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Tuesday, May 29, 2012

Sesamoid Fracture Followup: Email Correspondance

Blogging on Tuesday is Email Correspondance


About a year ago I emailed you about a sesamoid injury I had (still have).  Originally we were debating on fx vs. tripartite.  Both you and the podiatrist I am seeing agreed it was a fx. 
Dr Blake's comment: Sesamoids can become painful. When xrayed, sesamoids can be in more than one piece. It seems that no one agrees on how to treat these, relying on one generalization or another. The patient's pain should be treated, a pain free environment created quickly, and serious fractures will heal slower than bruised bi- or tri-partite naturally occurring bones. 

Tibial Sesamoid in 2 pieces. Broken???

 Looking back now a year later, it prob really didn't matter what it started out as, over the past year it hasn't been stable.  On the axial view the width of my injured sesamoid has spread from about 8mm to just over 9mm.  I have included a comparison view of the films I have taken over the past year. 
Dr Blake's comment: Due to privacy, I did not include the images since it identified the patient.

Overall the pain is less than when I first injured it, however it still bothers me daily.  (Some days more than others.)  And I have altered my gait and the way I adjust (I'm on my feet at work all day) to compensate.
Dr Blake's comment: Any pain that causes you to compensate is considered bad pain. The compensation (favoring) can cause more problems in the long run than the original injury.

Here is a brief rundown of the things we have done with it over the past year.  Some of which you recommend and some of which you prob would have advised against.  I have been icing it and taping it throughout the whole process.  Some times more faithfully than others.  When I tape it, sometime it's with regular athletic tape and others with kinesio tape. 

 Also before I first saw my pod I added a Dancer's pad to my orthotics that I already had. 

 After about a month of no improvement my pod ordered a different orthotic which gave more cushion and a met pad was added to offload the 1st MTP joint.

  They helped more than what I had been doing before, but pain still there.  (Bad patient, I know) I just dealt with it for a while.  Not running was driving me crazy, (even worse patient...) so about the beginning of the year I started doing about 1/4-1/2 mile at the gym.  When I'm running it is actually better than walking, but then afterwards is another story.  So I didn't keep up with this very long.
Dr Blake's comment: When doing any activity, assessing the pain produced during is easy, but afterwards harder. It is still considered bad pain to have increased pain after an activity. I like when rehabing a patient to have them run every other day to see if they can establish an amount that does not aggravate the injury. With this as our base, we can experiment with various treatments to see what helps. Much better than experimenting when the pain is out of control, or when you are not exercising at all. So, I do not have any problem with attempting to find this base.

  This was about the time I started noticing more intense deep throbbing pain that will last a few seconds or a little longer (less than a minute), but I notice this when I'm not on my foot.  Over the past few months this seems to have gotten more intense and happens more often. 
Dr Blake's comment: This has the sound of cartilage wear and tear. 

 I went back to my pod in Feb, we then added a Morton's extension plate under my orthotic to limit the motion it had.  This did limit it, but it still moved due to the profile of my shoe being low because of the added thickness of the orthotic.  After no real changes with the extension plate we decided to do a cortisone injection to hopefully knock the pain and allow me to function normally. 
Dr Blake's comment: Cortisone in a joint that has the potential to heal should be done very carefully. Feeling better now may, in the long run, not be the best. 

 (As a chiropractor this was very difficult for me... our profession is based on the fact that the body is self-healing and self-regulating, so to do something to just cover the pain was hard.)  It had increased sensitivity and tenderness for about 2 weeks after the injection, then it was back to pretty much the same as before the injection.  And that's where I am now...

Things that have not been done... obtaining an MR, being in a boot, being non-weight bearing, or using a bone stimulator.   Now that it's been a year, I'm not sure if anything will help. 
Dr Blake's comment: Whether one year or two years, or more, there is still a chance of healing these injuries, and let no generalization convince you otherwise. See what general rules apply to you as an individual. Yes, you may need surgery, but you may not. We definitely do not have enough info, and will not for 6 months. If you feel you are spinning your wheels, you will not heal, because you will just ignore what your body is telling you. Put all the positive energy towards creating a pain free, no limping, environment that you can coexist with for the next 6 months. 

 I want to believe that it truly wants to heal and that's why the injection didn't do anything, because my body was telling me not to continue to aggravate it.  If I end up ordering an MR for it, I'll be sure to send you info.  Obviously I want to avoid surgery.  

Just sending you an update... even if this goes into the file of how NOT to deal with a sesamoid injury... LOL

(Being a physician myself, I have tried to just be the patient on this one, but now looking back at last summer and I probably should have done some things differently, just because I knew they would have been the right thing to do.)

Thanks, Tiff

Dr Blake's response:

     Tiff, Thank you ever so much for helping others by this honest sharing of woe. I can tell you are a great healer of patients. This is what I would recommend now.

First of all, get an MRI and send me all the images (X-rays plus MRI), at the same time you review with your podiatrist. The MRI will need to be done twice, now and in 6 months to check healing, but the immediate one will tell us a lot on what is going on now. We can hopefully discuss the images on this blog.

Secondly, make sure your Calcium and Vit D3 intake is normal. If there is any chance you have osteopenia, get a bone density screen. 

Thirdly, continue to try to create a pain free environment with experimentation of shoes, inserts, removable boots for non work hours,  work standing positions, daily icing, etc. 

Thanks again, and hope to hear from you soon. Rich

Monday, May 28, 2012

Metatarsal Pain: Try An Accommodation

Blogging on Monday is Photo of the Week

An Accommodative Pad being designed for an Orthotic Device to Off Weight Painful 2nd/3rd Metatarsals

Here the same Accommodative Pad to protect the 2nd and 3rd Metatarsals of the Right Foot is being attached to the Orthotic Device as a Forefoot Extension. 

Musings from A Footstool: Let's Celebrate Our Feet!!

Blogging on Sunday is Musings from a Footstool

Anyone who sees the following Celebration of the Golden Gate Bridge's 75th Anniversary will know that San Francisco knows how to Celebrate. My wife and I watched this from my office yesterday. Unbelieveable!!

Celebrations are a great part of life, my family tries to celebrate everything, it connects you to life, to others, to joy, to this world around us.

When was the last time we celebrated our Feet. May is actually National Foot Health Awareness Month, and I am waiting to the end of the month to ask you to celebrate your feet. Do something nice to your feet this week. Buy some new shoes (another excuse!!), paint your nails, scrub off some calluses, massage your arches, be more committed to your YogaToes, make an appointment with your podiatrist if something hurts, or just say thank you.

In saying thank you to your feet, you stop for a moment to appreciate them. All they have done for you. The walks they allowed you to take, the marathons they endured, the start and stop in tennis or basketball they provided, the spring in your step when you heard good news.

My feet allow me to stand tall, jump for joy, take a charge in basketball, run to catch a bus, run to catch my children (and someday hopefully my grandchildren).

Thank you feet. Even as a podiatrist, I do not say thank you enough. Thanks for a job well done!! I will try to treat you better. Not abuse you as much. Thanks for letting me celebrate all the joys in life like the Golden Gate Bridge's 75th Anniversary. Thank you.

Saturday, May 26, 2012

More on Sesamoid Injuries: Email Advice

Blogging on Saturday is Email Correspondance

Anonymous has left a new comment on your post "Sesamoid Injury: MRI evaluation": 

Dr. Blake! 

Thanks for posting and explaining the MRI of the sesamoid. I found this in search of deciding wether the cost of a MRI will be useful in aiding my tibial sesamoid fracture. I wish I had started doing research earlier. I am learning new things such as using the exogen bone stimulator twice a day instead of the recommended once a day.

I did not see a Dr. for my foot until 3-4 months after the injury. My Dr. put me in an immobilization shoe (which i alternated wearing with a carbon fiber insert in cuter shoes) for 2 months. I had a prolo shot, then arfter 2 months recieved my exogen machine and vitamin prescription. she was going to let me go back to work (with continued immobilization) and made it sound like the 2 fractured peices had mended together on one side.

I grew nervous and just got a 2nd opinion. When I looked at the x-ray...the tibial sesamoid looks like a pile of mush with no defined sides...YIKES!! He put me in a bigger CAM boot, prescribed a steriod, wants me off for another month as well as an MRI. Any suggestions you have for me?? How will a MRI help my treatment??
Thanks! ....Discouraged 

Dr Blake's comment:

     Dear Discouraged: Definitely I think an MRI gives you a baseline value of the injury which can be compared to 3 to 6 months down the line if healing is being questioned and surgery anticipated. X-rays also can indicate one of the sesamoids looking weird and injured, whereas the MRI actually shows the damage to the other one, or to neither sesamoid and just the soft tissue or tendons. 

     If I recommend the Exogen for improved bone healing, I normally recommend twice per day and for 9 months, even if the problem only seems to take 3 to 6 months to heal. 

     As the bone heals it can look like mush as it remodels. Again, I encourage an MRI, but only when I hold the possibility that taking another MRI down the line will show us good healing. 

     If you have any bone problem, try to stay away from steroids which can retard bone healing. 

     How have you been doing? Are you feeling much better? X-rays can be poor indicators of actual healing, and need to be matched up with pain levels, and levels of disability to get a clearer picture of what is going on. 

     I sure hope this helps you feel somewhat less discouraged. Rich

Friday, May 25, 2012

Heel Pain: Simple Orthotic Adjustment

Blogging on Friday is Biomechanics for the Podiatrist

Hi Dr. Blake,
Sorry for the delay in getting back to you.  The updated orthotics are an enormous improvement, did a few Dipsea training runs with lots of steep up & down, heels much more comfortable afterwards.  Would love the ones I left with you to be just the same way.
I got a VM from the clinic earlier in the week that they are ready for me to pick up.  Do I need to try them out?  If so I can schedule an appt in SF.  Otherwise, if it would be possible to send them to the Marin Clinic I could swing by and pick them up on a Friday.
Let me know, and thanks so much for your help!

 So what happened to make this patient feel so great. Barbara came into my office with 2 pairs of orthotic devices from another doctor, and with a chief complaint of heel pain. The orthotic devices she had stabilized her feet well both walking and running. So, what was the problem? These orthotic devices had a plastic shell and a plastic rearfoot post. She also landed hard on her heels both walking and running. You could defintitely hear her coming. I classified at least part of her heel pain from impact stress. I removed both the plastic rearfoot post, and as much of the plastic under the heel area from the orthotic plate. I had put on a softer Birkocork rearfoot post. I then placed a small circular memory foam (1/8 inch soft plastazote) under the heel. I then replaced her vinyl topcover with full length 1/8 inch Spenco. She had tried this over the last month and thus the email. I am ready to do the same with the 2nd pair I have. 
Here is an example of a non posted orthotic. Image I removed both the post and most of the plastic material under the heel.
Here the same orthotic above has a soft, but durable, Birkocork post applied. An attempt at transferring the weight from the heel to the arch is also being attempted.

The Blue Dot under this first metatarsal is identical to the shape of the memory foam under the  heel. 

Thursday, May 24, 2012

Twitter Updates: @richblake756

Blogging on Thursday is Twitter Updates

Please follow my weekly updates on Twitter @richblake756 and on the left side of this blog

Wednesday, May 23, 2012

Golden Rule of Foot: Pushing Through Pain May Build Character, But It Also May Cause Permanent Injury

 Blogging on Wednesday is Golden Rule of Foot

      There is always some pain with athletic endeavors. But, one of my earlier Golden Rules of Foot: Follow the 3 day rule, If pain continues for 3 days without changing for the better, do something about it. I have spent 30 plus years in practice telling patients about my 3 day rule. Does anyone listen? Do I even listen?

      Yesterday I had my second patient need big toe joint fusion. It is supposedly the best operation for severe degenerative joint disease of the big toe joint, but how did the patient get there? How did the joint get so bad that she was the 2nd person ever to have such a drastic procedure? Did she push through pain daily? If she saw me 10 years ago, could the joint been saved?

     Probably the top post I refer my patients to daily regards understanding what is Good pain and what is Bad Pain. Here is the link.

     Life is too complicated to run to the doctor with every ache or pain, plus you may not get the best advice, or at least advice you want to hear. So, developing a better sense of when pain is harmful will definitely help us continue walking into our later years. Another Golden Rule of Foot: Listen to your Body. In sports medicine, this connects the patient to the treatment. The patient must be an active participant in the healing process. They must listen to the major and sometimes subtle trembling within the body. My wife Pat is one of the most astute listeners. I am in my head too much.

     So, with all my rambling, the Golden Rule of Foot I am focusing on today is Pushing Through Pain May Build Character, But It Can Also Cause Permanent Damage. Patients with high goals, I mean high, can be at risk of damaging their bodies permanently since the goal is so important. Patients with high pain thresholds may just not sense when they are hurting themselves. But even normal people, can do very stupid things and cause irreversible damage to important structures. Since athletics hurt, I must be hurting like everyone else. Who can they compare it to?

     From the Good Pain vs Bad Pain discussion, we learn that bad pain is definitely sharp and causes us to limp or favor the injury. In actuality, anything over level 2 pain (due to variations in pain thresholds) for a sustained period of time, can cause damage. It all boils down to that pain is our friend. Pain is normally telling us that something is wrong and we must fix it. We must reset the body back to homeostasis. A painful body must be taken seriously.

     I remember when I was first in practice that a patient in a lot of pain came into the office for treatment. Once he found out that the source of the pain was not serious, he said thank you and left. He never wanted treatment. He did not have time for that. But, he would of, if the problem he was dealing with was serious. He needed me to tell him to that all was fine, things were a little out of whack, but if he listened to his body he could be fine again without permanent damage. I was too new in practice to realize how much I helped him that day. I remember being amazed that he did not want any of the 10 treatments I had for him to try.

     So, if you have been in pain that is not improving for more than 3 days, if your pain level stays above 3 out of 10 when you are active, if you have sharp pain or limp, consider seeing someone to make sure you are at least not causing any permanent damage.


Post Sesamoid Removal

I hope we can follow Mark following his surgery in April 2012 to remove the fibular sesamoid. Bob and I had some correspondance before he went under the knife. He made the right decision. Here is his initial comments in the long road ahead. In 2 years he will have the power back into his foot. This first 3 months post op is for initial scar reduction and elimination of swelling. Then there are small gains from 3 to 9 months as initial strength is regained, activity gets back to some level of normalcy, and the pain level is controlled by daily icing, orthotics, shoe selection, some activity modification. From 9 to 12 months, the body's nature process occurs and more scar reduction occurs (the interior and external scar looses water content and the scar tissue thins). This sets the stage for a fast or slow recovery of more strength (more power, more endurance, or speed of contraction). So, it is in this second year, the true time when athletes get back to where they were pre injury. But, everyone has a slightly different time line. 

Hi Rich,

One month post-surgery update -
Excised fibular sesamoid was larger than expected, arthritic, and developing a spur.  
I was in a walking flat shoe first week or so.  No even up strap on leveler needed (no cam boot prescribed).  Doc said it was ligament healing, not bone fracture healing, no need for a cam size boot.  No problem.

So after a month, much improved.  No pain in ball of front area, some odd nerve/tendon feeling at tip of big toe but, absent that, uneventful.  
Occasionally sore after long period of walking and flexing foot, otherwise ok.
Incision site at side of big toe, gone.  No scar.

So far it looks like a great decision and I remain active and optimistic.

Regards, Mark

Mark, Thank you and I will post on my blog so people can see that there is life after sesamoid surgery. When you see the blog post, if you could continue to update your progress (probably a few ups and downs), that would be wonderful. Rich If you were given any post operative instructions specific to this surgery, could you send along. When were you told you could start lite running? What is your workouts now? Bike? Swimming? Do you have your orthotics to protect the area? 

Here is Mark's original email with my response. You can see this problem had been going on for quite awhile.

Pregnancy and Feet

During pregnancy, pain may often appear elsewhere in the body, says podiatrist Rina Bimbashi. In pregnancy, the impact of the weight gain is compounded by the effect of hormones. "During pregnancy, there is an increase in three hormones — relaxin, oestrogen and progesterone — which soften the muscles and ligaments in preparation for childbirth, making them more flexible," adds Mrs. Bimbashi. 
Rina Bimbashi
The problem is that if you have mild to moderate degree of overpronation before pregnancy, the looseness of the ligaments means your feet can roll in even more. As a result, you can end up with moderate to severe overpronation (the effects of these hormones are evident in ligaments and muscles for about five months after giving birth). "Pregnancy has a huge impact upon your whole joint alignment, and your muscles and ligaments need to work much harder in order to maintain stability. I commonly see women who have good, normal foot arches which collapse during pregnancy leading to very excessive pronation."
Source: Jenny Hudson, Daily Mail [5/21/12]
The source of this excerpt is the Podiatry Management Magazine online email service.

Tuesday, May 22, 2012

Joint Dysfunctions: Help Through Mobilization Procedures

Blogging on Tuesday is Email Correspondance 

      Melanie and I have been working on her foot and ankle problem for the last 6 months. There was a component of nerve pain, called Tarsal Tunnel Syndrome, but she really responded more to anti-inflammatory, and less to nerve, treatments over all. I had emailed her after several months of not hearing how she was doing and this was the reply I got. Melanie is a typical sports medicine patient whom takes ownership in her problem and deals with it. I am highlighting her email since it represents a group of my patients who do extremely well with joint mobilization. And, it is normally not I who recommend it, but a body worker or physical therapy.

      I once had a patient Olivia (real name for once) who longed to be a professional ballerina. She even lied about her age so the San Francisco Ballet School would accept her. Well, Olivia was one day away from ankle surgery since I was convinced an extra bone in the back of her ankle (os trigonum) was causing her pain. I tried 6 months of physical therapy and could not get her better. Two days before her surgery she accompanied her friend to the friend's chiropractic visit. The friend asked if the chiropractor would look at the ankle. All I know was that there was some adjustment done, and now 20 years later, she has never had to have surgery. She had a great 16 year career in ballet, and now is the mother of three. I still see her mom and get the updates. I grew up a little more the day we cancelled Olivia's surgery. 

Hi Rich,

Thanks for your email.  As a diagnostic tool, about three weeks ago I went swimming for a little bit,  because last fall it felt really good to swim and I wanted to see a little more what was going on now.  I was also feeling that, although you were able to diagnose tarsal tunnel syndrome, I felt like I never really knew what the underlying root cause of that condition was, and that seemed to be a missing piece in the puzzle.  Anyway, my tarsal tunnel area and the arch of my foot both did really well during and after the swimming, but I had some pain through a low horizontal plane in the front of the foot (at about the talocrural joint).  So, that raised a question for me about maybe there was something else going on that was the root of the tarsal tunnel syndrome.

Shortly after that episode of swimming, I saw a person who indicated that my talus bone was out of alignment and he did an adjustment to bring the talus bone back into alignment.  This adjustment brought immediate relief in walking, without the boot and without any Aleve.  I was able to walk normally a short distance without pain (I didn’t push it), althought there was significant weakness of course.  Over the next couple of weeks after that, I have been doing rehab exercises including walking, balancing on one foot, and stretching (calf/achilles).  I have worked up to walking 20 minutes each day, in flat shoes, without pain (I started at 10 minutes per day, adding about one minute per day).  Now I am going to add 10% more walking time per week.  Interestingly, he also said that I should continue to walk in flat shoes and not point my toes for the time being, and that the rehabilitation should take 6-8 weeks.  He also said that the nerve activity, which is very minor now, will die down completely on its own within about nine months.

One question that I have is – would you be able to see an alignment problem like this on an MRI? 
Dr Blake's comment: I am not sure if you can ever document these joint dysfunctions on X-ray or MRI. 

  Anyway, I am hopeful that this approach will result in a full recovery in a fairly short period of time, but if for some reason it doesn’t, I might ask for your help again.  I am appreciative of all the things you have done to try to help me before this.  Thank you for that.


Monday, May 21, 2012

Short Leg Syndrome: When Standing, Correct with A Magazine under the Short Side

Blogging on Monday is Photo of the Week

Statistically, 80% of us have a short leg. That Short Leg can cause back, hip, knee, and foot/ankle pain. Standing is by far the most stressful of activities most of us do in a normal day. Placing a book, magazine, etc under the short leg even when we are barefoot or in flip flops can provide excellent relief. This nice patient not only agreed to have his photo taken, he also emphasized at his appt how he had discovered this. I had prescribed lifts his shoes to correct his short leg, but 50% plus he did not wear shoes and was having significant pain. Boy do I have smart patients who can think outside the box!!

Sunday, May 20, 2012

Sesamoid Fracture and Conservative Treatment: Email Followup

Hi Dr. Blake!  I wanted to take the time to give you an update on my condition.  I first wrote you back in September: (, and am happy to report thast I appear to be on the road to healing!  I switched yet again to another podiatrist who is "the running doctor" of Houston and appreciated taking the most conservative approach possible.  I  have been using the Exogen once a day since mid November, recently got out of the air cast and into a custom athletic shoe orthodic (which I use inside of Sketchers shape ups to be extra conservative, albeit not very stylish with suits!).  So far everything seems to be going well.  I did recently send my orthodic back because one section just seemed to be too high right around my sesamoid (in front) so I got nervous and he agreed to lower that part.
So my questions at this point are: 1) Would you expect the athletic orthodics to have a cut-out for the sesamoid? The one I have simply has a raised (forgot the technical term) part in front of the sesamoid to alleviate the pressure, but I feel as though that small "mound" caused more pain in a new area. 
Dr Blake's comment: The goal of the orthotic device is to place the weight into the middle of your foot (2nd and 3rd metatarsals) as you move across the metatarsals in push off. This is the job of the plastic itself. Then, several additions can be used if the patient still feels first metatarsal pressure: cutouts to float the first metatarsal head (the sesamoid is under that), and metatarsal pads on top of the plastic to get more off weighting of the sesamoid and more centering of the weight. You definitely want your orthotic adjusted if it is causing more pain somewhere else, and you definitely want to feel the sesamoid is protected and your weight centered. If not, the provider may adjust what you have or go back to the drawing board. I love the art of all this. Some health care providers do and some don't. But, get what you need done!!
2) After going to the orthodics/sketchers, I felt some discomfort generally in the area, but it was very difficult to pinpoint if it was in the arch, around the sesamoid, in front of the sesamoid, etc.  It was also transient and seemed to hurt in different places on different days.  Is this just my foot re-adjusting to a new shoe after being in the aircast for so many months? 
Dr Blake's comment: Definitely if you were hurting the sesamoid you would not feel any difficulty describing the pain source. Sounds like you are in the good pain zone (read the blog post Good vs Bad Pain again if you have not). You have signs of cast disease or more aptly put "cast rot". The sources of various pain from prolonged casting are muscle weakness (make sure you are daily doing several of the foot and ankle strengthening exercises listed in the blog), muscle tightness (start doing pain free calf, plantar fascial, hamstring, and quadriceps stretching--all listed in posts on the blog), nerve irritation (your nervous system is trying to figure out what is happening, and swelling (chronic swelling in the injured and non injured areas can take awhile to work out, and could require physical therapy). 
3) My current doc at this point has only taken x-rays.  He says that he can see good ossification around the fracture.  I read on another of your blogs that a fracture would always appear to be a fracture on an xray and it was best to take an MRI for a definitive answer.  He does not agree with this and I was curious if I should be concerned and demand an MRI?  Can the trained eye see any healing on the x-ray series? 
Dr Blake's comment: X-rays can show healing given enough time, so your doc is right. X-rays can show a fracture line when technically the fracture is strong enough to do everything you want. So, there are many misinterpretations of X-rays that I do not want patients to fall victim to. An MRI in your case would be important if the symptoms increase to see what is going on, but it is normally the 2nd MRI that is truly the most useful 3-6 months down the line, showing a positive change in the healing of the bone. So, in actuality, I normally get an MRI so I have something to compare to 6 months later. You would get an MRI now, if your doc was good at interpretating it based on your symptoms, and 2, if he/she expects your symptoms to go for awhile and wants a test to compare findings to in 6 months. 
4) My Exogen appears to be on the out now after 180 uses.  Do you think I should push to get a replacement and continue the therapy, or would you think that the exogen has done it's job by now and I can discontinue? 
Dr Blake's comment: I would stop the Exogen when you are back to full function for 2 straight months. Alittle extra strength never hurt the bone. Hope this helps you. Rich
You'll probably giggle but while he has my orthodic to smooth down the bump in front of the sesamoid, I'm back in my Birkenstocks and feel great!  :)  Foot hasn't felt this good in a long time! 
Thanks so much for your continued information and service you provide via your website and blog! 

Musings from a Footstool: How to Appropriately Bill for Lending a Shoulder to Cry On

Blogging on Sunday is Musings from A Footstool (Philosophy)  

 Medicine is too much now a days about doing things. You do things so you can dictate you did something. You dictate that you did something so you or your biller can bill for that something. Was that something helpful? No one in charge really seems to care. Was that something hurtful to the patient? So what since you can bill for it. If you did it, you can bill for it. The more you bill, the more you probably will get paid. So do a lot, whether it helps anyone or anything really does not seem to matter (but it should help your pocketbook). 

     How sad? 

     When you talk to billing coordinators that deal with insurance companies, they do emphasize that the sky is not the limit on these matters. Normally health care providers can get paid for one something for any visit encounter. That provider may feel you need 5 or 6 things done to get the ball of progress rolling towards healing, but they feel the pressure of only doing 1 something. So, they might as well do the most expensive something, even if it is probably the least predictable to help you. They can rationalize that there will be another visit. More can be done to help next time. But, that next time, the pressures of making a living are still there. 

     So, where am I going with all this?

     And this soapbox is just as much directed to me as to any other health care provider.

     We need more hand holding, more shoulders for a patient to cry on, more smiles, more pats on the back, more gentle nudges, and more open caring. Providers care, but medicine tells them to be careful about showing that care. It makes you vulnerable, and you do not want to be that. You have to be in control of every situation. You have to say you know what is going on, even if you do not. And you sure can not bill for that extra meaningless time with the patient. There is no billing code for "Lending Your Shoulder For Patient To Cry On" even if that was the most important part of the healing process to have occurred in months. 


I have no Idea where my friend Kenn got these photos!!! Have a Great Sunday!!

The Last Photo in the Camera
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Saturday, May 19, 2012

Posterior Tibial Tendon Dysfunction: Email Correspondance

 Blogging on Saturday is Email Correspondance

Hey Doc!!

I found your blog and I am so grateful! I have already learned a great deal. I really need your advice and help.

 Last fall I started to play tennis again. I played daily and began to have foot pain.
Dr Blake's comment: When have taken time off from exercise, it is important to start every other day so that you can access the toll on your body correctly, and give yourself the 48 hours to regain your strength in your muscles. 

 The inside of my ankle and the bottom of my foot were sore. In November I saw the ortho and he said I had PTTD.

Impression Casts taken of a left sided PTTD showing the collapse inward of the heel and arch more than the right.

Dr Blake's comment: Posterior Tibial Tendon Dysfunction diagnosis can be like shin splints, you really do not know what is wrong by the name. The Posterior Tibial Tendon is the most important tendon to support your arch. The Dysfunction part implies that the tendon is not doing it's job, and patients have seen complete collapses of the arch in severe cases requiring surgery. Since I do not know the severity, but Melanie is implying that it seems difficult to treat, to protect her immobilization must be recommended until more info is obtained. 

Removable Boot with EvenUp

 He put me in a walking boot and that did not help.
Dr Blake's comment: This requires further information Melanie. The boot, like the photo above, should have calmed the tendon down. Did  it hurt just as much, 50% as much, hard to tell? There are so many factors that come into play with your injury. Normally, the below the knee boots are better than the mid calf or ankle high ones. They distribute the force of stability over a larger area. Also, with PTTD, normally wearing an arch support in the boot is crucial. If you do not have a comfortable custom one, get the heat moldable Sole supports soft athletic version ( 

 He also told me I had an accessory navicular bone.
My most favorite OTC orthotic because I can adjust and you can heat mold if the uncomfortable out of the package.
This X-ray captured an Accessory Navicular Bone, also called Os Tibial Externum, or 2nd Ankle Bone. It forms around 9 or 10 years old, and can be painful by 16 years (my earliest patient at least). 
CT Scan showing the Accessory Navicular bone of the X-ray above. This extra bone occurs in a small percentage of people and normally weakens the attachment of the posterior tibial tendon into the arch making it less effective in supporting the arch and stabilizing the inside of the ankle. 

 It seemed to get worse. ( no arch or foot support in the boot).

 So  off I went to the podiatrist. He gave me an a shoe insert. It didn't help.
Dr Blake's comment: One of the very crucial points I need to make to all orthotic wearers is why are you wearing them, and are they successfully fulfilling the purpose they were prescribed? Why did you get the orthotics? Pain Relief or better function??? Orthotics if done well should make the posterior tibial tendon work better, but maybe, just maybe, you are in the Immobilization Phase of Rehabilitation, not the Restrengthening Phase. So, a great orthotic device for PTTD can make you hurt a lot more just because it is being used to stabilize and restrengthen at a time you should be immobilizing and anti-inflammatoring. Not really sure if that is a real word!!! You are definitely in the removable boot with some sort of orthotic and arch taping period. 

Kinesiotape used as an arch stabilization tool.

About a month ago, I slipped in the kitchen and twisted the ankle on the same foot with the PTTD. Since the initial fall I have rolled it two more times!
Dr Blake's comment: Once you hurt a major tendon, you body naturally protects itself. You can roll your foot to the outside which makes you more prone to sprains, or if a step will produce pain, you can just let the foot collapse/shut off and you fall to the ground. These scenarios are quite common. And, if they are happening to you, I can see why you emailed. It is very very frustrating. 

 I look like someone beat meup!
I keep spending money on shoes,  inserts and I need some advice.

I started the tennis to lose weight, and I was.

Do I need a PTTD brace? I purchased some Orthaheel shoes but my foot for some reason gets to a weird angle in them.

I am doing the exercise you recommend for strengthening my ankles. I know losing weight will help me, but I need to know what to do so I can get back to tennis!

Thanks you so much!!

Melanie (name changed due to witness protection)

Dr Blake's response:

Dear Melanie, 

     Thank you very much for writing. I hope some of my initial comments were helpful. Please feel free to comment on this post and I will try to respond reasonably in a timely fashion. To summarize:

#1     You are probably in Phase 1 of Rehabilation: Immobization and Anti-Inflammatory where you try to create a Pain Free Environment to let the tissue heal.  We need to get you to that 0-2 pain level range for 2 weeks straight. 

#2     You can try combining the boot and orthotic, but may have to get another boot or a different orthotic. You do not want to spend a lot of time creating this pain free environment. 

#3     You should consider crutches, and even a RollAbout, for a short time, if that is what it takes. 

#4     For the Anti-Inflammatory part, definitely start ice packing for 10 minutes three times daily. The ice pack can be placed in the boot and you walk around (multi-task). Consider anti-inflammatory meds, flector patches, and physical therapy for anti-inflammatory only (although you can send me a video of you bouncing on the trampoline). LOL

#5     Normally, if the accessory navicular is the source of pain, the pain will localize there as the symptoms die down. 

#6     You should get (if possible) a baseline MRI of the ankle. It will show the rear foot also, and may give clues to what is broken. Hopefully, you strained but not tore the tendon. 

#7    Since tennis is out of the question right now, consider elliptical or stationary bike, even some pool workouts will not irritate, as long as whatever you do does not irritate the tendon. 

#8     One important bit of information I need to further advise regards pain. What produces it? How is it in the morning? See if you can write up and email the pain questionnaire from a previous post. Also, go through the various foot and ankle exercises described in my blog, at least the ones not requiring equipment, and tell me which ones are painful and which ones are symptom free. 

Good luck. Rich
The mnemonic goes like this---

Family History of similar problem? Frequency of pain (how often)?

What is your Assessment of the problem (what do you think it is)? 
What part of your Anatomy is involved? 

I How Intense (use Pain Scale) is the pain? What Irritates (makes it 


L With one finger, point to the exact Location of the worse pain?

What Eases the Pain? Does the pain have an Electric sensation with it

What has been it’s Duration (how long has it been going on)?

O What were all the events surrounding the Onset of Pain? Are there 

any Observable skin changes?

P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End

of the day?

Q What is the Quality of Pain (burning, tingling, dull ache, sharp, 

numbness, throbbing, pulsating, etc)?

R Is there Redness? Does the pain Radiate and where to?

S How does Shoe gear or barefoot affect it (or high heels, or various

types of shoes)?

What have you done to Treat the problem? What Treatment has 

helped? What Treatment has made it worse?

Are there Underlying Health Issues (diabetes, osteoporosis, 

arthritis, poor circulation, etc.)?

V Does the pain Vary (better at different times, worse at other times)?

Can you Work? Were you injured at Work? Does this affect your Work