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Friday, July 3, 2020

Sesamoid Fracture Advice

Dr. Blake's comment: The patient's mother kindly sent the MRI CD for me to review which I did not until 6/29/2020.

Hello again Dr. Blake,

Thank you for reviewing L's MRI.  Here is a recap of my initial email with updated/new questions.  We look forward to hearing from you and are very thankful for your time and expertise. 

L is a competitive varsity cross country and track athlete with her high school.   In February of this year she sustained a left metatarsal stress reaction (diagnosed via MRI) during track and field training.  She was immobilized for 8 weeks in a CAM boot, sat out the track season, received PT and did aqua jogging and swimming to maintain cardio fitness.  She had a  full blood panel and everything was WNL. Vitamin D was WNL, but in the lower range (we  live in South Florida and she gets plenty of sun on a daily basis). She supplements now with Vit D.   She is a very healthy eater, healthy weight and has regular menses. After a slow progression to return to running over the course of months she has been pain free in the left foot and doing summer training with her cross country team.  She has always run in HOKA Cliftons, but does rotate with Mizuno Wave Rider and Brooks Adrenaline during cross training.  She currently uses the customizable NB2400 (by Aetrex) shoe inserts in her left shoe.  
Dr. Blake's comment: I love the routine change in shoes to vary the stresses.
On June 11th after a practice she complained of R foot pain in the big toe region.  Due to her previous injury, we did not waste time diagnosing and the next day visited her foot and ankle specialist and had an MRI of the right foot the same day . They placed L in a CAM boot to be worn at all times until her follow up July 22nd (approx 6-7weeks post injury).  She has started Exogen bone stimulator 1x day x 20 mins, has had 2 out of 6 scheduled ESWT treatments , and has begun 2x week acupuncture.    She does not complain of any pain. 
Dr. Blake's comment: I would have to see what the literature says about ESWT for acute fractures. Please ask the doctor if there is anything for us to read.

1. How long would you recommend she remain in the boot? 
Dr. Blake's comment: My general rule is 3 months, however at 2 months you can begin to gradually wean out of the boot into bike shoes with embedded cleats or Hoka's with the rocker sole. You have to maintain the 0-2 pain level. 

2. Do you allow patients to remove the boot for gentle ROM of the ankle (the boot is driving her crazy with c/o foot cramping) ?
Dr. Blake's comment: Yes, it is a removable boot for walking. She does not need to wear it when she is not walking. Many patients find that around the house they can walk flat footed in soft sandals and avoid the boot since they can avoid toe bend and still protect. 

3. When should foot strengthening be initiated?   and massage to desensitize?
Dr. Blake's comment: Foot Strengthening is now!! Massage is now!! The massage is best done by the patient since she can make sure that she is avoiding pain. Each massage should b 2 minutes with some massage oil or topical gel like mineral ice. The foot strengthening she should don is metatarsal doming, single leg balancing with a float for the big toe, double and single heel raises also with a float for the big toe joint. 

4. Do you recommend she incorporate a dancer pad (or similar sesamoid cut out)  in her CAM boot? should we add a cluffy wedge with this? 
Dr. Blake's comment: Depends on her pain level. You place pads in like dancer's or cluffy wedges if you need to get the pain to 0-2 within the boot.

5. She is wearing a Darco Toe alignment splint while in the boot.  Do you prefer spica taping over this?    Do you use spica tape and dancer pad at the same time?
Dr. Blake's comment: If the boot gives 0-2 pain, no need for anything else. If not, you have to see what works to drive the pain down. Typically, dancer's and spica taping are used in the next phase as she re-introduces her activities. She should be cross training with cycling, or swimming without pushing off, etc. Some patients can use the eliptical if they stay flat footed. 

6. When could she attempt pain free short bouts of WB for mineralization?  
Dr. Blake's comment: Typically, this is a weight bearing boot, even if you need to off weight with dancer's padding. Around the house, you typically need the boot off to do the contrast bathing and, as long as you do not bend the toe, and you have dancer's padding and overall cushioning in a slipper, you can meander around. Keep the pain low!! At 8 weeks, if the patient is doing great, symptoms are where they should be, you begin to spend more and more time in a Hoka shoe or other stable but cushioned shoe. You need your orthotics with dancer's padding made by then. 

7. At what week post injury do you recommend beginning Physical therapy?   Aqua jogging?   or Swimming?   (we would like her to get some kind of cardio exercise when safe to do so)
Dr. Blake's comment: Agua jogging in the deep end of the pool is now just not emphasizing the toe motion. Swimming also great without fins and without pushing off the wall. Cycling without cleats with the pedal on the arch, not ball of the foot. Eliptical with Hokas flatfooted is fine without using the arms. 

8. Do you have a preference regarding  HOKA Clifton's vs Bondi?
Dr. Blake's comment: No, but it seems that the Bondi is more stable. With Hokas, each shoe has a different rocker point. So, I would make the decision based on how she feels the bend protects the sesamoid. If they both feel the same, go with the one that feels like it has the most toe box area. You will need it for all the sesamoid protection. 

9. At what part of the recovery do you initiate getting fitted for custom orthotics?
Dr. Blake's comment: This should be done as soon as possible. You need to have a good supportive and protective orthotic device, which could take adjustments or re-dos, when she is trying to wean out of the boot at 8-12 weeks. 

10.Do you have any recommendations for a physician in the Sarasota/Bradenton Florida area?
Dr. Blake's comment: I trust Dr Brian Fullem (Clearwater) and Dr. Matthew Werd (Lakeland) and Gerald Cosentino (Tampa). You can call their offices for a closer referral. 

11. We have been advised to avoid any icing and/or contrast baths at this time while she receives the shock wave therapy. Would she still benefit from it 6 weeks from now? 
Dr. Blake's comment: Shockwave is meant to inflame, but help in the healing. I have no experience with it for sesamoids. Sorry. I assume that icing and contrasts are fine after that stops. 

12.  As this is her second fracture in less than one year, do you think we should request a bone density test for her?
Dr. Blake's comment: Our doctors have gotten bone densities at her age and use the same values as the 20 year olds for understanding of the bone density. It is a test if she has low Vitamin D levels repeatedly, if her eating habits are suspect, if her menses is irregular, or if she is slow at healing bone. Did everyone feel she healed the metatarsal fracture fine and in the normal time length? 

13. Are we missing anything?    The MRI report  references sesamoiditis, so does she have a double whammy or will the fracture treatment help with the sesamoiditis?
Dr. Blake's comment: Heal the fracture, heel the itis part with the icing and contrasts and protection. 

Running is a big part of L's life and we want the absolute best care for her. We would like to be aggressive with her treatment to prevent a more chronic problem, however I want it to be within safe guidelines.  Her team is her family and it is hard on her to be away from them for weeks as she heals. 
Thank you!  

ps. on a side note, I should also mention that L was an idiopathic toe walker and as a toddler wore AFO's and spent years in PT.  She was a very difficult case to treat (we avoided surgery), and still has very tight calf muscles and poor dorsi flexion, which is more than likely pre-disposing her to her injuries.  Are you familiar with Aaaron Mattes and his stretching therapy?  He is in Sarasota and L was treated by him years ago for her toe walking.  His sessions are very costly, but if you are familiar with his techniques and feel it would benefit her, please let me know.  
Dr. Blake's comment: Tight achilles is a huge reason for athletic injuries to the front of the foot. You should do what you can to help stretch out the achilles and I will look at Aaron's work. On a ironical note, the tight achilles gives her power to do sports where you are up on your toes. 

Sunday, June 28, 2020

New Series: How I Approach Problems: Plantar Fasciitis

     This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.
                                                           Plantar Fasciitis

So, you have made (or been given) the diagnosis of plantar fasciitis (inflammation of the thick ligament under your arch that runs from your heel to your toes).

It is typically at its attachment at the heel where it is palpably sore on examination. If the soreness is somewhere else than its attachment, then the diagnosis should be in question. Since rare cases occur elsewhere, and if you are certain, the next diagnostic test will actually be the treatment to be prescribed. Plantar fasciitis should respond to this treatment.

The next test of the diagnosis is in the symptoms. Plantar fasciitis progressively gets sore over weeks and months. If the onset of pain is sudden, and the pain is under the heel bone, it is not plantar fasciitis. My next “How I Approach Problems” will be on sudden onset heel pain which is definitely not plantar fasciitis.

Plantar fasciitis also is always the worst in the morning when you get out of bed. Even though you should never use always in medicine, this is a pretty accurate rule. If the pain is not worse in the morning, it probably is something else. Again, we should see how it responds to treatment for plantar fasciitis.

Plantar fasciitis should have little to no soft tissue swelling. The patient typically can not feel heel swelling, but a doctor or therapist should. If there is significant swelling between the two sides of the body, it is probably not plantar fasciitis. Again, one of my next posts on “How I Approach Problems” will be on heel pain with swelling.

Plantar fasciitis should respond to typical treatments of ice massage, plantar fascial stretching, and taping. It can take a few months, but you should feel better and better each month. I love patients to continue doing activities that they can keep in the 0-2 pain range, even if it hurts more after. You do not run again until you are at the base line pain.

Treatment #1: Freeze a sport water bottle after filling 1/2 full of water. Roll over the painful area for 5 minutes 2-3 times a day with a towel on the floor as you sit and roll.

Treatment #2: I love the 2 achilles and 1 plantar fascial stretches described in the video below. These are typically done 3 times a day, especially before and after exercise like running.

Treatment #3: Tape the arch to immobilize the pull of the plantar fascia. I have replaced the time-consuming, but wonderful, low dye taping with Quick Tape from Support the Foot. This is typically left on 5-7 days at a time.

Plantar fasciitis always gets a lot better with this regimen. If there is little to no improvement, I doubt the patient (you) have plantar fasciitis at all. Next blog post will go over the decision making of no treatment response. If the patient gets 50% or so improvement but plateaus, we typically have to increase the treatment. Tomorrow I will discuss this scenario with partial success with plantar fascial treatment or no treatment success.

Plantar fascial treatment should allow full, but modified, activities. A non-response to treatment for plantar fasciitis, typically means that there is no plantar fasciitis but it can take a month of treatment to know that. A partial response to plantar fascial treatment typically means more specialized treatment is needed with inserts and PT.

Wednesday, June 24, 2020

Problems with Removable Boots and Swelling

Hi. Dr. Blake,

I wanted to get your take on my situation. I started having pain which turned to swelling at the end of Feb. 
I have very high arches (I have custom orthotics) but had not started wearing them yet. I went to a podiatrist who said that I needed to wear a boot. 
I wore the boot for about 4 weeks but still had some swelling. 
She suggested doing a MRI. During the time I was wearing the boot she said it was okay to walk around in the boot and so I was going for short walks with my son. 
I ended up seeing another podiatrist via tele med. He suggested Physical therapy. 
I did physical therapy for about 4-5 weeks. The PT hurt my foot and after the first visit I had swelling after I thought my foot was better from the boot. 
I continued the exercises and it felt like my foot was finally getting a little better but then he had me do some twisting balancing exercises that again really hurt my foot and made me think I re-injured it.
 He sent me back to the second podiatrist who did an MRI. 
He said I had a lot of inflammation and a small tear needed to wear the boot again, stop all PT and take  MEDROL or do a cortisone shot. 
I opted against cortisone, am wearing the boot but finding that my foot is swelling up again even though I am not walking and laying off it. 
I was also icing. I feel like the icing and the boot are hurting it. Is this possible? Maybe it's not getting blood flow.
 Before I got the MRI I was wearing my Dansko shoes at home and my sneakers and walking around an it felt better. I am really confused.
 Any sugggesitons?

Dr. Blake's comment: First of all, swelling can be inflammatory (typically painful), part of the healing/reparative process of an injury and chronic since it can last months and months after an injury (typically not painful), and related to venous insufficiency (veins having trouble removing fluid from feet and generally also not painful). 
So, when you say swelling, I need to know if this swelling hurts or not. 
Chronic symptoms, over 3 months, start to strain the venous return and swelling can get harder to drain out of your foot. You may need compressive socks or, at least, some period daily of elevation. Boots can begin to work against you and trap in the swelling due to the immobilization and Velcro strap restriction of the venous return. 
Icing controls inflammation, but usually does not get rid of it. Contrast bathing can be the best at removing inflammation and swelling produced by that inflammation. 
So, recommendations: Are we sure the tear needs to be protected? That is the million dollar question here. Inflammation is better served by contrast bathing not ice, no boot, some elevation, motion that does not cause more than 0-2 pain. I sure hope this rambling helps you. Rich 

Monday, June 22, 2020

Posterior Tibial Tendon Dysfunction (left side only)

Left Posterior Tibial Tendon Dysfunction with Arch Collapse and Heel Valgus

Here the actual degrees of Valgus is measured

I am designing him the first of three orthotic devices. The first orthotic will correct 7 degrees, the second orthotic up to 10, and the third orthotic up to 13-14. This is utilizing the Inverted Orthotic Technique based on heel valgus measurements. 

The Subtleties of Testing

There are many subtleties in tests ordered by doctors. This can be from brain scans to simple routine blood work. In my practice, foot X-rays and MRIs are a commonplace as the socks in my drawers. However, there can be subtleties in reading these well represented by this x-ray. While the report documented normality, the subtle signs of mid foot arthritis abound. Plenty of spurs and bone irregularities mark the painful area. For this reason, I always want to see the X-rays, and actually prefer to read them before I review the report. Many times I only get the report faxed to me and have to have the patient go out of their way in retrieving the CD of the actual images. I think it is worth it!!

Floating a Sore Spot on the Bottom of the Foot

 From the Image above you can tell where the patient is hurting. She took this image right after icing and was amazed at the color changed in the sore area. My schema is of the padding that I actually applied to the shoe insert that give her great relief. This is one of many patients whom the shelter in place has allowed for more walking, but that increased walking has brought out that some problems. She will continue to ice 5 minutes 2-3 times a day, and tape her 2/3 or 3/4 in a downward position. Another post covers that type of taping with KT tape or Rock Tape. 

Saturday, June 20, 2020

Vasli Dananberg Orthotic for Plantar Fasciitis and Functional Hallux Limitus

Hi dr Blake
I am 56 year old woman with plantar fasciosis of 2 years now since oct 2019 functional hallux limitus. In general have you found Vasalyi dananberg orthotic helpful if both  plantar fasciosis and hallux limitus Present .none of my sports med, ortho, podiatrists that I have seen  are familiar with it. Does it have any liabilities in your opinion. I read your blog am -doing the toe mobilizations and bought a toe spacer ( siliipos one)
Thank you

Dr. Blake’s comment: I am in favor of this design overall. The arch is deceit and the release of the first metatarsal to push off great. It will work less and less as the pronation syndrome gets higher, but a good place to start for sure. Rich 

Friday, June 19, 2020

Hallux Limitus/Hallux Rigidus: Conservative Thoughts

Let us start the discussion on avoiding surgery for Hallux Rigidus as our first option. Let's try conservative care for awhile. Here is my original Blog Post way back in 2010 on this subject.
Here are 2 PTs discussing mobilization of the joint. I typically do not recommend putting a rigid hard device under the toe that hurts initially, and I typically avoid the standard dorsiflexion and plantarflexion motions, but it is okay to see how it feels.

Sore on the Bottom of the Foot

Here is a patient from today's clinic. Yes, I am back after so much time off. Now, let's not blow it and forget our masks and social distancing!! I know I sound like your parents!!

     It is so important to off load sore areas on the bottom of the foot. This patient had a deep seated callus under the fifth metatarsal which I tried to dig out. Then I attempted off loading with my 1/8 inch adhesive felt. Thick moleskin also works, and you may have to layer to get the right thickness. 

Thursday, June 18, 2020

The Inverted Foot: What to Do?

I treat many patients that are inverted aka varus aka supinated. This is a great foot for me to help. Even though the exact numbers do not mean much, this is a patient with 10 degrees of genu varum (bow legs) with 10 degrees of tibial Varum. You can tell this patient likes to walk on the outside of their feet, however the compression forces are at the inside (medial) aspect of the ankle and knee. 
     As the patient stands they are inverted to the ground. You will want to perform the block test or have them rotate internally with the leg to see if there heels get to vertical. This patient easily had the range of motion to get to vertical. 

     Treatment wise you may decide on holding the patient inverted (say in the case of lateral meniscus injury or sesamoid injury) although allowing pronation for shock absorption, or getting the patient back to near a vertical position (say in a lateral ankle instability patient trying to avoid surgery, or chronic medial meniscus pain trying to avoid knee replacement. I will talk more on the inverted foot in the next few days. Rich

Sunday, May 31, 2020

Pronated Left Foot: New Orthotic Device to be Made (Posterior Tibial Tendon Dysfunction)

This patient presents with a collapsing left arch for several years. I inherited the patient from my retired partner (Dr. Ronald Valmassy) who kept him going on a 20 year old orthotic device. However the patient has noted a change in the last year with a collapsing left arch and more left arch pain. He has no pain in his right side. He tries to walk 3-4 miles daily, but the last 6 months has been limited to very little walking. 

I am going to start with my highest correction of 35 degrees Inversion for the left foot. I am only making a new left for 3 reasons: only has pain on left, the right orthotic device seems excellent, and he has no insurance and is paying for this himself. 
     This is actually a typical stage 3 PTTD patient. The RCSP (resting heel position) was 17 everted or valgus standing on the orthotic device. The highest correction I do is 35 degrees initially which should push the patient into more varus by 7 degrees (5 to 1 plaster inversion to actual foot change). I will go up from there after he is used to it. I am always hoping for more than the 7 degrees change, but sometimes it will be less with the first correction. 3 months after his new left orthotic device is dispensed, I will either push the orthotic correction 3 or 5 degrees more.      

Monday, May 25, 2020

Nerve Pain helped by Neuro One Topical

Neuro One is a topical that you can order through Amazon and other places. It has L-Arginine and Vitamin B-12. It is one of the medications, along with neural flossing, warm bathes or 5 min ice, non painful massage, metatarsal support, and foot mobilization, that I use routinely for foot nerve pain of any sort. This can include Morton's Neuromas, peripheral neuropathy, sciatica, etc. I advised this particular patient to reduce the Neuro One to once daily to see if we get the same great results. 

Hi Dr. Blake,

I hope that you and your family are keeping well! We are muddling along without too many problems.

You suggested that I check in by email right around now.

The only question that I have right now is whether you want me to change my NeuroOne routine.

I have been using it for about 14 weeks, twice a day, on my left foot.

The neuroma “pain” is diminished by about 50% on both feet since I starting using the NeuroOne in February. Now on both feet it’s in the 1-2 range, and the predominant sensation when I walk is something like having the ball of your foot brushed by a vegetable brush.

Also, I have stopped icing the balls of my feet at night. Now I just ice the boney ridges on the tops for 10 minutes in the evening, which is more relaxing than anything else.

I haven’t gotten up the courage to try any shoes other than my Chaco sandals. Sheltering in place (with daily walks between 90 and 120 minutes) doesn’t require any footwear more stylish then Chaco’s.

So, there you have it: the NeuroOne question, plus I’d be happy to hear any other suggestions or advice.

Thanks, and take care!

Sunday, May 24, 2020

Chronic Big Toe Joint Pain: Turf Toe?

Dr. Blake,

I have been reading your blog for several weeks now and have watched many of your videos. I am emailing you on behalf of my daughter who is a 16-year-old soccer player (who will be a junior this fall) with the potential to play soccer in college. She has been suffering from an injury and is desperate to feel better and hopefully be able to continue playing the sport she loves. I am hoping that if you have some time you could give me your thoughts. I completely understand if you are unable to do so. 

She suffered an ankle injury in September 2018 while playing soccer. The orthopedic surgeon at the time said she most likely had torn the ATFL. She was put in a cast, then a boot and then went through PT for several months. She was cleared to play soccer in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to PT and then was released to play again in April. Right at that time, she started to develop pain in the ball of her foot. She continued to have pain for several months until an MRI in June 2019 diagnosed turf toe. She was put back in a boot for several weeks and then went through PT for a few months. She returned to play in August but by October she started to develop pain in the same area after playing back to back games of 90 minutes each. All this time she continued to have pain and swelling in her ankle as well as the pain in her foot. She continued to play soccer until the date of her surgery on November 22, 2019.

After a year post injury, it was decided she would need ankle surgery. In November 2019, she underwent a modified Brostrom procedure and the doctor found that she had 3 torn ligaments in her ankle. I believe two were repaired with anchors and the third was reconstructed. (Note: this orthopedic surgeon was not the original doctor we saw when she suffered her injury in 2018) Once she was allowed to take her first weight-bearing steps weeks after surgery, she had immediate pain in the ball of the foot. The orthopedic surgeon had hoped that the rest after surgery would help and prescribed PT for both the ankle and the foot Jan-Feb 2020. We took her to a podiatrist in March of 2020 after continued pain in the foot. X-rays in the office were negative for any fractures or abnormalities of the sesamoids. He diagnosed her with sesamoiditis. He made her orthotics and shortly after she received them, the Corona virus hit and we were unable to see him for several weeks. During that time, we sought another opinion by an orthopedic surgeon specializing in the foot and ankle. He performed x-rays as well and found them to be negative also. An MRI was performed with the following results:

----There is very subtle bone marrow edema of the head of the second metatarsal. There is
no other bone marrow edema, marrow replacing process, or acute fracture. The
sesamoid bones of the first digit have a normal appearance with no signal or
morphological abnormality. The flexor digitorum tendons, flexor hallucis longus, and flexor hallucis brevis tendons are intact without edema or tenosynovitis. The extensor tendons are intact without edema or TR synovitis. The plantar fascia has a normal appearance without
inflammatory change. The muscle volume and signal is normal.
There is soft tissue edema in the interspace of the first and second metatarsal heads
tracking around the lateral sesamoid bone of the first digit.
1. Mild bone marrow edema of the head of the second metatarsal with surrounding soft
tissue edema extending into the first interspace and around the lateral sesamoid bone.
Findings likely relate to chronic stresses/ superficial repetitive trauma.
2. No evidence of fracture or osteomyelitis. No soft tissue fluid collection.

Dr. Blake's comment: Many patients have irregular sesamoids on xray, never get an MRI like your daughter, and due to the chronic pain have the sesamoid out sadly. So, I am so glad you did get an MRI. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I am confused that the MRI did not document turf toe, but maybe it was a severe stage 1 or mild stage 2. If we treat the MRI only, this should be all healed by now. 

He put her on a Medrol pack, showed her how to tape her toe (like the videos on your blog) and told her to wear a boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol pack. He did not recommend a cortisone shot or surgery. Shortly after, the podiatrist called us back to the office. He modified her orthotics. He took her out of the boot because he felt her muscles would atrophy and would require more PT to rehab her back.  He found her hamstring and calves to be very tight so he instructed her to stretch 3 times a day and ice afterwards for 20-25 minutes. She is to do this for several months. She just started PT this week. The therapist said she is strong in both the ankle and foot but is still weak from her surgery as she was never able to start conditioning due to the pain in her foot. She is wearing Merrell hiking shoes for more support. I put a J-pad under her foot and she did feel a little bit of relief. However, the podiatrist does not want us to use this...maybe because he wants the orthotics to start working to redistribute her weight naturally? She is continuing to tape her toe as well. Per your blog, we will file down the cleat right beneath the ball of the foot and will also purchase turf shoes for training and play when her outdoor cleats aren't needed. 

Dr. Blake's comment: This is wonderful. Dancer's padding (J Pad) are a must, and I will use on the orthotic and also on the foot. You typically need 1/4 inch sesamoid float to take pressure off, so you can see how much the orthotic does. It is time for her to get at least 5 things that are working for her: taping, orthotics, J Pads, cluffy wedges, icing, contrasts, stable shoes. Can you get a pair of Hoka One One to try to see if the rocker eliminates some stress? 

The podiatrist would like to see her back in a few weeks to determine her pain level. If she isn't getting much relief, he said he would consider giving a Cortisone shot. He also indicated that if she continues with conservative treatment for a few months without much relief, and the fact that she's had this pain for over a year, he would consider surgery. While he said this is the last option, he did say she could recover well from it because it's the lateral sesamoid that would be removed. He felt that she would be able to return to playing soccer about 4 months after surgery. My concern is the health of the remaining sesamoid and keeping it healthy for the remainder of her life. I have read what can happen if both sesamoids are removed.

Dr. Blake's comment: Whoa!!!! There is no problem documented in the lateral sesamoid, and cortisone into a chronic turf toe may be okay, but may be not. Turf toe, which I think is our working diagnosis, is a tear or stretch of the ligaments. It can make the joint unstable, and I do not know if she is already naturally loose. She may consider an arthrogram of the joint where dye is injected into the joint to see if it leaks out, although have not seen that test for years. If a lachman test for turf toe has been done, find out what it was. She made need a couple of sutures placed into the big toe lateral collateral ligament if that is the case. Convince me that this is not ligament instability due to turf toe. Sorry, I know this is hard. I sure hope this helps your daughter some what.

I am reaching out to you because my daughter is starting to feel hopeless that she will ever recover. She had to stop playing basketball a year ago because it was all too much for her ankle. She will be devastated to have to give up on her dream to play soccer in college. 

If you are able to provide any thoughts or advice, I would greatly appreciate it. I feel that the orthopedic surgeon and the podiatrist have conflicting ideas and a third opinion (hopefully yours) would possibly help us with our next steps.  I have been doing a lot of research and stumbled across your blog. By far, your site provides more information about this condition than anything else I have found. Thank you for all you do for the health of others.


Saturday, May 16, 2020

Application of Temporary Kirby to Achieve more Pronation Support

Typical Patient with Custom Orthotic Device giving less than optimal Correction
The Green Wedge has been skived prior to application to lessen the abruptness of the Transition
This is also a great way off adding more support without placing it in the Medial Arch
The surfaces of the wedge and orthotic device are glued

Since this is the left foot, this wedge is on the medial side, called a Medial Kirby Skive or Medial Heel Skive

The final trimming has been done

Friday, May 15, 2020

Cluffy Wedge and Dancer's Padding for Sesamoid Injuries

The famous Cluffy Wedge for sesamoid help, named after Dr, James Clough from Oregon, is typically a 1/8 to 1/4 inch square of adhesive felt worn directly on the foot

Foot Bone Schematic seen from above the foot looking down on the right foot

Here the same schematic shows a dancer's pad to off weight the sesamoids with 1/8 to 1/4 inch adhesive felt or other soft material glue to the shoe insert or orthotic device

Here the same schematic with a cluffy wedge also used for the sesamoid protection

Tuesday, May 12, 2020

Utilizing Inverted Orthotic Devices for Knock Knees (Genu Valgum)

Here is the patient with knock knees or Genu Valgum and Rear Foot Valgus deformities. In an ideal world, the subtalar joint could stay in neutral where the foot and ankle lined up although everted.

If we were to measure this patient, the heels would be everted to the ground the same degrees of genu or tibial valgum. 

However, reality sets in, and one of two things happens. The subtalar joint supinates to bring the heel vertical or close to that position (as shown on the right side), or the foot collapses more medially with subtalar joint pronation getting more everted than the tibial valgus position as seen on the left side. The right foot needs an orthotic that allows for contact phase pronation and I set it to typically pronate from 6 everted to 10 everted by using the inverted orthotic device of 20 degrees or a 4 degree change and then grinding 4 degrees of motion into the rear foot post.  The left foot needs to get them close to their everted neutral position of 10 degrees everted typically with a 25 degrees inverted orthotic device. 

Would you rather run on Asphalt on a normal summer day or the concrete sidewalks?

International Podiatry Greeting (that I was part of) for Return of Crucial Podiatric Care: Very Well Done!!

Monday, May 11, 2020

Podiatry Question #1: What 3 common orthotic RX would help the foot below?

This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are: 
  1. Unilateral pronation placing a strain on the posterior tibial tendon
  2. Some inherent weakness in the tendon 
  3. A Habit of wearing poor quality non supportive shoes
When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories? 
  1. An Orthotic Device with some inversion
  2. A varus foot wedge external or internal to the shoe
  3. A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
  4. Stable shoes, stability or motion control, with some heel elevation 
  5. Aircast Airlift PTTD brace
  6. Posterior Tibial J Strap for Inversion Support

It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include: 
  1. Anterior Tibial Tendon
  2. Intrinsic Musculature
  3. Peroneus Longus
  4. Gastrocnemius and Soleus
  5. Sartorius
  6. Lateral Hamstrings
  7. External Hip Rotators
And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation? 
  1. Mueller TPD orthotic device
  2. Inverted Technique with Kirby Skive
  3. Modified Root with Kirby Skive
  4. DC Wedge

This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.

What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are: 
  1. Too much correction in the heel fat pad for the body to tolerate
  2. Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
  3. You modify the Kirby skive, or the medial arch, for comfort losing support in the long run
The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support. 

Saturday, May 9, 2020

Sesamoid Fracture: Email Advice

Dr. Richard Blake,

I recently broke my sesamoid bone walking in a new pair of work shoes. As you can see in the xrays the fracture gap seems wide to me. How does one bridge the gap? And should removal surgery be on my mind. I am three weeks into the boot and just ordered a stimulator. I am hoping a couple months on the 0-2 level promotes healing. What are your thoughts? Is full recovery possible after therapy? Thank you for your videos and time.

Very Respectfully,

Dr. Blake's comment: Thank you so very much for the email. I am glad you are in the boot, and should stay that way for 3 months. The bone stimulator should be a 9 month ordeal, even if you are back running by then. Here is some advice that holds true from another post. 

  1. Put your foot on an ice pack 3 times daily for 10 minutes to reduce inflammation. You want to have all some symptoms from the break and none from the surrounding inflammation. Avoid anti-inflammatory meds since they can slow down bone healing.
  2. Talk to your podiatrist about getting a bone stimulator from Smith and Nephew called Exogen. You place on your foot 20 minutes twice daily. The bone stim company will work with you insurance company so you know what you have to pay beforehand. The bone stim will probably for the next 6 months.
  3. Discuss you Calcium and Vit D levels/intake with your internist to make sure they are not a problem. I would consider a bone density screen, and especially if you have any family history of osteoporosis. Get your Vit D 25 levels.
  4. Make sure you can make that removable boot into a painfree environment. All podiatrists know that one well.
  5. Learn how to do spica taping as shown on the video above.
  6. Get a baseline MRI. Plan on another one 3 or 4 months later.
  7. Have a PT show you some simple strengthening exercises to start doing now. Everyday you are losing strength, and it will take longer to get better the weaker your foot is, but you can not produce pain. My blog has ample exercises that you can review with the physical therapist including playing the piano, metatarsal doming, flat footed balancing, and inversion/eversion resistance band exercises.
Surgery is needed in 10% of the population, for many reasons. From 6-12 weeks in the boot, you will need to find someone to make good orthotic devices to protect you as you wean from boot to shoe. Some will use the rocker on the Hoka One One shoe to help, others just find the traditional athletic shoe is fine. Try to get some Dr. Jill's dancer's padding to begin using. You will need some protection, even slight, for up to 2 years at times, so the Dr. Jills can be used in sandals, high heel shoes, etc. Xrays are a small help, but MRI is crucial I think, especially if it gets to the point of deciding on surgery. I hope this helps you. Good luck in your journey as the country gets back to some normalcy!! Rich 

Wednesday, April 29, 2020

Hintermann Test or First Metatarsal Raise Test for Recognition of Posterior Tibial Tendon Dysfunction

     Hintermann published a paper in 1996 about a clinical test to help him decide whether a patient needed surgery for posterior tibial tendon dysfunction. It was based on the fact that with the patient standing, when the heel is inverted (or the leg externally rotated), only in the 21 patients that had posterior tibial disease (not necessarily ruptures) was this test positive for leaving the first metatarsal off the ground. It is now known more as the First Metatarsal Raise Test. When I read the article many thoughts crossed my mind, and I need to do this test some, but I need other podiatrists to give me feedback on their successes and failures. So, what bothered me about this test? The things that bother me are:

  1. 100% of the patients were positive even though the surgical findings were all over the place (from tendinitis only to complete ruptures)
  2. 100% of the patients without post tibial tendon disease were negative, but they do not go into any of these patients (allow they implied the test was being done over 4 years)
  3. They made no reference to what type of orthotics were being used preop to avoid surgery and whether the tendon being strengthened thoroughly before (there was no mention about posterior tibial strength at all)
  4. They seem to have no knowledge of deformities like rearfoot varus, rear foot valgus, forefoot valgus and forefoot varus. Any of these common deformities would greatly affect this test. 
  5. In most of my patients with PTTD, with 10 degrees of heel eversion, and 10 degrees of positional forefoot supinates, when I put the patient into heel varus the first metatarsal is going to be way off of the ground. This does not mean I need to do anything but rehabilitate them. 

I am so hopeful that my esteemed colleagues around the world will help decipher the importance of this test. 

Saturday, April 18, 2020

Surgical Complications Post Bunionectomy and Pes Cavus Foot

Hello Dr. Blake,

I hope you are doing well and staying healthy during these crazy times! 
I have been thinking of writing you for quite a while, but my question is quite lengthy.
 I have attached some x-rays and photos to this email, but I also have a CT cat scan
 and an MRI of my foot if having those would be better.
Dr. Blake's comment: Yes, send those to Dr. Rich Blake, 90 Beachmont Drive, 
San Francisco, CA, 94132 to see if those are revealing. 

I have developed a hallux claw toe in my right foot after I had a bunionectomy
 and tibial sesamoidectomy in 2014 and I am wondering
 if I should get surgery to prevent a joint fusion surgery in the future.
 My toe does not bother me terribly now. Every other day I can go on a 1 mile walk,
 with minimal discomfort. However, I have noticed that as time has gone on
 it has become progressively more sensitive 
(able to walk less and less mileage without the next day hurting)
 and I want to maintain a relatively active life as I am 33 and a mom.
 My right big toe does not really touch the ground, and my other four toes
 on the right foot are starting to develop hammertoes.
 My left foot also has hammertoes so I know I am prone to them,
 but they are still relatively mild on both feet.
 I have been recommended two different surgical techniques to prevent further problems 
down the line with my foot, and am wondering whether you think
 1) surgery is a good idea, and 2) if so, which surgery you think I should opt for.


Initial Breaking of Tibial Sesamoid with subsequent Surgery: I have high-arched feet, 
and have worn orthotics since age 13 or 14. 
I broke my tibial sesamoid after wearing heels to a party in 2013.
 It was described as a freak accident (as I guess most bone breaks are!) 
but people had always remarked at how high my arches were,
 so I guess the pressure was too much. 7 months later 
I was told there was no healing and it was recommended I have a tibial sesamoidectomy
 as well as a bunion surgery (chevron osteotomy), 
as I already had a bunion but the broken sesamoid was accelerating its progress.
 I wish I had found your blog back then, as it was described as a relatively easy surgery
 with minimal complications. After the surgery I went to physical therapy. 
It was always hard for the physical therapist to get my big toe to touch the ground even then.
 A year after the surgery I noticed my right big toe no longer touched the floor when barefoot.
 As long as I wore orthotics in shoes I was pain-free and comfortable
 and could go about my daily life. Walking barefoot was uncomfortable 
because the ball of foot was pushed into the floor without weight bearing from the big toe.
Dr. Blake's comment: This is a common problem with the tibial sesamoid removal 
which weakens the short flexor under the joint. This enables the tendon on the top
 of the toe to win, called the extensor.This dynamic imbalance pulls the toe up 
starting the hammertoe. With the pes cavus or high arched foot, you probably
 even before surgery had a tighter extensor ready to pull the toe up. With this being said, 
it does not explain why the PT could not get the toe down which let this get out of hand. 

Most Recent Setback: In May 2019 I wore a pair of heels on date night
 and walked about 10 minutes on the cement sidewalks. (No heels allowed in my closet again!) 
The next day my fourth toe and especially my big toe were very inflamed,
 and it took 5 months of me wearing a boot and daily icing in order for the symptoms
 to calm down. This is when I found your blog. During those 5 months
 I visited multiple podiatrists and two orthopedic surgeons to try and figure out
 why it was taking so long to heal. It was determined that I stretched the collateral ligaments
 in my stiff big toe. The second orthopedic surgeon had a nerve-conduction ordered
 to ensure I did not have charcot-marie-tooth disease, due to my high arches,
 raised toe, hammertoes and slight atrophy of right-side calf muscles. 
Luckily it was determined I do not have the condition, but both orthopedic surgeons 
commented on how raised my big toe was, and were concerned about how my foot
 would handle such biomechanical stresses for the duration of my lifetime. 
Both of them suggested some surgical techniques to prevent the further deterioration of my foot.
 I know you are not a proponent of “preventative surgery”, but I am wondering
 what you recommend in my case.
Dr. Blake's comment: All we know right now in this correspondence is that you 
have a very sensitive
big toe joint. I think everyone, except a few surgeons, would agree 
that an operated on joint, is and will
be forever a weaker joint. When you do hip surgery, and slightly less with knee surgery, 
you can 
establish great stability on the surgical site with the surrounding muscles. You
have great opportunity to really tone them up. The foot has some crucial
muscles to help, but as podiatrists we mainly have to rely on shoes, orthotics, 
accommodations, taping, 
etc, and physical therapy to breakdown scar tissue, remove inflammation, 
and stretch and 
strengthen the muscles up the leg to the hip. 

Current Pain and Issues:

1) My current symptoms are that my toe is quite stiff at the MTP joint, 
and semi-rigid at the IP joint. I have good range of motion with the toe going upwards
 but pretty limited motion when trying to force my toe down. 
 The bottom of my big toe is sore (scale of 2 out of 10) if I go on a 1 mile walk or more.
 If I go on these walks for more than a couple of days I have to take the next day off. 
Furthermore, the side of the top of my big toe gets sensitive too if I go on long walks
 or walk barefoot on hardwood floors. I have noticed this is because my big toe 
actually turns into the rest of my foot, in addition to the claw toe. 
It feels like the bone is pushing out? This varus has been increasing over time. 
Dr. Blake's comment: So, if you were in my office I would have you practice and get really good at
spica taping to hold the toe down for the next 8 weeks. Patients usually can advance 
from the easier KT 
or Rocktape to the 3M Nexcare Waterproof tape. You should have a PT over the next 
month to year 
(when corona quarantine is lifted) measure the amount of plantar flexion 
of the big toe joint which
we will compare to 3-6 months from now. 

Also begin to experiment with the dancer's padding idea to shift weight from the 1st metatarsal
 and toe 
onto all the other toes in whatever shoes you can.  

Surgical Options:

1) First Doctor (Scar Tissue Removal):

a. Concern: The first orthopedic surgeon was concerned that without the use of my big toe
 the ball of my foot would take too much pressure and I could therefore damage
 my remaining sesamoid or put too much weight on the other four toes, 
causing an acceleration in the hammertoes in this foot. He noted that the IP joint
 was still flexible, and thought I had developed a claw toe largely because of
 scar tissue buildup from the first surgery in the MTP joint. 
He thought my symptoms would be greatly improved if I could get
 another 20 degrees downward or so from the big toe.
Dr. Blake's comment: He has the right idea. We need the joint measured so we can 
document this 
improvement. We need the tape and dancer's padding to do what he wants his surgery to do
 at this time. 
3-5 times a daily you need to stretch down the big toe at the ball of the foot joint.
 Hold 30 seconds, relax
5 seconds, and hold another 30 seconds. You need to straighten the IPJ which is
 flexible by pulling the 
toe out again 30 seconds times 2. You need to strengthen the EHL by pulling 
the toe up at the IPJ only, 
you have to hold the proximal phalanx down. You need to strengthen the FHB
 you have left (same 
exercise as in my video on bunion). Do these once daily in evening and build from 
10 to start of each 
to 30 over next 6 weeks (adding 5 more every 10 days or so). 

b. Timing: No rush, whenever is convenient for me and my family life.

c. Surgery: He recommended a 1st MTP dorsal capsule release and EHC scar release. 
Since there would be no bone being cut during this surgery, recovery would be relatively simple.

d. Recovery: Two weeks in a short cam boot and two weeks in a surgical shoe, 
with physical therapy afterwards.
Dr. Blake's comment: I think from the 2 photos above people can get an idea 
of your downward 
restriction of that joint. The 2 surgeries suggested are on the top of the joint
 to release things, but what 
if the whole problem is coming from the tibial sesamoid removal and blockage 
there to bring the toe. 
That makes more sense, since the surgical done effected the bottom more than the top.
 When you try to 
push the toe down, as in the photo above, where do you feel you are restricted? 
Do you feel tightness on 
the top limiting the downward motion, or do you feel a block in that downward
 motion from the joint 
itself? I am going to have you do my self mob routine from several weeks and 
see if you can get the joint 
looser. Now, for sure, you can have all the restrictions on top, 
and you will sense the restrictions inside, 
so this is not perfect, but I would like to make as logical a guess. 

2) Second Doctor (More Extensive Toe Reconstructive Work):

a. Concern: The second doctor seems quite concerned about the structure of my foot and toe
 (he originally ordered the nerve-conduction test for CMT) and is concerned that if the structure
 of my foot is left the way it is I will have significant degenerative changes
 on my toe going forward. He seemed pretty confident that if I left the toe 
untouched in its current state I would have to have a joint-fusion surgery in the future,
 possibly in both the IP and MTP joint. He said I really want to avoid a joint-fusion surgery
 and thinks this surgery would have an 80% chance of success.

b. Timing: Recommend to do the surgery within a year as he is concerned that my toe 
will stiffen if left in the current state.

c. Surgery: More substantial surgery. I would have a 1st metatarsal crescentic osteotomy,
 toe lengthening, IP joint arthrotomy and possible FHL lengthening.
Dr. Blake's comment: Let me start with the last 2: The arthrotomy just means 
to free up the joint (which
hopefully you can do with stretching or pulling the joint straight 
twice daily, and FHL lengthening
means to weaken it so it does not pull downward on the end of the toe so much.
 Let's mobilize, stretch, tape,
strengthening and off load as we have discussed.
 The image you sent talks to the osteotomy and toe 

d. Recovery: 6 weeks in a boot with no driving during that time. This is daunting to me
 since I am a stay at home mom right now taking care of a toddler (and I don’t have a yard!),
 but I would do it in order to better my chances of long-term foot health. 
Full recovery would be 6 months. Physical therapy afterwards.

So that is a summary of my problem. What are your thoughts on whether I should opt for a surgery, 
and if so, which surgery would you opt for? I am cautious since the first surgery
 I had took almost 1.5 years to feel better, but I want to maintain mobility! 
Do you think I need to get surgery or I will end up with a joint fusion later in life? 
I would appreciate your thoughts and advice on my issue. 
Let me know if you need more information…ie videos or the CT scan or MRI I also have.

Thank you for your time!

Dr. Jill's Sesamoid pad can help

Dr. Blake's comment: The side view xray of your cocked up toe and 
high arch showed nothing amiss, nothing obvious to cause concern.
The view from the top of your foot showed that the first surgery left 
the first metatarsal too short, thus the tendons retracting and creating 
the hammertoe. Yes, you can go back and correct for that mistake, but 
the rest of the joint looks perfect. A small bunion is starting so when you 
the spica taping try to straighten the toe slightly at the same time. Start 
wearing large toe separators sold everywhere, and use yoga toes 4-5 times
a week as a 30 minute stretch. What I do not know if it is best to do the dancer's
padding or a Morton's extension. I think you should see what feels better with 
a week of each. I use adhesive felt from Alimed 1/8 inch to create my Morton's Extensions 
and dancer's padding.
The morton's extension could go from the ball of the foot with a cut out for the
 good fibular sesamoid 
to the end of the toe. This all makes the most sense for the next 3 months. 
Hope this helps. Rich