Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. Please email your questions to rlb756@gmail.com. Please consider donating to this blog if I was able to help in some way. Rich
Tuesday, January 19, 2021
Sesamoid Fracture: Email Advice
Sunday, January 17, 2021
Sesamoid Fracture to Return to Activity: Email Advice for 12 Year Old
https://youtu.be/0wAvxIOXY9o
My daughter is 12 years old and plays soccer. I will give you what happened month by month starting in November 2019 until now January 2021. It helps me to keep organized with how everything has gone.
November 2019
-She starting to complain of foot pain toward the end of Fall Soccer season. She had some pain in both feet but more on the right foot. She also had some knee pain. The pain would come and go and did not impact her playing. I knew that she would be getting a good 6 week break from end of November to beginning of January and made an appt with a sports podiatrist that my friend knows and this physician is involved with the podiatry care of a professional football team and seems to have a lot of experience.
December 2019
-Had her appointment with the sports
podiatrist and based on the way her foot hits the ground and her mechanics it was recommended to get custom orthotics. She was fitted for the orthotics. She was on break from playing soccer.
-She was given a sort of temporary insert to put in her sneaker and cleat to try to help until her real orthotics came in
January 2020
-She went back to off season training. Her feet and knees were feeling better from the rest. Also, the off season training was 30-50% of the usual fall soccer training, so she was getting more rest days and it was less intense.
-At the end of the month, her orthotics came in and we also started to find a cleat that would fit the orthotic.
February 2020
-During an outdoor soccer practice, she felt a pop in her right foot when she was making a cutting type of move. She then felt pain. She was still able to finish up practice. At this point we had a follow up appt in one week at the sports podiatrist. Things were very hectic that week and we iced her feet and took that week off from practicing and her feet were feeling better.That weekend though she had 2 futsal games and felt well enough to play.
-After the 2 futsal games she could not really walk in her feet. Our follow up appt at the sports podiatrist was a few days later and the x-rays revealed 3 fractures in the one of the sesamoids in the right foot. She was put in a boot. No soccer and no exercise.
March 2020
-Still in a boot
-Follow up appointment was moved back so to lockdown with Covid
April 2020
-Was able to get 2 telehealth appts
-Continuing to wear boot and then toward end of April could start to stop wearing boot.
-Left foot started to hurt but not as bad.
May 2020
-Some pain still
-got an in-person appt toward the end of month
-x-rays revealed 3 fractures of sesamoid on both the right and left foot.
-fitted for thick rehab orthotics
-plan is to be out of soccer until Spring 2021 season
-offload feet
June 2020
-rehab orthotics came in
-wear rehab orthotics
-off load feet
July 2020
-continue rehab orthotics
-mentally feeling very sad about not being able to play
August 2020
-continue rehab orthotics
-appointment with Caroline Jordan to see about how to deal with this injury
-started Physical Therapy - working on strengthening overall body while still offloading foot
September 2020
-continuing Physical Therapy offloading foot and rehab orthotics
October 2020
-X-Rays reveal Right Sesamoid fractures almost healed and Left Sesamoid fractures improving
-Continuing Rehab Orthotics and Physical Therapy offloading feet
November 2020
-Continue Rehab Orthotics and Physical Therapy offloading feet
December 2020
-X-Rays reveal both Right and Left Sesamoid fractures clinically healed
-Physical therapy begins to gradually increase loading feet in small increments
January 2020
-Physical Therapy continues to increase loading feet and moving towards integrating soccer
-Physical Therapist and Soccer Coach talk and agree on plan to gradually work on in corporations her back into off season practice drills
-fitted for sports orthotics to fit in cleats
-finding appropriate cleats to wear with sports orthotics
So far, she has been to 3 off season practices / her pain level has ranged between a 0-7. Is this normal? Should we get an MRI? What do you suggest we do?
Dr. Blake's comment: This is where the timing of the pain is necessary to advise you. What is the baseline pain during the day? What pain level during weight bearing activities? What is her pain after practice? Is there any swelling or redness? When her pain is over 2, what is she doing? These and any others will be added to this post. I hope some of my thought process helped. Yes, an MRI of both feet would be great, but you may not need at all now. Since we have both feet supposed with three fractures each, you should answer individually for each foot. Rich
I really appreciate any thoughts you have on her case.
Sincerely,
The Mom’s response to my questions:
Get Dr. Jill’s Dancer’s padding both right and left and both sizes: 1/8th inch and 1/4 inch. These usually take alittle effort finding the right position for their hole, and discovering which side you need. These however only supplement the dancer’s pad built into the orthotic device, or can be attached later. I will try to show one below that is simply added to the shoe insert.
Thursday, January 14, 2021
Big Toe Non Union of a Fracture: Email Advice
Hello Dr. Blake,
I broke my big toe 6 months ago by 1st proximal phalanx.
It wasn’t too painful. While it was ‘healing’ I developed pain under my big toe which I thought was pain from the break. It turns out I developed sesamoiditis.
Also my toe is now a healed nonunion. I have been significantly impacted with pain most of the time. Walking even short distances was almost impossible for a while.
Even now it almost always hurts some to walk at all. I had a boot for 2 weeks at 3.5 months. I am getting PT which seems to help with general pain in toes but not pain on bottom of foot.
I was able to snowshoe on soft snow but hard ground is painful. I can swim with some pain and can’t push off wall with that foot. Biking hurts some. MRI showed no fracture or inflammation of sesamoids which presumably means tendinitis or capsulitis.
I have arthritis which I had before break but it wasn’t painful. MRI 3 months ago shows inflammation under 1st metatarsal area. Tight shoes make pain worse even if soft. Touching spot on bottom of foot with shoes or ground hurts. I am also now getting similar but less pain in other foot. I have a bone stimulator for toe now.
Is it possible to get better? Is cortisone a bad idea? If it hurts so badly wouldn’t that mean the bones are sore? Is there any treatment for tendons if that is it? Do ultrasound or other treatments work? What should I ask my doctor at this point?
Thanks for ideas.
Dr. Blake's comment:
So sorry to hear! A non union of the big toe typically requires surgery! Has this been offered? The bone stim is great but the toe has to be completely immobilized for 3-6 months while the bone is trying to heal! Typically any tendinitis or sesamoiditis is secondary to abnormal gait from the nonunion. So, do the best to heal the non-union or have the non-union surgically pinned. Hope this helps and I hope I understood the situation adequately. And, cortisone could help the joint capsulitis, but not good for bones trying to heal. Rich
Wednesday, January 13, 2021
Varus Wedging: A Simple but Powerful Means of Seeing if Correcting Pronation will Help An Area Painful
Tuesday, January 12, 2021
Repost: General Advice for Patients with Foot Pain or Numbness Related to Nerves
I live in London, U.K. My job is in I.T. - so desk based all day.
https://youtu.be/E0E60NpOSHg
- Neural Flossing three times daily (find out if sitting or laying techniques more productive)
- Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness so you would wait on this right now) etc
- Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
- Heat over ice
- No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques).
- Oral meds (start with evening doses only of Lyrica, Neurontin, or Cymbalta).
- Epidural injections into the L5 nerve root
- Soft based orthotic devices like Hannafords
- See if there is a Calmare Pain Therapy center near you
- Sometimes TENS and Capsaicin is helpful (but you have to go through 14-20 days of more pain first)
Monday, January 11, 2021
Stretching Principle #3: No Bouncing!!
The third stretching principle I would want all of my patient doing was to hold the stretch steady and not bounce or move in any way. We have talked about holding the stretch for 30-60 seconds (Principle #1). It is also to important when doing 2 or 3 sets to alternate between the sides right and left (Principle #2). Therefore, stretching should be relaxing, non hurried, and gentle to the body. These principles can be applied to any stretch you perform, and I have individual examples of problems when these rules are broken. I usually have my patients demonstrate how they stretch and I look to see if they are breaking any of my rules.
Sunday, January 10, 2021
Plantar Fasciitis: Top 10 Treatments
Plantar Fasciitis
The top 10 common treatments for plantar fasciitis:
1. Plantar Fascial wall stretch for 30 seconds 5-10x/day
2. Rolling ice massage 2-3x/day for 5 minutes
3. No negative heel stretches
4. Avoid barefoot walking (something like dansko sandal at home)
5. OTC or custom orthotic devices to transfer weight into the arch (you must feel that the heel is protected and weight is in the arch)
6. Physical therapy or acupuncture (2x/week for 4 weeks and then re-evaluate)
7. Posterior sleeping splints when morning soreness over 5 minutes (these can be used at any time as rest splints when you are going to sit 30 minutes or more)
8. Low dye/arch taping daily initially and then with strenuous activity (Try Quick Tape from www.supportthefoot.com for tape that works and lasts up to a week)
9. Activity modification to avoid “bad pain”
10. Calf stretches (straight and bent knee) 2x/day
This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery (even if you have a heel spur noted on x ray) for this since there are so many options for treatment. I once did a thorough review of the literature and found easily 72 different treatment options that made sense. These treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week (or every 2 week interval) there should be improvement once active treatment begins. If improvement plateaus, make a change. Analyzing what is working and what is not working should be part of the process.
When treating plantar fasciitis we typically deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanical support (transference of pressure from the painful areas to non-painful areas or limiting the pull of the fascia by less pronation, less big toe joint dorsiflexion, or less impact stress to the arch). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, and many other options. Cortisone shots are actually never given for plantar fasciitis, since you do not want to inject and weaken the plantar fascia. Cortisone is given to the area under the heel (typically a bursitis which develops secondary to the chronic inflammation) and away from the fascial bone attachment.
In resistant cases, 3 months in a removable cast can help calm down the inflammation and strengthen the plantar fascia which may have some micro tearing not well visualized on MRI or felt by the patient. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical support. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, plantar fascial tears all head the list in the differential diagnosis that may need completely other forms of treatment.
The above was an excerpt from my book “Secrets to Keep Moving”.
Saturday, January 9, 2021
Avoid Negative Heel Stretching
Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)
A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. The photo above shows a very powerful achilles and plantar fascial stretch. The position is normally used in an eccentric achilles strengthening program. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch, called Negative Heel Stretching, or Negative Heel Position, can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I mainly emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of Foot: Avoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas. Whereas you should not do with achilles or plantar fascial pain, you have to be very cautious even when you have no prior pain history in these areas. Eccentric achilles training can go from you heel off the ground as much as possible to a stable level ground position (it is still eccentric).
The following is an excerpt from my book “Secrets to Keep Moving”.
Friday, January 8, 2021
Metatarsal Doming or Arcing: One of the Best Foot Intrinsic Muscle Exercises
Thursday, January 7, 2021
Ankle Sprain Advice: General Treatment Rules
The top 10 treatments for ankle sprains are:
1. Understand that the more severe the disability is right after the sprain typically correlates to the damage produced
2. Create a pain free environment (0-2 pain level) as soon as possible with whatever is needed (crutches, boot, brace, etc)
3. If you see black and blue over the first 4 days, you have torn something
4. Just because you have negative x rays does not mean something is not broken (you may need an MRI)
5. Use all aspects of PRICE (protection, rest, ice, compression, elevation) for a minimum of 6 weeks.
6. Begin strengthening the ankle as soon as you injure it with pain free strengthening exercises
7. Ice only for the first 4 days, then start once daily contrast bathing, with more icing with aggravations
8. See a specialist when you think it will take longer than 2 weeks to completely heal, when you need crutches initially, when you can not bear weight, when you have sharp pain with each step, when you heard a loud pop with immediate swelling, and if the ankle looks deformed.
9. Do not begin to exercise without a brace until minimum of 6 weeks and you have done some balancing exercises
10. After 2 weeks, if your disability is marked (limited walking or can not think about running) consider an MRI.