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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.
IMPRESSION:
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. 

https://www.physio-pedia.com/Turf_toe

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.

Sincerely,

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