protect the other sesamoid in high impact sports your whole life.
     So, you have to create the 0-2 pain level, get a bone stimulator, start doing daily contrast bathing for swelling reduction which improves circulation, get a Vit D test to make sure you are fine there to heal a fracture, eat healing, cross train with biking, swimming, flat footed eliptical, get Dr. Jill's dancer's padding at 1/8th inch and 1/4 inch for various shoes, get good custom orthotics to take pressure off the sesamoid, and learn spica taping and cluffy wedges and see if important for you. Some of my patients love some of the Hoka One One shoes, but that depends if the roll is in the right place. Zero drop shoes are better in general than traditional shoes. I hope this points you in the right direction. Rich

Thursday, February 28, 2019

Chronic Foot Pain: Email Advice

 Hi Dr. Blake,
I found your blog while doing some research for my husband, and I hope you don’t mind if I shamelessly solicit your opinion on the below situation J.
My husband had sesamoidectomy completed on both big toes well over 15 years ago and he continues to have very debilitating flare ups. He is 48, very active, and has a busy work travel schedule and an active job that requires him to be on his feet a large majority of the time. He frequently has flare ups where either his big toe, middle toe, or all toes will become discolored, very inflamed, and extremely painful. During these episodes he takes Naproxen and wears a boot, but he is still in pain even after taking the Naproxen. These events will last anywhere from 2-3 days to over a week, and although he probably wouldn’t admit it, cause him some degree of depression. He has been to his doctor and was recently diagnosed with gout, BUT, his uric acid levels are normal, so I don’t buy it J. I am trying to encourage him to seek out additional opinions on his condition and to get physical therapy of some kind, but I frankly think he is scared. He is very resistant to my suggestions to the point of stubbornness. I can’t quite understand it.
I am curious what information I might be able to share with him around physical therapies and exercises for his condition. Everything I have read around joint issues, such as arthritis, is to stay active and keep joints mobile. What are your thoughts?
Any feedback at all would be GREATLY appreciated.
Dr. Blake's comment: Thank you so very much for your email. This situation could be a lot of things, and I agree gout flare-ups quite commonly present like this. His gout test, uric acid in the blood, can just run high normal and he is prone. It would be great if you could find his uric acid level and email to me. I would need his level, and the range of the lab that they consider normal. Does he have any family history of gout? Do you think he has rich foods a lot? Or is he chronically dehydrated?
     What he is experiencing is not normal, and getting to the diagnosis is essential? Any other blood work abnormal? If he has one side that is worse, and he feels the trigger for the pain is the big toe joint, then he should get a CT Scan to look for pieces of the sesamoid that were left behind. That could be causing the problem. A Plantar Axial view of the feet shows the sesamoid area, and any doctor can order that. I hope this helps some. Rich

Monday, February 25, 2019

Crush Injury leading to Sesamoid Injury and CRPS

Dear Dr. Blake -

I am writing about a crush injury to my right foot 6 months ago (Aug 21 2018) when a large metal object fell from a top shelf onto my bare right foot  I’ve seen a variety of doctors and practitioners, but nothing I’ve learned has improved my condition, and I am in confusion and despair. I’ve read your blog during this time, and your recommendations always make more sense to me. I sent previous emails, but want to try one more time, because the end of my rope is near.

As a quick summary, the initial diagnosis was fractured 1st metatarsal. Second doctors found additional fracture to tibial sesamoid (also deformed), 2nd metatarsal (bottom), inflamed MTP joint, nerve sensitivity on top and bottom of foot.  

Pain has gotten worse rather than better.  Sesamoid/metatarsal area feels like shards of broken glass in my foot.  MTP joint is sensitive, and I keep my foot wrapped in sheepskin inside the boot for relief.
Dr. Blake's comment: That symptom would be intense nerve pain (neuropathic). 
During the day, pain increases the more active I am (light chores around house); better when I stay off it entirely.  During the night, pain can be worse, making it difficult to sleep. I’m still in boot, using wheelchair for total non-weightbearing, homebound from no driving.

Dec 2 MRI:
  • Bones and joints:  No dislocation.  Moderate hallux valgus alignment with mild lateral subluxation of base of 1st proximal phalanx.
  • Moderate 1st MTP osteoarthritis; severe sesamoid osteoarthritis. No joint effusions.
  • Ligaments:  Lisfranc ligament intact.  No evidence of acute injury to collateral ligaments at MTP or IP joints.
  • Tendons and muscles:  Mild edema/strain of the medial head of the abductor halluces muscle.  Mild muscle atrophy.
  • Soft tissues:  Mild soft tissue swelling, greatest along 1st to 3rd MTP joints
Dr. Blake's comment: Your symptoms are of nerve pain secondary to the crush injury to an already arthritic big toe joint. 

Dec 18: 2 Cortisone injections, which caused extreme pain, fever, disorientation. No pain relief, but some reduction in inflammation.
Dr. Blake's comment: This is diagnostic as it only addresses inflammation. Since it did not work, the neuropathic pain must be addressed. 

Physical therapist has helped flexibility/strength in foot, ankle and leg. Electrical stim and light massage reduce pain temporarily, but sometimes nothing can be done because foot is too sensitive.

My two doctors recommended 2 different courses of action, both surgery. I resisted.
  • Dr. 1:  Aggressive: remove both sesamoids, reconstruct MTP with pins, shave outside of bunion, all in one operation.
  • Dr. 2:  Conservative: remove tibial sesasmoid.  If that doesn’t work, then remove 2nd sesamoid.  If that doesn’t work, reconstruct MTP joint.
Dr. Blake's comment: No surgery should be contemplated until neuropathic pain is recognized and addressed. The treatment is not easy, so as soon as you can have the neuropathic pain treated successfully the better. 

Jan 19:  Woken up by worst pain yet, like broken beer bottle jammed in my foot.  Decided surgery was necessary.
Dr. Blake's comment: Again, this is neuropathic pain, surgery has to wait for now, but could be avoided. 
Jan 24:  Went to yet another doctor for 2nd option on which approach to use; aggressive or conservative.  He temporarily put the breaks on, wanting more info.
  • Increased nighttime pain may be related to L4, L5, SI nerve. I need to see ortho spine doc.
  • X-rays show osteopenia in MTP area.  Bones may not have integrity to hold pins/screws, creating worse problem in future.  I need to see osteoporosis specialist.
Dr. Blake's comment: Localized osteopenia could indicate that the neuropathic pain has developed complex regional pain syndrome. I have many blog posts on this subject. 

I sit here befuddled, exhausted, and defeated. I truly hope that you can provide some clarity on what is happening, and how to best proceed.  Thank you for your time and commitment to healing.


This is a foot that looks like CRPS Stage 2 (vascular stage)

Dr. Blake's comment: I wrote to the patient at this time that I was on vacation and my response was going to have to be delayed. 

Hello Dr. Blake.  I hope your vacation was rejuvenating!

You asked that I resend the email below after your return.  Here are a few updates as well.  Thank you so much for your generosity.

Pain Relief:
I got a medical marijuana card last week. A daytime tincture hybrid of THC/CBD keeps me alert while reducing pain.  The nighttime tincture is 100% Indica for sleep.  To my surprise, the daytime product has reduced my pain considerably, particularly around the tibial sesamoid.  I’m mainly feeling nerves, but in a lower pain range. 

The amount of pain I have right now is bearable, which makes me more resistant to surgery. It feels good to have the boot off.  I’m still putting all weight on my heel and outside of foot. Only a few steps here and there.  Doing exercises recommended by physical therapist.  Still in wheelchair most of time.

Doctor Opinions:
Here is the full array of opinions that have my head spinning.

Dr. A (podiatrist):  Recommends removal of both sesamoids, rebuilding of MTP joint, shave bunion bump. Should all be done all at once in order to maintain my gait, but also recognizes it will be a difficult recovery.

Dr. B (Dr. B's partner):  Recommends removal of tibial sesamoid only.  If that doesn’t work, then follow with 2nd sesamoid removal, followed by reconstruction of MPT.  More conservative approach, but possibility of 3 separate surgeries.

Dr. C (my chiropractor):  Advises against surgery because of complexity of foot, but if surgery is necessary, then do it all at once.  He recommended Dr. D for a second opinion.

Dr. D (third podiatrist):  Not rushing into surgery after reviewing the MRI.
#1 - He thinks the tibial sesamoid is not that deformed, and the pain/inflammation is likely severe osteoarthritis aggravated by the accident. He also thinks some nerve pain may be originating in my lower spine...L4, L5, S1. He asked for a workup from an ortho spine doc. If foot surgery is necessary, he recommends it all be done at once.
Dr. Blake's comment: This is my choice of direction, but CRPS has not been discussed?

#2 - He is concerned with osteopenia in the big toe joint, and not confident that pins would hold.  He wants a workup from an osteoporosis specialist, before he would consider surgery.

CNP (my primary provider):  She did not understand Dr. Haas’ concerns. 
#1 - She doesn’t agree lower spine should be an obstacle.  She ordered x-rays, and results were as expected. 
Mild degenerative disc disease at L4-L5 and L5-S1 with disc space
narrowing. Facet arthropathy is present throughout the lower lumbar
spine. No acute fracture or malalignment is seen. No evidence of

#2 - I had a bone density last March, and there is osteopenia everywhere. It's being treated with Vit D3 caps, and calcium through diet.  Marcie doesn’t see a problem with pins holding.

She said I’m between a rock and a hard place, but agrees with Dr. B; one bone at a time.
Dr. Blake's comment: In California we have pain specialists that are neurologists, physiatrist, or anesthesiologists who need to be consulted. Dr. D was right about the nerve part, but CRPS type 2 is nerve hypersensitivity from nerve injury. This has very specific treatments. 

Finally, my physical therapist): He has seen my ups and downs more than anyone. Most recent trend is down, so he can’t even do exercises with me, and we've cancelled appointments until this gets sorted out. He said it will be a difficult recovery, but he recommends the full surgery.
Dr. Blake's comment: The full surgery is only recommended by caring people who want desperately to help you. You can not blame, but if the pain is neuropathic, the surgery is going in the wrong direction. See if there is a neuro-physical therapist in your area. They have a national organization and are attuned to CRPS.

Me:  When feeling my foot prior to medical marijuana, I am resigned to surgery.  Feeling my foot right now, under the effects of medical marijuana, I don’t want surgery.  

Bottom Line:  where do I go from here?

Warm regards,

Common presentation of CRPS post injury

Dr. Blake's first response after vacation (3 weeks ago), but before the two photos above were seen. 

Just read through all the emails to get my brain working. Do you have any images you should send of xrays or MRIs? If you have surgery on your foot, you only want the tibial sesamoid removed for sure. More and more surgery at one time is less predictable, and more trauma to your body. You had a very bad accident, which everyone wants to help you with, but more surgery does not make sense right now.
Secondly, I treat patients every day with tibial sesamoid fractures, and no one hurts like this. The crush injury may have caused a complex regional pain syndrome to develop which behaves like this. If so, you need a sympathetic block in your back soon. So, please have a neurologist or pain specialist work you up for this to rule it out, but also to treat the pain. If you are having nerve pain from this, surgery may make you worse unfortunately. So, get away from the surgeons for a few weeks and focus on nerve pain and its treatment. Send me any images. Keep up with the cbd oil which works well for nerve pain in some/most patients. Rich

The Patient's response:

I’m writing because I’m stuck, and need to make a decision on treatment for my foot. Last night, I had another high pain episode. My physical and emotional reserves are depleted after 5 months since the injury. 

It is very generous of you to provide your expertise, and i cannot imagine how busy you are. While understanding that, I also need to make a decision soon about surgery. I’ve been putting it off for months, and my foot is only worse. 

Is it possible to talk by phone/Skype, or do you have enough info to make a recommendation in writing?  I am so happy to make a contribution to your blog or pay you outright for your time. I just don’t know where else to turn. 

With respect,

Dr. Blake's next response:
I just reviewed the foot MRI. The Spine MRI is out of my expertise. The fibular sesamoid is out of its normal position, probably from the bunion or possibly a ligament tear. It will probably have to be removed. There is some arthritis in the joint, which could be part of the pain. I will have to read your original email to put it all together tomorrow. There is a lot of swelling around the tibial sesamoid which also probably hurts. The L4 nerve root is problematic and this goes to the big toe. Lucky you!!. I will think more on it tomorrow. Rich

Image under the big toe joint showing the fibular sesamoid out of its normal alignment

Another image of the same thing

Arrow points to intense fluid under a normal appearing tibial sesamoid, the fluid seems to be why she is hurting

This is another image of the intense inflammation under the tibial sesamoid in the subcutaneous fat, the tibial sesamoid looks arthritic, but it does not looked fractured or needing to be removed.

Here is the comparison more normal fibular sesamoid and fat pad

The arrow is on the flexor hallucis longus showing intense inflammation above near the fibular sesamoid. I wonder with the injury if the ligament connecting the 2 sesamoids was not torn. This would explain why the fibular sesamoid in the earlier images looked way out of place.

This image points to the gap between the tibial and fibular sesamoids possibly created by a tear of the ligament.

The architecture of the tibial sesamoid does not look injured, but you can see the swelling below in the soft tissue which will hurt on pressure

This image shows the mild wear and tear of the joint itself, osteoarthritis, that could be stirred up in the injury and resulting demineralization process going on

Another view of some mild wear and tear.

Thank you, Dr Blake. This is important information.

I’ve been regulating pain with medical marijuana (mm), and also using the Curable app. Both are helping a lot with calming down my nervous system, reducing discoloration and swelling. Mm is supposed to be good for nerve repair. Reading that I probably need surgery has released a flood of anxiety, and I’ll focus on that now. 

You are most kind.

Dr. Blake's comment: Yes, if you need surgery due to the fibular sesamoid out of alignment, that can wait and you may avoid it. Get the CRPS evaluated. Sounds like you are already calming your nervous system. On your recommendation, I introduced the Curable app for nerve pain in a recent blog post. It definitely looks promising. Keep me in the loop.

Monday, February 18, 2019

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.

Sunday, February 17, 2019

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,

Saturday, February 16, 2019

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.

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.

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,