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Saturday, March 31, 2012

Sesamoid Fracture Advice with MRI images

Dear Dr Blake, 
I've been studying your blog for a few weeks now. I'm so grateful that you take the time to do this!

So, I was hoping you could help me with my sesamoid gone bad situation. Here is my story: 

A few years ago, I fell during yoga. My toe swelled up like crazy. I went to the dr, had an X-ray and was told it wasn't broken. It healed quickly-- I was walking fine within a week and just had occasional soreness in the ball of my foot for a few months. My toe, however, never quite regained full movement. But, all seemed good. I could work out and wear heals, so i was happy! 

Fast forward to this past October. Id started running more and had felt just a little bit of pain. Then I got a Thai massage-- in which they stepped on my feet-- it was really intense. (the funny thing is i had just gotten back from a trip to Thailand and had lots of massages without issues! ) I knew she did something. A few days later, my toe swelled like crazy. 

I went back to the dr and had another X-ray. They said no fracture and referred me to a podiatrist. He said it was broken in half, there was no hope of healing it, and the only thing to do was give me a cortisone shot.
Dr Blake's comment: No one can ever tell with complete accuracy if an injury has no hope in healing. My patients have been fooling me for years, healing sometimes very difficult fractures without surgery. In most cases, we should always give the body a fighting chance to heal. Cortisone in this situation could only mask the pain, and the injury get worse (with more damage being produced by the lack of pain). Cortisone also slows the normal activity of the bone forming cells that are needed to heal bone injuries. There are so many treatments for sesamoid fractures that may be tried in an attempt to heal without surgery. Most of these treatments including orthotics, taping, dancer's pads, shoes, etc can be used if surgery is necessary. And, you have already learned what works and does not work. 

 At my questioning, he ordered a MRI. When the MRI came back, that report found no fracture and suggested sesamoiditis. (which confused me-- if it was indeed "broken in half," how did that not show on an MRI!?) He said it was still fractured, dismissed my questions and gave me a boot, but I also fired him. (Seriously the worst Dr I've ever seen) 
Dr Blake's comment: Here is where I will try not to insult my friends the radiologists, but podiatrists read these subtle foot injuries so much better in general. This is why I always want to see the actual films/CD, and not just the report. The game I play is to review all the films first, come to my conclusions, then review the report. The radiologists who read the films do read many more than I, but they always are not treating the painful foot. The responsibility of treating the foot can awaken a sense of what causes pain and what doesn't. 
On the advice of a friend, I got an exogen machine on eBay-- i used it a bit, but then started to notice a slight bump on the side of my foot -- suspect a bone spur-- and wondered if the machine could be causing the bump. Can the exogen machine hurt my foot if it's no fractured? ( which I'm not certain of at this point.) 
Dr Blake's comment: Never heard of a bone stimulator causing excessive bone formation. They do not work like that. Exogen sends a negative charge at a fracture which allows one side of the fracture to be negatively charged and the other side positively charged. This pulls the sides towards each other. This does not cause bone formation. If both sides are positive, which is what they have found in bones that do not heal, the two sides of the fracture will not be drawn together. 

I'm currently waiting for a new referral to a different podiatrist. But, it's slow moving with my HMO. (and I'm not sure how helpful he'll be--  losing hope! )
Dr Blake's comment: Check out if you can see any of the podiatrists in San Diego that are members of the AAPSM, generally a great group. See the website at and check the membership list. You can send me a list of who you can see in your HMO and I will be happy to refer you, or at least have you call someone in San Diego I know that knows the docs on your list. 
I've been in and out of my oh so lovely boot since November-- it will get better, then I have to get back in the boot. 

I just got a copy of my MRI -- and am trying to read it by looking over your blog posts. Haha! Then I thought, maybe I should just email him to see if he is willing to check out the images! 

Anyhow, thank you so much for reading this and for all your blog posts!

Ann from San Diego

Ann, thanks for contacting me. I will be happy to look at the images. You can fed ex to Dr Rich Blake 900 Hyde Street San Francisco Ca 94109. Never heard of any problems like that with Exogen. Do not lose faith in podiatry for the next one may be great. When I had a severe life threatening problem 27 years ago, I got 10 opinions. The last one saved my life. Hang in there. Rich

Then Ann sent the images below clearly showing that the tibial sesamoid bone under the first metatarsal was trying to heal. Quick recommendation: 2 months solid in the boot from this moment, find a new podiatrist who understands all the conservative treatments available, get a new MRI in 2 months to check progress, do not be out of the boot unless you are in shoes, inserts, taping, etc that produce a pain free environment for healing.

On this image the tibial sesamoid is dark when normal bone is white. Above the injured tibial sesamoid the first metatarsal looks very healthy, let us keep it that way.

Same image except the normal bone is dark and bone trying to heal is full of fluid and is white. Note the swelling in the top and bottom of the big toe joint. This swelling produces significant pain and we need to gradually reduce. As you walk the sesamoid pushs on the swelling and produces pain. So right now you have pain from 2 sources. You need to eliminate the pain from the swelling by three times a daily cooling the joint down. 10 minute ice pack twice daily, and one full contrast bath treatment, normally is enough to accomplish this goal. 

This image of the area just below the metatarsal head dramatically demonstrates the pooling of swelling under the sesamoid. When you walk on the sesamoid, even after the sesamoid is healed, this swelling produces pain. Pain produces the terrible image that you are not getting better so when someone recommends surgery, it can be hard to resist out of frustration.

Image section just above the last one showing that the swelling at the sesamoid level is all around the tibial sesamoid, and probably where the swelling seems to produce a bump.You may be developing a ganglion cyst in that area, but definitely not excessive bone formation from the Exogen machine.

Another image now higher on the metatarsal 3mm or so above the sesamoid still showing swelling. When swelling gets into this part of the joint (closer to the arch), the bend of the joint may get restricted adding to the pain.

This image is another 3mm higher than the last and clearly shows that the metatarsal head has no arthritis. Looks great.

This type of image shows the good fibular sesamoid and the broken tibial sesamoid. The fracture line is only seen by inference at the junction of one part of the fracture to the other. This is quite common to see one part of the 2 fracture pieces looking more involved with the healing process. The arrow is pointing to the damaged tibial sesamoid.

Another image of the healthy metatarsal head. Very important to make sure that we are only dealing with sesamoid problem, and not also hallux rigidus/limitus.
Clear view of the injured tibial sesamoid all in one piece (not displaced), and no darkest in the metatarsal head above which would indicate some cartilage breakdown.

Small bone spur is noted on the top of the metatarsal.

Another small irregularity noted at the base of the big toe.

This is probably the main reason you hurt. The swelling under the metatarsal head that you need to reduce. You want your rehab to be based on pain from the sesamoid injury, not pain from the swelling that collects here during the healing process. From the looks of the sesamoid it is going to take 6 to 12 months to get totally better, but you should be running much earlier than that.

Here is swelling also seen at the top of the joint.

Friday, March 30, 2012

Psoriasis: Patient Recommended Topical

Psoriasis medications can be very expensive. Helen had one of the worse cases of psoriasis on her foot that I had seen. The salves recommended by her dermatologist were just too costly, even though quite effective. Helen experimented on her own for one year and found the below treatment to be equally effective at a fraction of the cost. Some of the herbs used by the Chinese herbalist were unknown to her. I asked her to send me this info so I could pass it on to you. 

Dr. Blake,

It was good to see you today. Here is the information you requested on
psoriasis. This is what I used and it helped a great deal.

Acupuncture ( I went to Evelyn Roberts, she's good and has all the
herbs right there in her Chinese Pharmacy)
Chinese Herbs for soaking feet.
Psoriasis Control Cream by TriDerma
     Sometimes available at Walgreens.
Zinc Pyrithione Cream
Moisturizer for Extra Dry Skin

That's it.
Hope it's helpful.

Thanks for all your help,

Thursday, March 29, 2012

Fractured Fibular Sesamoid Email Advice

Hello Dr. Blake:

Thank you for your awesome blog. I have found some very useful information with regards to my own problems. However, I do have a few questions for you. I have a fractured fibular sesamoid. I believe I am in the healing stages, but I have some concerns on what is normal/average in healing.
This is an image of the broken fibular sesamoid on the left side. See how round the normal sesamoid looks.

Here is a case where the fibular sesamoid to the left has small dark cracks that are healing, and the obvious bipartite (2 pieces) tibial sesamoid to the right also shows signs of bone healing (irregularities within the bone). 

My background is that I am a 26 year old male and I am moderately active. In mid-September of 2011, I was on a hiking trip/ get away with several friends. We went on an intensive half day hike and spent some time playing some ridiculous dancing game, which I participated in without shoes and on hard wood floors. While on the hike, I wore an old pair of athletic shoes. The following day my foot hurt significantly in an aching sort of away. This continued off and on for a few months as my chiropractor cited their own suspicions for the pain and tried different practices on my foot. However, none of it worked so I went to an orthopedic doctor in January 2012. I had my foot x-rayed and he immediately diagnosed my fibular sesamoid as having a visible stress fracture.
Dr Blake's comment: When diagnosis goes 3 plus months from occurring, thus delaying proper treatment, the treating physician should be more conservative/more cautious in the treatment. Stress fractures of the sesamoids without fracture displacement take normally 3 months in a removable cast to heal, then a 6 week weaning process out of the cast. During this entire time a painfree environment should be established. This is especially true with delayed diagnosis.

I spent four weeks in a cam-walker/boot and returned to have more x-rays. He said that is still showed a fracture, but it was healing. In physically examining my foot he found spot that was still tender.
Dr Blake's comment: The tenderness to palpation can exist for months and months after full healing occurs. So it is of only slight importance at this stage, since the bone swells during the healing process as it brings in the nutrients for healing. The cam walker, like below, should be used with an EvenUp on the opposite foot, and if orthotics are successfully made that take off the weight and produce pain free ambulation during the second month of casting, gradual weaning of the cast can begin. Two months is the fastest to begin weaning out of the cast. X-rays can show the fracture line many months after the bone has completely healed. Part of the reason is that the fracture area will have the most fluid, making the calcium content diluted. X-rays only pick up relative calcium concentrations, so more water in an area will make the bone look less healed. Also, healing of the fracture occurs internally first with strong but immature bone, and the fracture healing on X-ray can be 2 months the actual intrinsic healing. Which is really all we care about. So, X-rays are also a relatively poor indicator of overall healing, although can show the fracture is getting worse, etc, so still used.

 That is when he discussed with me that sometimes the sesamoids don't always heal and that they sometimes have to be removed. (Not something that I wanted to hear.)  I was told to wear the boot another two weeks with an additional two week transition out of it. He stated that if I was still having some pain issues to schedule another visit with him.
Dr Blake's comment: If I took this approach, I would recommend surgery to 90% of my patients unnecessarily. Stay in the boot for 3 months total since you are too young to screw this up. Get some Sole Arch Supports or Superfeet (may have to see what naturally feels better on the sesamoid). The third month in the cast is the time to get the insoles that you will use out of the cast in order with some version of a dancer's pad, learn to spica tape, have your Vit D3 levels analyzed, ice twice daily to reduce the remaining inflammation, and pick up the most comfortable shoe of the sesamoids (normally running shoe or cross trainer). It is not the right time to start figuring that stuff out the day you are ready to wean out of the cast. 

Two weeks later, I am at the present time. I still have aching underneath the ball of my foot. Though it is not constant or necessarily as strong, I am concerned that it may not be healing as it should be. I have not scheduled another appointment as of yet. As a side note, I have been taking a calcium supplement that equates to about 1200 mg a day and 800 units of Vitamin D3.
Dr. Blake's comment: I like 1500 mg Calcium and 1000 units of Vit D3 for athletes in general, and this is a great time to take these levels. 

Here are my questions:
1.     Is it normal to encounter some soreness/ aching while healing?
Dr Blake's comment: Yes, and keep the pain level between 0-2 on the pain scale. Read my post on good vs bad pain and commit to memory. 

I have been visiting the gym and using only the elliptical and bikes for cardio. I attempted a treadmill for about 10 minutes, but it made my foot really ache.
Dr Blake's comment: I hate the treadmill at this stage of most foot injuries. The biomechanics of stress free treadmill walking or running is based on you hitting the treadmill at the exact speed that you set the treadmill at. If your speed is slower than the set speed, the belt jerks your foot to speed you up. If your speed is faster than the set speed, the belt puts tremendous stress on your foot to apply the brakes. I try to keep my walking and then running rehabilitation on the streets. 

2.     Are the machines I’m using likely to aggravate the foot or are they safe to use? Should I be using other machines instead? At what point is it safe to return to the treadmill?
Dr Blake's comment: Do not know enough about you in specific, but I would definitely stay away from the treadmill at this time. Biking is normally fine, and a stationary bike perfect since you can control where you foot is on the pedal. Swimming great. Elliptical without arms is okay if you have the right orthotic/dancer's pad protection. I try to have my patients go with no arms, since that arm motion forces your heel to fit off the supporting surface. Even with that, the elliptical can still put unnatural force against the ball of the foot since it is a solid metal platform pushing back on the sesamoids with great force. But, listen to your body. It tends to tell you as an individual what you can and can not do. 

3.     I asked my doctor at my last appointment if there were special inserts or shoes he would recommend and all he stated was a stiff soled shoe. What would you recommend?
Dr Blake's comment: Stiff soled shoes are wonderful unless you actually try to push off against the stiffness. Patients really vary in the shoe gear. Some patients need more cushion in the forefoot, others need it stiff, others actually need it to be very flexible. We use generalizations for everything in medicine. This is one of them that has a lot of truth, but there are many exceptions to that rule.

4.     Lastly, should I schedule another appointment with my doctor or is this all part of the normal healing process?
Dr Blake's comment: Yes, unless you decide to get some other opinions, which I love when patients are not improving or elective surgery is being recommended. Go in with your cast on, read all the posts on the tips for conservative treatments on sesamoid injuries, but also Hallux Limitus/Rigidus. The same rules and exceptions can apply. Ask a lot of questions. Never stupid questions at this stage since your life long foot health is at stake.  Hope all this helps. Rich

Thank you Dr. Blake. I look forward to hearing your expert advice.

Brian (name changed to witness protection)

Sunday, March 18, 2012

Severe Neuroma/Nerve Pain: Email Response

See the Link to the post that this email is in response to. 

First, you are so wonderful to post about conditions to give people an idea of their options.

I just wanted to point out since I have a neuralgia and take elavil for it that Neurontin/Lyrica do not work for everyone.  If Neurontin doesn't help, it is unlikely Lyrica will since they are the same type of drug, Lyrica is a second generation. 

Makes more sense to change to a different class of drug before spending another 1-2 months waiting to see if Lyrica will help.  People usually change within classes due to side effects eg change from elavil to Pamelor if they are having good pain relief. 

Elavil helps me, neurontin does nothing.  Other people have a different response. 

thanks again,

Love getting your blog feeds in my mail.


Dr Blake's comment: This is a wonderful email in response to my recent post on Neuroma pain. I have used Elavil with Neurontin or Lyrica also. Elavil in this instance is used at bedtime, similarly to the use of nortriptyline or amitriptyline as an additive to Neurontin or Lyrica or Cymbalta. Thank you S.B.

Flat Feet Got U Down: Read This Story on Running Legend Darryl Beardall

At 75, local running legend hardly slowing down
Santa Rosa Press Democrat
To run 300000 miles on flat feet? I'd have an easier time of it if you tried explaining a Bassett hound playing Angry Birds on my computer. Bewildered, I looked for some perspective. I went to Dr. Peter Redko of the North Bay Foot and Ankle Center.
See all stories on this topic »

Dr Blake's son's wedding in Kona Hawaii: See Steve and Clare Blake in the center

Can you pick out the flatfoot?
So many generalizations surround feet that just are not true from a medical prespective. The general rule that all patients with flatfeet have very weak feet is totally insane. Flat Feet can be strong, weak, or somewhere in between. Flatfeet can be very stable, and very unstable. Flatfeet can run marathons and not walk across the street comfortably. One of the fastest woman runners I ever treated had the flattest foot I had ever seen. The foot is too complex to use these general rules, but it did get a lot of people out of the military in World War II. The shape of the foot should not be used to generalize treatment programs or success in athletics since there are just as many exceptions to the rule as people who fit the rule. And some generalizations actually only apply to less than 30% of the population. Sorry. Treatments are started with general rules and it is up to the practitioner to see if the general rule actually applies in followup visits. 

Saturday, March 17, 2012

Hallux Rigidus/Limitus Patient Blog Request (3/17/12---A St Patrick's Day Request)

Anonymous has left a new comment on your post "Hallux Rigidus: Surgery or No Surgery": 

It would be so great if there was a blog for all the people living with Hallux Limitus and could offer their tips on how they deal with this condition. I am looking to maintain an active lifestyle. I am hoping that there are a great number of people who are able to continue to work out and walk/run and are able to be somewhat painfree. Also, to find out what type of shoes that they have found to accommodate the orthotics. Hopefully, some that are somewhat fashionable and not the beige othopedic ones with the velcro closures. It seems everything I have read has been very negative. I am hoping there are those people out there who go day to day without this issue ruling their life!! 

So what do the readers think about this? Hallux Rigidus patients do very well overall, but the literature seems all doom and gloom. Why not at least offer this post where patients with Hallux Rigidus/Limitus can offer all there stories of what helped them?? I will try to direct my patients to this posting. Dr Rich Blake

Friday, March 16, 2012

Fractured Fibular Sesamoid: Email Advice Before and After Surgery

Hi Dr. Blake,

I sent you an email with lots of questions about a month or so ago. This is the link if you need: I have a couple other questions for you. I saw a podiatrist and he suggested removing the fibular sesamoid bone rather than trying the bone graph that the orthopedic doctor suggested. So I am waiting to see him again to schedule surgery. My question is about the surgery to remove the bone, what are the statistics for the surgery as far as positive and negative outcomes?
Dr Blake's comment: I am unsure of the exact statistics, but 50% excellent (no problems), 45% good (some problems, but surgery still successful), and 5% fair to poor (surgery not considered successful) would be a close estimate of my experience.

Also how long does it take to recover from the surgery mostly in order to return to work and of course to the dojo too. I am still working to find a comfortable arrangement of the taping and the off setting the foot with the pads, that is a work in progress.
Dr Blake's comment: Return to work and activities vary immensely because of the demands on our feet. Overall, 2 weeks the stitches come out, then 10 weeks of physical therapy for swelling reduction and scar reduction, running in 6-9 months with the proper shoes and orthotics. Most people take 2 weeks off work even if they have a desk job. 

While looking at new posts you have made I found this link: and I have a question about the pictures. On the fourth picture where you are showing the placement of the felt, the boot you are showing is much shorter up the leg than I have been able to find. It looks like it comes up just above the ankle. If this is so, where can I find one? I have just about worn out my second cam walker and I have been looking for one that is this low.
Dr Blake's comment: It is called an Anklizer, and you can google where to find it. Of course, do not forget the EvenUp for the opposite side.

My final question is about orthotics, the doctor suggested purchasing orthotics with a morton's support which is supposed to keep the big toe side of the foot straight. After I have surgery to remove the bone, will that be necessary or will the orthotics need something different?
Dr Blake's comment: Typically for 2 years after the surgery, the big toe is protected with orthotic devices. The ordering practitioner must experiment with amount of arch support ordered, amount of additional metatarsal arch applied, and whether it is appropriate to use a Morton's Extension or a Reverse Morton's Extension. The goal of all of these factors is pain free function.

 If I am going to buy the orthotics which are not covered by my insurance, I would like them to be good for a while until I wear them out. Or is this something that I talk to the person when they fit them?
Dr Blake's comment: The basic design of the orthotic device is to shift weight to the center of the foot. There are soft based orthotics which will probably last 2 years, and more permanent plastic based orthotic devices that may last 20 years with some regular refurbishing. 

I have been using the bone stimulator for about 3 months over night, wearing the cam boot daily with taping and the padding to off set the foot placement. I am not consistent on taking the vitamin D and calcium or the soaking which I am working on since I know it will help. This weekend marks 8 months since the injury and I feel my foot is in the same situation it was 5 or 6 months ago. Reading the information from your blog helps to see what you suggest and how others are dealing with this injury. I appreciate your wisdom and your willingness to share that information with everyone. Thank you again for your help and have a wonderful Thanksgiving!


Hi again Dr. Blake,

I hope you are having a great Christmas and New year. I read your latest post and I am sad to hear that someone else is in my situation, but at least she has you to take care of her. When you mentioned that your new patient may move to using a bone growth stimulator, I remembered that I have one that I used for 4 months and now it needs a new home. I have no use for it now and she can have it is she would like.

As I write to you, I am nursing a foot that is now minus one bone. The surgeon removed the fibular sesamoid bone that I broke back in March. He did say that the bone was completely broken in two, I guess that would explain why my foot has been so painful. I go to see the doctor next week to have the stitches removed and to talk to him about orthotics and therapy. I am going to take your suggestions with me when I see him and see if we can get orthotics with those stipulations. Even though I am still a long way away from going back to the dojo, I am on the look out for light weight shoes that I can put the orthotic in so I can keep my foot protected while getting back to the fun of katas and sparring. To begin with though, I need to get back to work. I am a teacher and my students have moderate to severe disabilities so I need my feet ready to stand all day and run when necessary.

Thank you again for your help and suggestions and please let me know if your patient can use the equipment.

Happy New Year!


Dr Blake's comment: After I never responded to this email, I did write Tammy a note one week ago asking for a progress report and apologizing for my laziness of sorts.
Hi Dr. Blake,

Yes, a lot has happened since this last email. Right now I am one week away from the anniversary of when I hurt my foot to begin this whole mess. I had surgery on Dec. 16th to remove the sesamoid bone and the dr said that it was completely broken in two pieces. So I guess it is no wonder why it has been hurting. I was out of work for 7 weeks since I am a middle school special ed teacher and my students have severe to profound disabilities. I am on my feet all day pushing and pulling wheelchairs, lifting students etc. I continued to use the shoe padding to off load the area of tenderness in the boot as well as in shoes, but I still haven't mastered the use of the happads or the dancers pads, they just seem to hurt the arch of my foot.
Dr Blake's comment: Tammy is 3 and 1/2 months into a year journey to get the majority of her healing done. Sounds like everything is still quite aggravated. Make sure Tammy that the dancer's pads are just under the metatarsals. No need to get them near the arch. And ice for 10 minutes 3 times daily. If the foot is swollen, the try contrast bathing listed in one of my YouTube videos for one of those sessions. Since you have to walk on the operated foot, cool it down on a regular basis. 

When I went back to work the doctor wanted me to be in regular shoes all the time, but I couldn't make it the entire time. I am currently wearing the cam boot and the regular shoe during the day. I have been walking on the outside of my foot still, even though I can walk gently on the entire foot, but it is almost like I have to concentrate on walking heel to toe. I presume it is a bad habit I have taken up in the last year.
Dr Blake's comment: Tammy I see patients limping unconsciously 5 years after surgery. When some other body part begins to hurt due to the limping, chances are that the limping is not blamed and treatment is based on the wrong premise. It is important at this stage to walk slow, and walk correctly. I allow occasional limping to avoid pain. And walking normal with pain is not right. If you can not walk normal without pain, go back in the cam walker. I have my patients use the cam walker for some purposes for even 6-9 months after surgery. It is okay. There are too many protocols for these things that do not address the individual patient. Just to say you are at 3 months, and you should be full time in regular shoes, is based on averages. Averages are based on Bell Shaped Curves. If you know anything about Bell Shaped Curves, 1/2 of the patients are in front of the average and 1/2 of the patients are behind the average. General rules are just generalizations. Should I get to the Point? You are doing great Listening to Your Body. Have the Physical Therapist gradually remove all limping. They can be objective. 

 I started physical therapy last week, it consisted of some stationary bike riding and then the PT stretched the foot and massaged the scar. It was uncomfortable since it is still sensitive, but manageable.
Dr Blake's comment: Please check into buying Blaine scar treatment. It is a silicone gel pad to use for self massage, and another to wear that gradually gives off moisturizing oils to soften the wound. See my YouTube video on Self Mobilization of Scar Tissue using cross frictional or circular massage techniques.

 (He gave me some exercises to do at home too) The next evening and following day I was in the worst pain I had been in a long time. So I reverted back to trying to get it into a pain free state. It took a lot of drugs, ice and the blumjk topical stuff that you listed on your blog, this went on for two days.
Dr Blake's comment: This is my love hate affair with physical therapy. It takes a physical therapist 3 or 4 visits to know how sensitive tissue is to gradually produce positive change over the normal 10 week post operative period. You did the right thing reverted to what makes you pain free. Never ever go to a physical therapy place that has you see different therapists every time. You need consistently with the same physical therapist every time you go in for treatment. I normally like my patients to even cancel when they find out the physical therapist they have been seeing is off that day, and another PT will sub in. Physical Therapy is crucial for the healing of these injuries, but sometimes the physical therapists forget that.

 I went back into the boot all day too. Right now I am on the next day and it feels a little better, but I have taken it easy all weekend. I started using the blumjk the week I went back to work, so 4 weeks ago, and it made my foot feel so much better it was amazing. I have used that product a lot and shared with everyone I know. I think if their profits have recently increased I should be getting a kick back. :)
Dr Blake's comment: Tammy is doing all the right things to create this pain free environment for optimal healing. After you go through surgery, you want and demand every thing to go right. It is not a time to hope that things will get better, the patient must step up to the plate as you can see Tammy doing. It is her future, not the doctors or the therapists. I am not sure what medication she is talking about exactly.

 The PT also suggested that I wear a lace up ankle brace to give my ankle some support and hopefully help to get back into shoes, but the brace along the bottom of the foot cuts off right where the painful part is. He was going to try to come up with something else next time I see him. When I wear the ankle brace it is tight in the shoes so I don't use the padding to off set the weight. So I am kind of at a loss of what I should be doing.
Dr Blake's comment: Not sure why an ankle brace is at all necessary for big toe joint surgery!!!

 I went to talk to the man who makes the orthotics, the surgeon said they would be helpful and that I wouldn't need to have mortons extension, and he said to come back to see him when I am wearing shoes all the time. I haven't gotten there yet, earlier last week I was making it about half the day in regular shoes and then the rest of the day in the boot. It seems like I am taking one step forward and then five steps back and it is frustrating and painful. I haven't been at the dojo, other than standing and pointing, but have tried to increase my exercise carefully by riding the stationary bike. Definitely not as fun as sparring and working on katas and self defense.
Dr Blake's comment: Morton's Extension or no morton's extension, you need your orthotics to off weight the big toe joint right now. You wear the orthotics in your shoes, you wear the orthotics in your cam walker. The only role of the orthotic guy/gal is to make you a comfortable orthotic for the big toe joint that works in shoes and cam walker, and someone who understands how to think outside the box if things are difficult. Morton's extensions are a possible addition to the orthotic that may help your situation, it is not the main event. Get one now from someone who knows what they are doing. 

I know you had mentioned before that it will take a long time to heal and get back to normal and I am probably getting impatient. It just seems like I am going from one pain to another and maybe I am just being a baby and whining about pain from the Thursday and Friday. I am generally a tough cookie and can deal with pain, but those days I thought I was going to die and cry myself a river at the same time.
Dr Blake's comment: These are totally normal emotions, and I know you are tough by what you are saying, I hope others find strength in your words. Post surgery you have to throw out the clock and just accomplish one goal at a time. You goal right now is to gradually get out of the cam walker. Then you will set another goal. I did not say that your goal is to get out of the cam walker in 2 weeks, 5 weeks, or any weeks. Just use pain as your guide.

 I have been trying to not take the Norco medication the dr gave me for pain and had gotten down to one per day, but the last few days I have been taking it regularly. I had hoped that after the surgery there would be more improvement, however I also understand that I am only three months out after surgery.
Dr Blake's comment: Why are you taking this medication now? If it is to spend more time out of the boot, then stay in the boot more. If it is so that you can ice less due to time, try to ice more. If it is to sleep better, okay, but try to figure out with the doc or therapist how to cut this down. If the therapist wants to massage so hard to break scar tissue down, may be okay to take the medications the next two days. Goal: no pain medications after 2 weeks after surgery. Yet, again, just a goal. 

 I am at a loss of what else to do or even if I am close to doing the right thing. I am icing daily, attempting to off load the weight, taking the vitamins, doing the exercises from PT, and using the spica taping. I have some improved range of motion but my foot is still red and angry so I am trying to ice as much as possible. Thank you for checking on my progress and for any additional suggestions you can make.


Dear Tammy, I am sure you are doing well. Make sure the physical therapist measures your joint range of motion at every visit to document improvement, or lack of. Look into the Blaine Scar Treatment, and get those orthotics. Spend more time in the cam walker if you need to. Do not look at any time table this year. That being said you should be better each month in function and pain. Are you better than one month ago? Always think about that with your doc visits and your therapy visits. I hope this gives you some perspective, and I am happy to help as the months go. Rich Hang in there.

Wednesday, March 14, 2012

Sesamoid Injury vs Hallux Limitus/Rigidus: Important Pre-surgical Decision-Making

Mark's Sesamoids and First Metatarsal Heads

Hello Dr. Blake,

Long-term reader, first time writer. I'm impressed you appear to take the occasional email and offer up your opinion, with the usual disclaimers, but at least you've got an opinion. I'd like to see if you can offer me some advice, a 'tie-breaker' of sorts.

I have two surgical opinions, they differ but both have merit. Both seem plausible but the Doctor won't' be sure until 'We're in the foot and have a look.." No guarantees.
Dr Blake's comment: I love MRIs, but I have seen too many cases where the MRI did not show the full extent of the damage, or showed more damage apparently under healthy cartilage that was not appreciated at the time of surgery. And the last thing you want to do in surgery is dig up good cartilage in search of something bad.  So, for many cases, as we will see in Mark's case here, there may have to be some decision making at the time of surgery. Never my first choice, but quite necessary at times.

Male 50, right foot seasmoid pain (fibular).
Dr Blake's comment: Sesamoid pain is very tricky since generalized swelling in the tissue under big toe joint can cause localized sesamoid pain when the sesamoids are fine. I have been convinced it was the fibular sesamoid (the one closest to the 2nd toe), when all the testing showed it to be the tibial sesamoid was misbehaving. The foot tends to humble foot care providers daily. 

Over-pronater, a few pounds over weight, good health otherwise.
Dr Blake's comment: Over pronation is deadly for big toe joints. As you over-pronate, body weight at pushoff jams the big toe joint against the ground, at a time it should be relatively free to plantarflex and push off the ground. As it is jammed into the ground, this is called functional hallux limitus. It is functionally taking too much pressure, which makes it hard to do it's normal job. This, over time, and Mark is over 50, can gradually break down the joint. Stopping this over pronation, not all pronation needed for shock absorption, is crucial for orthotics, and shoe design in athletes. 

No known trauma - unless you count cumulative stress from playing the game 'kick the can' as a kid...

Conservative treatment over 14 years has been, NSAIDs, orthotics, walking shoes and cortisone shots. I'm not a big fan of needles but the one day I crawled into the Podiatrist office, I did beg him to shoot me, it was that bad.
Dr Blake's comment: If you are designing orthotic devices for the big toe joint, you must have orthotics and shoes that together as a team place your weight at push off through the center of your foot (more 2nd and 3rd metatarsals). I try to ask my patients this important observation when dispense the orthoses, and try to get them to do one foot at a time, and walking vs running. Sometimes, totally different orthotic devices are needed for running vs walking to achieve this effect. Sometimes, a lot more correction is needed in one foot vs the other. Sometimes, it is not the foot you are treating for pain and needs the most attention. But, it is important to make the good foot as good as possible. All of this is best to experiment with before surgery than afterwards. All of the treatment modalities you learn will help if eventually you do have surgery. So, Mark, please analyze the orthotic devices for this criteria.

Dr Blake's comment: Cortisone into joints are used to delay surgery, but rarely to prevent them. If you have had cortisone that made a significant improvement, when done in a joint, it is always at a risk of possible masking of pain long enough to speed up the need for surgery. Cortisone is wonderful, and some patients have done well with cortisone shots for years, and some patients never seem to need surgery, but it is a strong warning on the Cortisone label. Avoid unless forced into the corner like you were. Hopefully that doc didn't just give you a shot, but talked to you about some of this stuff. 

Early tests were -

Nuclear bone scan revealed some 'hot spots'. Nothing alarming.
Dr Blake's comment: Nuclear bone scans have been a crucial part of the differientation of sesamoid fractures vs bipartite (normally in 2 pieces) sesamoids for 3 decades. I always tell the radiologist that if they find hot spots in the area of injury to make me blow up images. Mark do you know where the hot spots were? Were they in the joint, in the sesamoids, both, etc? This can be very important.

Bone tomograpny revealed bipartite seasamoid. Nothing unusual.
Dr Blake's comment: This is 3D images of just bone and should tell bipartite from true fracture. However, a healthy bipartite sesamoid functions as one bone. When a bipartite sesamoid is injured, the weakest link in the chain is the ligament between the 2 pieces, so that gets injured. Now the 2 pieces are functioning differently with their rigid ligament bond injured. This can produce just as much pain as a broken sesamoid. Even worse, there is no chance of healing the ligament, and all the tests show that their is no broken bone. No one know what to do but remove the bipartite sesamoid or try all the conservative treatments used for sesamoid fractures. A sticky wicket I'm afraid. 

Ten years later, yes, ten years, I'm conservative in my treatment, I get an MRI and X-ray. X-ray shows some arthritis and MRI shows some edema, early bone defect. Probably explains why now it feels like it throbs at night and keeps me up. That's something relatively new. The usual sensation is one of a 'hot knitting needle jabbing my ball of foot'. Or running my foot over hot oiled ball bearings, that's a typical sensation for years. But nothing broken, more wear and tear stuff I'm told. I walk with some pain and limp, some days better than others.
Dr Blake's comment: The bone edema is under the first metatarsal and more over the tibial sesamoid on the images which are at the end of this post. The symptoms of throbbing is general inflammation, so definitely things at present are out of control. This does not mean they are getting worse, only means the joint has been irritated and is now in the Immobilization/Anti-Inflammatory Phase of Rehabilitation. It can be calmed down with ice three times daily, removable boot with EvenUp, and activity modification. Also, accupuncture and PT can be very helpful along with spica taping to restrict big toe joint range of motion. The symptoms of "hot knitting needle jabbing my ball of foot" and " running my foot over hot oiled ball bearings" are classic nerve symptoms. Cartilage is a pillow protecting the bone. Cartilage has no nerve endings, whereas bone is full of ripe juicy nerve fibres. When the cartilage is damaged, even slightly, it can not longer protect the bone as well. The nerve fibres sense more stress and complain is very descriptive phrases that you used. Nerve pain gives me the most exciting symptoms of any other source of pain. I remember one patient describing her pain as hot lava pouring onto her foot. We got her better by appropriately dealing with the source of her nerve pain.

Both docs said I've run the course for conservative treatment for ten years, it'll only get worse with age.
Dr Blake's comment: Do you think this is true? Do your orthotics need improvement to take more pressure off the big toe joint? Do this now, not after surgery. Do you have a good physical therapist that will help your post op that you trust? If not, find one, and perhaps she or he can help you with exercises, taping, gait training, etc. Have you learned to spica tape? Are you in a removable cast right now, and does it take all of the pressure off your big toe joint where you have no pain? If not, best to do it now, so when you go into it post operatively you will already be set. Get an EvenUp for the other shoe, all guys definitely need one to balance the spine.

 Doc 1 suggests some big toe top bone shaving of sorts - theory being it's more hallux ragidus. Says my foot bone needs to be scoped and scrapped like a bum knee. Well, it is a little limited in flex and makes some sense.
Dr Blake's comment: A little limited does not normally mean Hallux Limitus/Rigidus. As the joint really gets limited, normally the pain increases. This sounds like a mild part of your syndrome of big toe joint pain, not the primary concern for surgery. I am sure you have some Hallux Limitus, and that you do have some Hallux Limitus symptoms, but I am unsure if this is the part of your problem that needs surgery. I can only listen to what you tell, and Doc 1 does not make sense in light of your chronic persistent localized sesamoid pain. 

 Doc 2 says, "Sure, that could be a part of it but your patient complaint and tests reveal a likely sesamoid problem. When I palpate your fibular sesamoid it's very localized and pain inducing. I'll know when I excise but that's my read."
Dr Blake's comment: Sounds more right, but presently not sure if it is the fibular sesamoid, tibial sesamoid, or the undersurface of the metatarsal head adjacent to one of the sesamoids. Let's not take out the wrong bone shall we?

Hmmm, later Doc is highly rated foot surgeon, so I went with his opinion and surgery date is set for late March.

But it is nagging me, what if there's a hallux variable, what if the sesamoid is some referred pain and I'll be laid up for the wrong reason? Hence, I'm kind of fishing for a third opinion, hoping someone points and goes, "See Mark, that spot there is no good, we take it out, you feel all better…." Ok, asking too much, huh?

I do have MRI report and a CD disk of images, that's about it, would you care to look at it? Or have I done enough due diligence that now, as a patient, I make the best informed decision and move forward?
Dr Blake's comment: Mark has since this email sent me selective images from his MRI that are following this post.

Regards, Mark

P.S. After a year or so of reading your blog, the sesamoid section is, obviously, my favorite. You've hit on a number of issues and this response seems to sum up my blight - (this is from a previous blog post)
Dr Blake's note: Significant Arthritic Changes mean Hallux Limitus or Rigidus, which is a totally different animal. Read some of my posts on this. Make sure if this is the cause of your pain, and you are going to have surgery, that you attempt to treat that condition appropriately before surgery. I am still confused about the MRI showing only bipartite sesamoid, and somewhere you being told you have significant arithitic changes?? Isn't this fun. Now you have 3 possibilities of your pain: 1) Sprained bipartite sesamoid with excessive motion between the pieces on weight bearing causing pain (this is where the surgeon may be going when he talks about removing a piece), 2) nerve trauma and chronic nerve pain, and 3) hallux limitus/rigidus with severe arthritic pain. Unfortunately, all 3 of these conditions may need surgery. Fortunately, all 3 of these conditions can respond to conservative treatments, if we know which one to treat. At least, the surgeon, who probably knows all this, will get a good laugh out of this. Surgeons do like to be black and white in their approach.

Dr Blake's comment: I then emailed Mark months later to apologize for not getting to his email sooner, and to send me a progress report on how things stood 3/1/12.

Greetings Dr. Blake,

Thanks for responding, still time before the surgery, March 26th. I've attached a Word file, hopefully you can open and read the MRI report and select images i copied. The pain points are indicated by lightning bolts. The first is mild, on top of first big toe joint. And, yes, mention of Hallux Rigidus and shaving was mentioned as one possible surgical option. However, Doc2 said mine was a very mild cases, he's seen many many worse. Doc2 points to the double lightning bolts - this is the decade long pain and is clearly under, or near, the fibular sesamoid. One finger tip touch to this area is all it takes to elicit major discomfort.

The one thing that has changed over the last year is a clear throbbing and burning at night (maybe during the day but I'm typically on NSAIDS…) and it's more top of big toe related. I wonder if that's simply arthritis kicking in. X-rays rule out any obvious fractures. All blood test for like gout, etc. are negative, I have good overall health, seems to be a wear and tear, or cumulative, joint problem.
Dr Blake's comment: Mark, stop taking the NSAIDs. First of all, they slow down bone healing, not a good idea. Second of all, they can mask more pain then you think, and therefore you can hurt yourself more while on them. 

Massage and physical therapy only aggravate the pain, even years later. Orthotics, dancer pad, special shoes, cortisone, nothing.
Dr Blake's comment: This is very confusing, since most the above treatments normally help either condition, at least somewhat. And if it helps somewhat, it is a clue to try to make it better. That being said, you may want to postpone surgery until you figure out how to make the joint feel at least 50% better with orthotic modifications, taping, shoes like the Specialized Tahoe, etc. Any info obtained now will help with the ease of rehab after. Does a removable boot help? You definitely should be fitted for one now to eliminate pain completely so it is ready and waiting to accept your post surgical foot. 

Finally, presuming I go with seasamoid excise, the EvenUp strap on shoe accessory seems to be a good choice to keep the hips and back even, why isn't this standard procedure? I'll ask nurse on pre-op if they offer it and then pre-order if need be. What is your experience?
Dr Blake's comment: It is a relatively new device which I think should be standard with any casts/removable boots.

Hopefully, something jumps out, or can be ruled out, by you glancing at what is a handful of data points. Many thanks and happy feet,

Mild irregular top of first metatarsal at the big toe joint. Minimal concern.

If you look closer at the bottom of the first metatarsal head (at the ball of the foot) compared with the first photo, some graying of the bone is noted indicating bone edema (some cartilage damage).

Above are 2 frontal plane cross sections through the metatarsals at slight difference. The bottom image shows some subtle changes in both the fibular and tibial sesamoids, with significant changes in the bone just above the tibial sesamoid. The image of the same foot just above shows more extensive bone changes involving bone above both sesamoids, with the most irregularities in the tibial sesamoid.

The bottom image shows the significant swelling (white area) in front of the fibular sesamoid, yet the image above shows most boney changes in the tibial not fibular sesamoid.

These images show a clear irregularity in the fibular sesamoid.

This odd image of the first metatarsal head definitely shows more irregularities in the lateral side of the first metatarsal. 
Dear Mark, Thank you for giving me the opportunity to attempt to help. As always, the disclaimer is that I can only have partial information, which could be not the right amount to make the best decision. I can only give you my gut-level educated guess. So, I apologize for this. 

That being said, your wonderful images sent do tell a nice story. I have looked over and over the photos and do want you to Fed Ex a CD so I can see them clearer. When looking at subtle bone changes, the graying of the bone when it should be white on T1 imaging is crucial. The clarity of these images is not great and I may be jumping to some wrong conclusions. Call my office at 415-353-6400 for mailing instructions. Thanks, and sorry for the inconvenience. There is no charge for this read.

My take is that you have injured the articulation (joint surface) between the sesamoid and the first metatarsal. Both sesamoids could be involved, although the tibial sesamoid seems the most. True to form with many sesamoid injuries, and the pooling of inflammation between the first and second metatarsals, the fibular sesamoid may seem more involved. Slowly the joint may be developing more wear and tear, and Hallux Rigidus may be creeping in (you will know in 20 years). The radiologist read a normal fibular and bipartite sesamoid on the report. The bipartite ligament bridge may have sprained giving you that sharp nerve like sensation. These ligaments do not heal. Unless I see the other films, I would say to remove the tibial sesamoid. When the surgeon goes in from the side, they will see the entire bottom of the first metatarsal to see where the wear and tear is. If none is noted in this area, my bad, they would close up and open up laterally to remove the fibular sesamoid. When you remove the fibular sesamoid from plantar you can see the whole bottom of the metatarsal to check where there is damage. , but you have to remove the fibular sesamoid first. So, to me, if makes more sense to start from medial, look at the tibial sesamoid and as far lateral as you can go, and make the call. And before embarking on this, the surgeon and you have to agree that this is the right thing. It is one thing for me to sit here in respect of you and this process, but it is another thing to take the responsibility as a surgeon for the success of the surgery. At least you have a lot more talking to do. Email me if you are sending your films and I sure hope this helped. Rich Blake

Mark then sent me a followup email exquisitely describing some of the events following this blog interaction.
Dr. Blake,

I was thrilled with the blog posting and assessment.  This is a most generous service you provide as, I hope, your blog stats reveal - people do really Google and want to understand how a foot can be so intricate and challenging.

I had my wife read the blog, she was more frustrated, fearing I'd 'back up the cart' and start anew.  She's seen me with this condition for 15 years and it's time to get aggressive, not wait more years tweaking my gait, shoes, orthotics, ice bags, and $300 shoes.  And that's just one pair, one color.  Let alone no golf shoes.   Granted, it makes no sense being aggressive and doing the incorrect thing but I found great comfort in you confirming, "Yes, there is concern on/in/near the sesamoid and first joint."  Not like I"m making this stuff up, it hurts, I know the area, just don't no with certainty this one fix will be a cure all.  Hence, some apprehension.  

I was surprised you wanted to see more images, perhaps cases like mine read like a good mystery novel - so close to finding the culprit, yet they're just out of grasp.  I can hardly get my existing Docs to take such interest.  Remember, it took me a few years, and a couple DPMs, before they even took an x-ray, let alone an MRI.  I have good insurance, heaven help those less fortunate.  I got the impression to tape my foot, or use a Dr. Scholl pad, and to 'man up' and deal with a little ache. Apparently, they're worse cases than mine, but my pain is my pain, hence the quest to seek relief.

Anyway, you ended up printing my letter verbatim, it's another element that makes your blog a quick and appealing read - it does not read like a case study littered with footnotes and references.  And you interject where appropriate.  Plus, a sense of humor helps. 

Specific to your questions,
The nuke bone scan was done ~14 years ago, there was a handful of hot spots, in/around joints, nothing I recall.
I'm going to hold off sending the MRI CD to you until Doc2 has a chance to comment.  I'm out of town over the next week, then back  to Madison for surgery. 

I did call the assisting DPM nurse to ask about EvenUp (she had heard one patient brought it up but has no knowledge or its use or availability).  You said it was relatively new and the foot care I'm getting isn't in some third world country.  They've got a bit time sports clinic (well for star college athletes at least…), orthopedics, the full gamut of resources.  Surgeon is top dog!!

He's been great so far.  I mentioned that my 'foot was on the internet' and the nurse said, "Wow, your our first internet foot, a celebrity of sorts."  I asked if she'd think Dr. K would look at Dr. B's assessment if I provided a link.  She thought he most certainly would, he's out office, but next week for sure.  I said I didn't want interject any West Coast DPM confusion but to please consider this as another professional data point.  She thought no problem.  Plus, you had mentioned and poked fun that you offer an opinion on select data and respect and advise one to work with one's attending health care providers.   

But the nurse was unaware about EvenUp, hmmm, I'll guess I'll be mail ordering this weekend.  Don't you guys go to conferences where they show off the newest gadgets? 

So I'm leaving it at 'Please have Dr. K read this blog assessment, that I'm concerned we remove the fibular sesamoid without consideration of nearby potentially ailing structures.  I don't want to be back in in a year to tackle the tibial sesamoid." Duly noted.

I completed my pre-op physical today, all systems are go, and am looking forward to tackling the next foot chapter so to speak.

I'll be happy to update you as the next week unfolds, including any Dr. K feedback.  I told the nurse, "You've got to Google this guy, his blog, and get the word out, its a great repository of information for the lay, and maybe not so lay, person."

i'm grateful for your interest, concern, and education Rich,