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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,

Friday, February 15, 2019

Sesamoid Pain with Fragmentation: Email advice

Hi Dr. Blake,

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

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

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

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

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

A couple of weeks ago after a day of walking at Universal Studios park my feet were in some serious pain, i also started cycling in dirt/off road about a month ago which caused more stress and i would feel it more on the bottom of the foot. 
Due to the higher than normal pain during universal i went back to the doctor where the xray showed now a fragmentation of the inner sesamoid. And this is where i am at now.
Dr. Blake's comment: Wow, that is very disappointing. I am surprised nothing showed on previous xrays. When you said the MRI did not show sesamoid fracture, but did show swelling, was any of that swelling in the sesamoid (a possible sign of a stress fracture)?

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

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

And then the patient responded with an Important Decision!!

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

And my response!!

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

Saturday, February 9, 2019

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

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

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

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