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Sunday, September 13, 2020

AVN Sesamoid: Email Advice

Hi Dr. Blake,

I’m so happy to have found your blog and YouTube videos, and I hope you can provide some insight and guidance for my situation:

About me: 38 y/o female, chemistry professor by day, professional belly dancer by night and aspiring amateur Muay Thai fighter all day, every day (thai kickboxing).

History: late in 2019, I started noticing some pain in my left big toe upon extension. The pain was never severe, so I kept training. Nothing a little tape wouldn’t fix (or so I thought). Then the pandemic hit, and I started running a lot since my gym was closed. The pain got worse, I did less and less. Still, the pain was never terrible but it was persistent. I saw my podiatrist, and he diagnosed me with AVN of the fibular sesamoid by MRI in early June 2020. This was confirmed with spect CT in early July. My x rays were normal, there was no apparent fracture or degeneration. Both the MRI and CT showed some soft tissue inflammation/edema but no tears. I went in a boot for 6 weeks, and I was given a bone stim (ortho fix) that I’ve been wearing for 3 hours a day for almost 3 months. My pain was at a 0-2, so I have been attempting to gradually step up my activity, but it seems that it’s always 2 steps forward, 2 steps back. My PT primarily does manual therapy, and I’ve been doing toe yoga and trying to go for walks or short hikes (In the shoe recommended by my podiatrist - hoka Bondi 6). Anytime I do this, my foot starts to swell again and be painful. I am so frustrated.

Here is my dilemma - I also have some mild/moderate scoliosis, and the lack of activity has severely flared up my back pain - to the point that the idea of spine surgery has been floated by my sports med doctor. As a result of the crooked spine, I have degenerative disc disease (Several herniations, stenosis and facet joint arthritis) that I have been keeping in check by remaining fit and active. Resting my foot and doing seated exercises (like a stationary bike) has been hell on my back. Obviously, abnormal gait and wearing a boot didn’t exactly help my back either. I need to get back to my regular training/dancing schedule to ensure that my spine stays functional and I avoid back surgery.

What is the best course of action to return me to normal activity as soon as possible? In your experience, does this type of injury heal with conservative treatment and is the person able to return to their activity? I’ve scoured the literature, and the lack of studies is frustrating, and what little there is focuses on surgical treatment. How do people fare after surgery in your experience? I’m not keen on doing unnecessary surgery but I am trying to balance the needs of my back with the needs of my foot. Lastly, what is your opinion on the use of NSAIDS during AVN? I am concerned about the anti-angiogenic effects.

Thank you for taking the time to read this and consider my case.

Kind regards,

Dr. Blake's comment: Definitely switch out of the boot for your back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides, something your back will be happy for. Your physical therapist should be able to put you on a program to keep your back loose and strong as you go through the foot rehab. When will you get another MRI? I usually wait 6 months, but in your case, every 3 months to see some light at the end of the tunnel with the AVN healing. In your whole discussion, you mentioned nothing about all the other things besides Hokas: orthotic devices, dancer's padding on the orthotic and separate, cluffy wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. Send me a photo of coronal view injured sesamoid both T1 and T2 weighting to see the AVN. And yes, no NSAIDs, but you should be doing contrast bathing for deep bone flush and circulation every evening. Rich 

Tuesday, September 8, 2020

Article on Hamstring Tightness and Plantar Fasciitis

https://journals.sagepub.com/doi/10.1177/1938640010397341

     I have to admit that when patients present with plantar fasciitis I fail to measure hamstring tightness as much as I should. This is a good reminder that plantar fasciitis been be shown to be associated with achilles tightness, with pronation, with obesity, and with tight hamstrings. It is important to stretch out the tight hamstrings when plagued with plantar fascial symptoms. 

Liz, a nurse which used to work with me, discusses 7 principles of stretching while stretching the lower hamstrings. 

Sunday, September 6, 2020

It is Just the Wrong Timing of Events: Athletic and Other Injury Rehabilitation

     I am saddened when patients prolong their injuries with the Wrong Timing of their Treatments. Many times it is only because the definitive diagnosis has yet to be made. Many times it is because the health provider has too short of range of options to offer (as I do sometimes). Many times it is because the patient is impatient for a cure, or the subtleties of any treatment regimen is not followed or fully explained (and thus the patient keeps irritating things). And thus there are so many variables, so many different provider that will practice their treatment protocols, that I have found following the 0-2 pain level in all treatment phases must be followed. I know only some good physical therapists that can make you hurt and still get you better. I know that when surgery is required (1-2% of all athletic injuries) you will have more pain for awhile. But, in general, after you get the proper diagnosis, you should get better and better on a month basis (so September should be better than August, and October better than September, etc). 
     So, you develop pain with or without an injury. If the pain is between 0-2, and you can do full activities, you can probably wait a month before you see someone (and maybe the pain will go away by then). Of course, when you do see someone, you expect their diagnosis to be correct (which it normally is by the way), and month by month you get better and better (I assume 3 months on average to greatly improve if the injury requires a doctor visit). It is important in my mind to drive the pain down to 0-2 as quickly as possible (a week for sure), and then keep it there. This could initially be done by stopping an activity, put in a cast, and/or up on crutches. This is how you know you have the right diagnosis and treatment plan. You should be able to increase function, with no increase in pain, month by month. Of course, if your diagnosis requires a cast or boot or surgery, you may not be able to start that progression to full function for several months. In these cases, the diagnosis is definitive from the start (verified by xray or MRI or ultrasound).
     So, that is the Right Timing of Events: Injury or Pain Development, Proper Diagnosis and Treatment, Pain Quickly Down to 0-2, and Pain Kept There as Full Function Returns. Sounds simple, but it gets messed up all the time due to the limitations on medicine listed above. And, we can add insurance issues that block both diagnosis (say inability to get MRI) and treatment (do not cover the expensive bone stimulator you need). The patient is carefully moved through the phases of rehabilitation (immobilization, re-strengthening, and return to activity) and all goes well. 
     I will give you 2 recent examples of the Wrong Timing of Events. The first was a patient that partially tore her achilles, pain level 6-7, limping. She went to the local hospital clinic, and received 3 stem cell injections one month apart as her only treatment. No cast. No driving the pain to 0-2. And, no better, so 5 months later comes to me for a second opinion. This is one of the top hospitals in the country, or so they advertise.  The second was a patient whose plantar fasciitis was improving with orthotics, taping, icing and stretching, but when she had a flare from running too much on the weekend, when the pain got to 5-6 from the 0-2, all the doctor did was put some more padding on her orthotic devices and give her a Rx for PT. This does not sound bad, but she had never had this much pain, and it took 3 weeks to see the PT for the first session (which is typically just information gathering). So, one month went by, the heel padding had made her worse, the PT really not started, and her pain from limping had increased to 6-7 levels. The doctor had a second chance to right the ship, but again the orthotics were adjusted, and taping was applied which did not help. She clearly had a severe flare of her plantar fasciitis or a new injury. After seeking a second opinion, due to the level of pain, an MRI revealed a calcaneal stress fracture, and definitive treatment started. So, when the pain you are treating gets worse, ask yourself if you still believe in your working diagnosis first, and ask how can I reduce this patients pain to 0-2. 

Friday, September 4, 2020

Bi-Partite vs Fracture in the Sesamoid Bones

Hey, I came across your site yesterday while doing some research. I have been dealing with some pain on the side of my left big toe joint since December of last year. I initially went to a local orthopedic where they x-ray both feet and they said I have bipartite sesamoid on both feet. They didn't really have any answers as to why I am experiencing pain though. I am able to run fine but and the pain is more of an annoyance than a debilitating pain. I can run for 3 hours or even do hike/runs for 6 hours and the pain doesn't get any worse. I would say the pain level is between 4-6.
Dr. Blake's comment: To most of my patients, pain levels over 2 and they are going to the doctor, and over 5 they are not running at all. 

Just walking around the pain is at a 1-2.

I recently went to a podiatrist foot and ankle specialist and he immediately said I in fact have a fractured sesamoid on my left but the right is a bipartite sesamoid.
Dr. Blake's comment: Only an MRI is conclusive, but to me they both look bi- and tri-partite with smooth borders. Sesamoids that are in multiple pieces congenitally can get irritated, even the junction between the bone fragments sprained or fractured. If you are not getting an MRI, you have to go by the amount of swelling, the level of pain, and use comparison xrays 3 months apart or so that will show a change. A broken bone will change and the xrays after 3 months will show that difference. Month to month changes will be less definitive. Unfortunately, when I have a decision between fracture and bipartite, and I can not get a definitive MRI, I treat it as a fracture with a cam walker for 3 months and I definitely do not allow my patients to go over pain level 2. 







He said I could try some custom orthotics or have surgery to remove it and that would fix the issue. Attached are images of the x-rays.
Dr. Blake's comment: To do surgery on a probable in your case non-fractured sesamoid is pretty absurd. So, custom orthotics (which should be only one of 10 things you are doing for your sesamoid to drive the pain now and let this heal: removable boot, hoka one one rocker shoes, spica taping, dancer's padding, cluffy wedges, activity modification, icing, contrast bathing, bone stimulator, and some PT to get their advice). 

If I get the surgery will I be able to run again? I am a competitive trail and ultra runner and I also race mountain bikes.
Dr. Blake's comment: Typically, unless you are the 1 in 10 that gets some complication, or has other unknown factors at play, you can run again, but the sesamoid bone will have to always be protected. Always. And this is why patients fight getting the right diagnosis and right treatment no matter how long it takes. Good luck Rich 

thanks