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Tuesday, May 28, 2013

Shoe Wedging for Knee Pain

Many patients come into orthopedic clinics with knee pain. The exam is quite simple, an MRI ordered, and surgery suggested. I have done extensive work on knee pain and biomechanics. When I first joined the Center For Sports Medicine at Saint Francis Memorial Hospital in San Francisco, I was the only podiatrist. I was called upon daily to design wedges to off weight the injured knee area and allow it time to heal. So, if you have knee pain, seek the advice of a podiatrist, pedorthist, physical therapist to make sure your foot function is not the culprit or a contributing factor.

Ganglion Cyst Mimicking Sesamoid Injury: The Positive Role of an MRI

This young lady emailed me back in Dec 2012 to let me know that she fractured her sesamoid bone and was scheduled for surgery and should she seek another opinion. Her original email is at the bottom of this post. I encouraged her to get a second opinion. She cancelled the upcoming surgery and followed her gut. What was so different from other cases of sesamoid injuries was her feeling she was stepping on a golf ball. She was able to get another opinion and a MRI documenting the ganglion cyst with no fracture to the sesamoid. 

Dr. Blake,

 I am so sorry that is has taken so long to get back to you but I had an MRI yesterday and I am attaching 2 images. The Dr. suspected and the MRI confirmed that I don't have a sesamoid fracture but a very large ganglion cyst in my foot. I have been scheduled for surgery the end of May to remove the cyst and start the recovery process. Thank you so much for your encouragement to seek a third opinion, I consider you my second opinion,  I truly believe you have saved me a lifetime of suffering. 


Large Ganglion Cyst is seen next to a totally normal sesamoid

Large  Ganglion Cyst noted on MRI under the first metatarsal near the sesamoids

Dr. Blake,

I was diagnosed with a fibula sesamoid fracture on my left foot. I feel like I am walking on a golf ball and that is what I call it now. I walk on the side of my foot to keep the pressure off of the ball of my foot but that is causing knee pain and hip pain.  The podiatrist that I saw took one set of x-rays sold me cushions for my shoes and arch supports to wear. I tried those for 2 weeks and no relief. When I returned to the podiatrist he suggested since the arch supports provided no relief that I try a cortisone shot. The shot took the inflammation out of my foot, for about a week,  so it felt like the golf ball went away but the pain was more severe since there was not any extra padding on the ball of my foot. I returned to the Dr. 2 weeks later and he said there is nothing else he can do surgery is my only option and sent me home. I feel after reading your blog that I really need a second opinion before I let anyone do surgery on my foot. My question is do I get that second opinion from another podiatrist or do I try to see an orthopedic doctor? I am scheduled for surgery on December 28, 2012. Any help or advice is very much appreciated. I have cried with my husband over this whole situation and how frustrated I am please help. 


Monday, May 27, 2013

Lifts for Short Leg in Water Shoes Website
San Francisco View from Alcatraz Island

I am a female with osteoarthritis and I would like to enroll in aquacise classes near my home. My problem is that my right leg is 1 3/8" shorter than my left leg and I would like to know if there is a company that can make custom water shoes for my needs. Please let me know if you know of someone that can help me with this request. Thank you so much!

Dr Blake's response:

Here is a link that I hope will help. Rich
We should only be limited by our imagination here. 

Integrated Solutions to CRPS Conference Notes (Part III)

Integrated Solutions to CRPS 

May 10, 2013

 San Francisco, California

This was a great conference on CRPS and I recommend to those suffering to familiarize yourself with their website. This is Part III of my notes from this conference. 

Always try Neurontin and Lyrica first in attempt to control the symptoms. This process can take awhile with gradually weaning on and off these medications to check their effectiveness. 
Based on your response to Neurontin/Lyrica, you can add or switch to Cymbalta or Savella.
Cymbalta and Savella block the pain signals going from the spinal cord to the extremity, with the presenter liking Savella best (Savella tends to need an anti-nausea drug and an anti-headache drug in combo). I personnally prefer Cymbalta.

Exercise and PT are crucial, must do daily with the Goal of Restoring Function---there is a fine balance between honoring the pain and ignoring the pain. 
Full Immobilization increases RSD symptoms and should be avoided--however there are many ways to protect, slightly immobilize, and then allow function
PT Goals are to  Restore function and learn how to properly adjust limb movements
   Avoid hurting
PT with a new RSD onset must stay below pain level, varies day to day
PT with a Chronic RSD must be more about restoring function 
Time focused PT---at times avoid pain, at times push through pain

Marketed in Europe
Marketed as Normast or PeaPure
Used for Neuropathic pain

Presently being experimented with

DMSO 50% successful if applied with other topicals 5 times day
Better affect in warm RSD
Must get 99.9% purity

NAC is an Antioxidant
It is better used in Cold RSD

Use Vitamin C 500mg for 45 days, and with flares

I have attached below an email from a patient actively looking for help with her CRPS. I provided the checklist and she outlined all of the treatments she was working with. It takes a tremendous effort to gain back your life. The notes from this conference as I retype constantly remind me how little I know, but definitely the medical world and those who are suffering are being to find answers.

Plantar Fasciitis Stretch: Comment from my YouTube Channel

This video was really helpful! Most of what I'm told is "stretch with a towel" but it's never explained too well. This actually showed me what to do and I'm going to try it when I get up. Thank you!

Understanding the Diagnostic Tests for Low Back and SI Joint Symptoms

All too often, my patients present with pain in the pelvic area. These sensations can be part of a complex of mechanically induced symptoms which bring a podiatrist into this treatment arena. Podiatrists commonly treat the mechanics around short leg syndrome, poor shock absorption, abnormal pronation or internal rotation of the lower extremity, abnormal supination or external rotation of the lower extremity with lateral instability, tight and weak muscles, and other abnormal gait findings (especially inadequate or excessive hip motions). All of these abnormal mechanics have caused pelvic and low back pain in specific patients at certain times or specific reasons. Since podiatrists are called to treat the pain, this video may help understand the problem and solution by understanding whether the pain is coming from the SI joint. 

Hiking this Summer: Here is a list to guide possible purchase of boots

Getting ready for some summer travels that requires hiking. There is our current list of hiking shoes and some great recommendations from Smarter Travel.

Day Hiking Boots

Ahnu Montara
Asolo Fugitive
Keen Alamosa
Keen Targhee
Merrell Chameleon
Merrell Moab
Merrell Siren
Vasque Breeze

Mid Weight Hiking Boots

Asolo Stynger
Asolo TPS 520
Lowa Bora GTX QC\
Lowa Renegade
Lowa Zephyr
Northface Verbera
Saloman Quest
Zamberlan 310

Backpacking Hiking Boots

Asolo Power Matic 200
Asolo TPS 535
Lowa Albula GTX
Scarpa Bhutan GTX
Zamberlan Vioz
Zamberlan 760 Steep GT

Smarter Travel recommends:

Clark's Quantock Run GTX

Lowa Hiking Boots for their Goretex

Vasque Talus UltraDry Hiking Boots

Sunday, May 26, 2013

Post Partial Sesamoidectomy: Email Advice

Dear Dr. Blake,

As you know from our previous emails, I had a fractured sesamoid. After going all of the treatments, I had the surgery 11 weeks ago. My doctor made a partial sesamoidectomy for the fibular sesamoid, he only took the smaller piece of the fractured sesamoid, which already has AVN.

 6 weeks after surgery, I noticed that there are some color changes in my foot and lower leg, so they made a doppler and found out there is a thrombophlebitis around my ankle. They gave me antibiotics and anti-inflammatuar drugs and also compression socks. After 1 month, i went thru the dopler again, and now there is no clot or anything just minimal chronic venous stasis on my upper legs.

 But when I dont wear compression socks and stand on it long time, my foot which i had the operation from goes red and warm, but when i elevate it, it immediately turns normal. I have swelling as well, but not very bad. I am not applying ice or heat because I'm afraid it will affect the circulation. I never iced after surgery. 
Dr Blake's comment: Typically patients who develop thrombophlebitis are on anti-coagulants for 6-9 months so yours must have been minor. The fact that you can elevate and the circulation returns to normal is great. However, you should always be wearing, minus sleeping, the compression hose for the next 6 months all the time. Since you had surgery, and the healing process goes on for the next 9 months quite actively, you should ice pack at least once a day for 10 minutes, and do one set of contrasts each evening. 

Apart from this, before the surgery I have mild halux valgus deformity with no pain. My incision is directly on that part of my foot, i mean around the bunion area, and now it hurts with touching, do you think it will go away?
Dr Blake's comment: yes, but get a Blaine's scar kit from a local pharmacy and massage the scar for 5 minutes twice daily. It should be cross frictional, across the grain of the incision, and non painful. 

I am reading a lot, but there is not much about partial sesamoidectomy, I hope the remaining part will not hurt. Do you have any experience? I am still wearing tennis shoes with custom orthotics, I don't know when I can switch to regular shoes and even to heels(if possible).
Dr Blake's comment: Surgeries of this sort can be rehabbed gradually and progressively. First you build up your walking, without limping, and without pain over level 2, up to 60 minutes with tennis shoes. Then you slowly introduce wearing of dress shoes (wide enough not to push on the scar). When you are up to 2 hours in dress flats without symptoms, than gradually begin to wear 2-3 inch heels with a dancer's pad. 

Another thing I wonder if I can feel the sesamoid by touching, because I can feel something like a bone when I touch which is more palpable than it is onthe other foot.
I'll appreciate any answer to my concerns:)
Thank you very much...
Dr Blake's comment: Sure you can touch the sesamoid since it is right under the skin. Can I ask why you decided to the partial and not complete sesamoid removal? My readers would definitely like to know what went into your decision. 

Integrated Solutions to CRPS Conference Notes (Part II)

I had a great time learning from these very dedicated people to help patients with Complex Regional Pain Syndrome, aka RSD (Reflex Sympathetic Dystrophy).

Integrated Solutions to CRPS 
May 10, 2013
 San Francisco, California

Integrated Solutions to CRPS is a conference created for people just like you. Individuals with CRPS, friends, family, and caregivers of the CRPS community are invited to attend. The RSDSA, along with the help from generous sponsors, has assembled a friendly forum where you and experts in the CRPS field will spend the day sharing valuable information and exploring new solutions to help manage CRPS.  You will have the opportunity to talk to and network with members of the RSDSA and others who experience what you do, day after day.

My notes (continued):

2 deg temp difference between the good and bad extremity is a common diagnostic tool early in the syndrome, with the injured side either hotter or colder

Patients often complain of the symptom of disturbed body perception is an incredible website to explore for help from the netherlands
50,000 new cases per year in the US
Tests not helpful (including xrays, MRIs, Nerve Conduction Tests)
The physician carefully taking a detailed history and performing a physical examination is the best diagnostic test     

It is very important to Start immediately treating the condition
This is a syndrome typically treated by Pain Management Specialists (Physiatrists, Anesthesiologists, Neurologists)

Treatment is for restoring function, not pain reduction. The emphasis has to be on getting back a life lost with this incredible pain. True suffering occurs with CRPS. 
PT must start below level of pain, then progress slowly and gradually. 

What type of medications can help?
Glial Cell Attenuators are needed to calm down the inflammation in the Glia cells.    Minocyline, propentofylline are glial cell attentuators that can help.

Opioids increase glial cell activity--patients taking opioids initially feel much improvement, then need more and more and more without gaining relief. Important to get CRPS patients off opioids. 

Low dose naltrexone good 1 to 4.5 mg as a glial cell attenuator with little to no side effects

IV Ketamine is the main stay of invasive treatments
    Many ways to administer, orally most side effects since have to take higher dose
Usually IV Ketamine in an Infusion center starting with  low dose over a 4 hour period. The dose is gradually increased  over 10 days. The effect is documented. 
Booster at 2 weeks for 1-2 days and then at 4 and at 6 weeks

Patients should be given sublingual Ketamine for flare

Topical Ketamine only helps initially when the pain is just starting and not when gets into CNS (called centralization), yet it does help skin lesions that may develop at any time during the process

Nerve blocks low help, potential of harm
SCS  (Spinal Cord Stimulators) are painful and expensive , 30% complications
    Improve quality of life for 2 years only

Saturday, May 25, 2013

Integrated Solutions to CRPS Conference Notes (Part I)

Integrated Solutions to CRPS

CRPS (Complex Regional Pain Syndrome) AKA RSD (Reflex Sympathetic Dystrophy

Lecture by Dr.Pradeep Chopra (Rhode Island)

90% of our Central Nervous System (CNS) are Glia cells
Glia Cells are activated with RSD releasing an inflammatory reaction 

During this inflammatory reaction there is a 24/7 barrage of pain signals
The CNS can not keep up and the pain cycle gets out of control

Central Sensitization occurs meaning the pain now processes normal stimulus as painful--localized treatment peripherally does not help

    NMDA receptors activated in the CNS more responsive to pain signals
    Also there is a decrease sensitivity to opiods (classic pain killers)

     Glial Cells are activated in this process with NMDA Receptors acting like keyholes. 

Drugs that block NMDA receptors include ketamine, and can decrease this abnormal pain response.

Glial cells are normally dormant
Active glial cells during RSD release cytokines, making nerves inflamed

Exercise helps decrease this inflam

Long Walking Schedule: Great Website

Whether you are planning to walk a lot on an upcoming vacation, or scheduling an extended hiking trip, this website gives you 3 (10) week schedules---beginning, intermediate, advanced---to make sure you are on the right track. As I turn 60 next year, my goal is to walk the Camino de Santiago in Northern Spain and my wife and I are using this schedule. Since we have along time to prepare, we are doing 2 times through each level---so 60 weeks of preparation. It will keep me motivated during the winter months ahead particularly. Well, my iPad alert just beeped---off I go on my 20 minute walk!!

Severe Low Back Disease: Look to a Physiatrist for Rehab Help

I have severe spinal stenosis, spondylosis, pinched nerves, bulging disc & L4 & L5 out of place, degenerative arthritis, sciatica. What is my best options? I have had epidurals with no luck. Plus I need 2 joint replacements in both knees & it pisses me off more than anything when doctors or people in general tell me to exercise. I can't even stand up for 5 minutes without screaming pain in my back. I can hardly walk because of my knees. What are my options?

Dr Blake's response:
Unfortunately, this is the role of a neurologist or physiatrist to help you. Contact the office of Dr Irene Minkowsky in San Francisco to see if she knows someone in your area or what organization to contact. She is a genius in knowing what the role of surgeons, physical therapists, chiropractors, etc for your condition. She is a physiatrist with an osteopathic bent and definitely attempts rehab over surgery. Hope this points you in the right direction. Rich

Thursday, May 23, 2013

Plantar Fasciitis and Cortisone Shots: Email Correspondance

I am so thankful to the Golden State Warriors for the great enjoyment they brought to the San Francisco Bay Area and fans spread around the world.

In the last few years I've increased my activity level significantly, taking up running and power lifting. After about a year of running, I started having horrible pain in my heel and achilles, which my PCP and Chiropractor diagnosed as Plantar Fasciitis. I spent about six months doing everything I could to take care of it. Icing, massage, rest, adjustments, you name it. In this time, my physical activity has been extremely limited, as I haven't been able to put any weight on my heel without pain.

I finally saw a podiatrist today, who decided to do a cortisone injection and gave me a boot to wear for the next three weeks. Somehow, with all of the questions I had, I forgot to ask what has been at the forefront of my mind for the last six months. I imagine that I should ease back in to physical activity, but how soon? I'm willing to do whatever I need to prevent future injury, but am REALLY missing all of the activities that I had grown to love. Any suggestions for the best way to get back to normal? Thanks!
Dr Blake's comment:

     Thank you so very much for your comment to the post on cortisone shots. After a cortisone shot, you must wait 2 weeks to see what the overall effect is. I always consider that I may have to do up to 3 shots minimum of 2 weeks apart in an effort to bring the pain level down to 0-2. Remember with each shot you can not do anything that hurt before the shot for 2 weeks. Then, at 2 weeks you gradually start adding what hurt before the shot and see where you stand. This is how you decide on the 2nd and possibly 3rd shot. Continue to ice 2 times daily because it really helps the shot (s). I have many patients in your boat to have to wear the boot completely for 3 months, with another 6 weeks of gradually weaning out of the boot. So, now that you put yourself in the Immobilization/Anti-Inflammatory Phase of Healing make sure you do it right!!! And, I always love MRIs to tell me where I am at, but you need to wait for 2 weeks after a shot to do the MRI. Good luck my friend. 

Sunday, May 19, 2013

Neuropathy: What to Do?

Dear dr. Blake

my friend  saw you a few years ago with a broken ankle, recommended I write to you about what happened to me recently that resulted in neuropathy in the soles of my feet and toes.  She says you are wonderful.

Well, cheap footwear from a drugstore apparently had some toxic substance in or on the shoes.  These were a pair of flipflops, boy's size 4/5, with fabric covering the foot-bed.  Being chemically sensitive, I chose this model over all the plain plastic ones (which often reek of plastic fumes), thinking fabric would make them safer -- plus the fact that none of the other models they had available fit me anyway.

 I wore the shoes for about one hour total, and about 2-3 hours later began to notice the sensation of numbness in my feet.  This happened on Sunday April 21st, and there has been zero improvement.

That evening (soon after I noticed the problem) I soaked my feet in epsom salts dissolved in warm water, for about an hour.  Still had the problem, so next two nights I packed clay on my soles and toes (a friend suggested this detox method, and I was glad I had some clay ready to use).  I felt after these two nights that the toxins had been removed but that I was left with lasting nerve damage.  My right foot is worse, the first 4 toes and the sole of ball of my foot feel numb, sometimes there is a burning feeling, and if I stub a toe just a little there can be a sharp pain.  There is nothing visibly wrong, but the sensation I have when walking around is as if I am walking on wadded up kleenex.  I also noticed the skin of my toes felt clingy, as if the toes were sticking together, and my feet seemed to cling to my old plastic flipflops with a very unpleasant sensation.  I have found some relief from this by  putting cornstarch between my toes and wearing loose socks (no flipflops of course). Fortunately I have a pair of Aerosoles w cushiony insoles, which I discovered make it possible for me to go for walks -- and get some exercise.

But now I am scared to buy shoes of any kind.  I wonder if you can recommend some footwear known to be safe (even for the especially chemically sensitive).  I feel kind of ridiculous even asking such a question, but there it is.   Actually I think those shoes from the drugstore would be toxic to anybody but maybe the non-sensitive might not have an acute reaction.  The fact that these were a child's size gives me real concern for the intended wearers.
Dr Blake's comment: Here is a blog posting on this topic.

And if you have further suggestions what to do for neuropathy beyond:  I see that you recommend a lot of vitamin D, which I already have been taking for a long time now, so that should be covered.  I started taking B12 and other Bs, plus lecithin and various herbs that I saw recommended online.  I have the impression that massage is NOT a good idea.  Deep probing of the affected areas seems to hurt and not be helpful.

Any ideas appreciated.  Thank you.

Dr Blake's comment: 

     Thank you for the email, and I am sorry for your suffering. One of my medical assistants getting allergic reactions to the dyes in leather shoes and now uses only vegetable based shoes. She went to an allergist who tested everything, and it really helped her begin to control her symptoms and live more normal. Below is my nerve pain outline and so much can be used in your situation. I have highlighted in red the most common things you can do. Also see the video emphasizing exercise, healthy diet, sugar restricted diets, and no smoking or alcohol. 

3.      Topical Medications/Applications (should be gels for ease of application)
§         Warm Compresses
§         Non Painful Massage
§         Parafin Wax
§         Chinese Herbs
§         Lidoderm Patches
§         Neuro-Eze
§         Multiple Compounding Medications which include (usually not all of these):
ü      Ketamine 10%
ü      Clonidine 0.2%
ü      Gabapentin 6%
ü      Baclofen 2%
ü      Nifedipine 2%
ü      Lidocaine 2%
4.     Alternative
§         Biofeedback (Thermal to increase circulation)
§         Hypnosis
§         Meditation
§         Accupuncture (can be to opposite limb or ear)

·       Nutritional (next 3-12 months)
1.      Lipoic Acid 300mg 2x/day
2.      Acety-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B6 50mg/day
5.      Vit B12 1000mg/day
6.      Vit E (up to 1,600units/day)
7.      Thyroid Natural Supplements

This Mayo Clinic article gives a good overview. I hope this points you in the right direction. 

Sesamoid Fractures with Slow Healing/Reflares: Email Advice

Hi Dr. Blake,

Thanks so much for your past responses; they have helped tremendously (physically and mentally).  Though all the ups and downs, I seem to be on a downward slope again.

A few months ago (January 2013), you had replied to my below email regarding a reflare/set back of my left tibial sesamoid fracture (initial injury September 2012). Per your advice, I put myself back in the boot and I was out of it in 1.5 weeks and have been (left foot) pain-free ever since (so between 3-4 months).  THANK YOU!  I took your advice and never stopped icing, have been using the bone stimulator daily, and taking vitamins.  About 2 months ago, I starting removing the carbon fiber plate from my shoe and have been using primarily a toe spacer (occasionally), a dancers pad (all the time), and custom orthotic with arch support (most of the time)... sometimes all three together.

The last x-ray taken was in March and the top view of the sesamoid basically looked like a snowman (so two connected balls... key being fairly connected).  Last week (7 days ago), I reluctantly decided to walk to/from lunch (0.75mi total) without any dancer's pad or orthotic.  This was really the first time I walked any distance without the dancer's pad as I regretfully thought I was healed enough to walk without it.  It absolutely the classic "too much, too fast".  I did not feel any pain while I walked to/from lunch, but rather it progressively got worse over the next 1-2 days.  It also was unseasonably hot that day/night in Chicago, so both feet were pretty swollen that evening.  

Anyway, I'm SUPER worried that I reinjured my sesamoid as I'm having varying pain from a constant 2 and occasional throbbing up to a 5-6 (keeping in mind it was at a constant 0 for months... I might be hyper sensitive right now). 
Dr Blake's comment: Unfortunately, with all injuries, we have to test them. You did nothing wrong, and the force produced by that walk would have irritated, not reinjured the sesamoid. I am sure you will be fine. Just, once again, back in the boot, etc to create that pain free environment. 

 I notice in the shower that it doesn't hurt so much when just standing barefoot, but when I lift my foot up, I get pain.  Also, the cause of the reflare in January (riding bike) vs this current one (walking 1st time without padding), indicates more potential for reinjury (from my perspective).  Anyway, yesterday, I put myself back into the boot and have been aggressively contrast bathing (3 times a day) and icing.  Given your extensive experience, it also helps to know what you have historically seen with people who have had sesamoid fractures and have felt NO pain whatsoever for 3-4 months (actual injury 7months ago) and did everything initially correctly.  
Dr Blake's comment: Unfortunately (sorry I have to use this word), I have too many patients like you with flares, but they seem to 95% get through them the way you are. There is hope, and it is not false hope. If your last MRI was over 6 months, get a new one. If not, wait until the 6 month interval. 

After going through your blog in the past 7 months, I have not found any exact similar circumstances.  Should I be getting an MRI? (never had one on the left foot given the positive progression of symptoms and x-rays). 
Dr Blake's comment: Yes, MRI crucial to follow this. I would rather follow symptoms than X-rays at this point. 
 Would an x-ray in the next few days reveal any bone damage indication or give us much to compare back to in the March x-ray?  Should I cut out the contrast bathing and just ice?  
Dr Blake's comment: I love three times a day of something. Try three times a day of a simple 10 minutes ice pack under your foot, and compare how you feel with that vs how the contrasts made you feel. Some version of icing and contrasts should feel the best. 

Should I concentrate on off-loading?  I know I should probably give this 2 weeks in the boot and go from there, but it's hard to face this music right now.  I feel like I totally screwed up here and am looking for your guidance, thoughts on potential harm I may have caused, and future plan of action.  
Dr Blake's comment: I know this sucks, but do not be so hard on your self. Off weighting with orthotic and dancer's pads are fine if they create our pain free environment, or back in the boot with you for 3 days longer than you think you need it. I find that the length of time you have to be in the removable boot with each flare, is a strong indicator (better than X-rays) of how much irritation you caused. Remember each day from the initial injury this bone is getting stronger, and less fragile, so it takes alot more to reinjure it. I can not imagine you re-injured it, only irritated it. 

Thanks so much Dr. Blake,

Nothing to do with Feet: Just Unbelievable!! // Media » Britain's Got Talent - Charlotte & Jonathan

     What is life about? It can be the relationship of us to our friends, family, neighbors, strangers, and a Higher Being. Jonathan would not have been there without Charlotte. Jonathan stood firmly with her under fire. She had his back, and he hers. A team was born way before the song was sung. A music teacher off in the shadows. It was this teacher that allowed them to fly. I say Teacher of the Year!!! I bet Jonathan will remember that teacher always with gratitude.

     Charlotte and Jonathan represent a TEAM--Together Everyone Achieves More. I disagree with Simon. This team has magic, and they support each other. There is no "I" in team. I wish them well.


Sesamoid Fracture: Email Advice

Dr. Blake,
I was recently doing some research and came across your orthotic blog. About a year and a half ago I was diagnosed with a stress fracture in my right foot sesamoid bones. I ran cross country in college freshman and sophomore year and was running about 45 miles a week. In the middle of the sophomore season the bottom of my foot began to hurt but it wasn't bad enough to stop running. By the end of the season it was very painful so I went to see a doctor.

 An MRI revealed that I had bipartite sesamoids as well as a stress fracture. I was in a walking boot/cast for 8 weeks. After that I did not run for at least a year. I did other activities like spin class, elliptical, and aqua jogging. In December of 2012 I began to run again. I started with 10 minute bouts and that was painful but eventually got better. I slowly began to increase and at first it would be painful but after a few weeks at the same time and speed it began to get better.

 I am emailing you now because I seem to have gotten stuck  at about 30 minutes. I usually run 3-4 times a week. The pain is mild when I run but afterwards is about a 7/10 on  pain scale. I want to increase my mileage but am afraid I will be doing more damage. Is it okay to have pain? Can I make it worse by running?
Dr Blake's comment: You have to listen to your body and honor the pain. The worse pain is when it occurs during the later stages of a run, but the second worse is when it occurs afterwards. You must manipulate the running to have the pain stay at 0-2 afterwards. This can be running more flatfooted, making sure your shoes and inserts adequately take pressure off the sesamoids, running shorter time or every fourth day, avoiding hills, icing for 30 minutes as soon afterwards as possible, etc. If this fails to make a significant change, a repeat MRI to compare with the old will always help. 

 My physical therapist said that if it was a fracture it should have grown back stronger and that I can't damage the bone anymore.
Dr Blake's comment: I kindly disagree. That general rule does not work with sesamoids since it is a weight bearing bone with poor blood supply.

 I forgot to mention that I am seeing a physical therapist. We are working more on mobilizing my mid foot, I have very high arches and a very rigid foot.
Dr Blake's comment: Rigid feet pound more, and high arch feet have more metatarsal and sesamoid problems. This is due to the fact that the metatarsals point downward more in the high arch foot leading to more pressure on each of the metatarsal heads (where the sesamoids are). 

 Other things that I am doing are: wearing custom orthotics, icing after every run, not wearing heals, and taking NSAIDS when the pain/swelling gets really bad. I've been thinking of switching to altra-zero drop shoes to see if that will help any. I keep looking at sites and seeing that this pain should be gone within 6 months-year after the fracture and yet mine is still hurting.
Dr Blake's comment: You can not use time to judge since everyone is different. You need to create this pain free environment by manipulating each aspect of treatment. I agree you should be running some to help find out what works. Can you make your orthotics better? Do you feel that the arch support puts your weight off the big toe joint when you run? Do you have a dancer's pad within the orthotic device? If so, is it high enough to off weight the sore area? You should be icing 3 times a day for ten minutes minimum, and probably use the evening icing time to actually do a full contrast bath to flush inflammation. I agree to keep the NSAIDs as needed. Look at when you are irritating your foot. Is it only running now? Or how bout barefoot? Dress flats? 

 I don't want to have surgery because I know that the chances of being able to run again after that are slim-none. 
Dr Blake's comment: Not running after sesamoid removal is due to a surgical complication, not in the nature of the surgery itself. I always expect my athletes to run after sesamoid removal, and I presently have a 4:10 miler doing just that. However, surgery has a 20% failure rate for return to running, and even though great odds for surgery, not great if you are the 1/5 that can not run. Goal: Have surgery only if you have done everything else and waited until the MRIs (at 6 month intervals) document no longer any healing. The more sports medicine learns about this problem, the fewer patients have surgery. We get smarter. 

I'm not looking to be running 45 miles a week again. I'd love to be able to do 20-25 miles/week. So I guess my main questions are:
1.) Should I keep running? Yes, with modification.
2.) If I keep running can I damage my foot further? If you keep running with level 7 pain, yes. 
3.) Is there anything else I can do...should I be going back to see a doctor? If MRI is over 6 months, get another one. If PT can do the rest for you, including orthotic modifications, stay there temporarily. You are in the Return to Activity Phase of your rehab, and you are having problems. This is when we learn the most to individualize the treatment, no cookbooks. Make sure the bone density, calcium, Vit D3 is great. You want a D3 level around 55 or you will break something else when you start running. Hope this points you in the right direction. Rich

Anything else you think might me would be greatly appreciated.

Thank you for your time,
Mari (name changed)

Saturday, May 18, 2013

First Toe, First Metatarsal, and Sesamoid Injury: Email Advice

X rays notoriously misdiagnose sesamoid injuries. I can see irregularities in her tibial sesamoid, but is that really what is causing pain? We see normal joint space in the big toe joint denoting no significant arthritis. You can see the first metatarsal head is longer than the second. It needs to be 3 mm or so shorter than the 2nd or jamming of the joint can occur. This is a major cause of big toe joint pain, and mechanical changes with arch support and dancer's pads are very important. 

Dear Dr Blake,

I have been reading your blog and have found it to be an amazing resource - and by far the best on the seemingly incredibly tricky area of sesamoid issues.

My story: I have had pain in my right forefoot ever since snowboarding in Feb 2011. Initially this centered on the distal interphalangeal joint in my big toe. I had an x-ray which purported to show a fracture on the outer extremity here and treatment to relieve the pain was a cortisone shot in August 2011.

In March 2012, the pain returned - both in my big toe joint, and now around the sesamoid region. An MRI showed edema in the sesamoid region, but no apparent reason for this. I had an ultrasound guided cortisone injection into the site of the edema. This did not relieve my pain at all.
Dr Blake's comment: Even though the pain is in the same area, this sounds like a new injury. However, long acting cortisone can mask pain for 6-9 months, and patients can be worse when the cortisone wears off. Overall, try to stay away from cortisone shots into joints for this reason. Just using cortisone, without understanding the injury mechanics/cause, can be a dangerous proposition. 

Over the months the pain worsened. After going horse riding, which placed a lot of friction on the sesamoid area, my entire joint swelled up massively. I had a further MRI in Feb 2013, diagnosis this time was sesamoiditis.
Dr Blake's comment: Sesamoiditis rarely causes massive joint swelling. There is definitely something wrong with the joint, but it is not the sesamoid.
Unhappy with this I got a 2nd opinion on my scans which has recently come back as a fractured tibial sesamoid. In April 2013 I had a further cortisone injection (bringing my total to 3 in this area!) and am now in an aircast boot.
Dr Blake's comment: Hopefully you are not getting long acting cortisone which is contra-indicated in fractures. 

My questions...

1. Given that I have gone undiagnosed for so long, I am understandably keen to confirm that I do indeed have a fractured tibial sesamoid - are you able to identify this on my attached scans?
Dr Blake's comment: Thanks for sending me all these images. You did injury your tibial sesamoid, but that seems to be doing well. You still have some major healing to occur on the first metatarsal fracture, and perhaps some mechanical treatment of the first metatarsal to help you speed up the cure, and prevent relapses.

2. The pain in my distal interphalangeal joint is now insignificant in comparison to my sesamoid pain, but I wonder if you can see anything on the scans to confirm a fracture here? Could it be that my seasmoid fracture resulted at a later date after walking differently to compensate for this pain?
Dr Blake's comment: Yes, the distal phalanx (under the toenail) was injured and is still showing inflammation. Hard to know if it all occurred at once, or were separate injuries. Has is your Vit D3 levels and overall bone density? 

3. Will the multiple cortisone shots I've received have done any irreparable damage and act to prevent my healing? I assume you would advise absolutely no further shots now a fracture has been identified.
Dr Blake's comment: Probably not, and yes try to avoid. 

4. If I sustained the sesamoid fracture so long ago in Feb 2011, is it now unlikely to heal whatever efforts I make?
Dr Blake's comment: Your sesamoid fracture with it's resultant inflammation is probably less than 5% of your overall pain right now. Most of the pain is from the inflammation within the first metatarsal head (very obvious on the MRI images below).

5. My doctor advised just 6 weeks in the aircast boot, I am assuming you would recommend much longer?
Dr Blake's comment: There is no fracture displacement necessitating casting or surgery. It is going to take a long time to have the first metatarsal feel better based on the present inflammation. You need to wait 6 months to check on the first metatarsal head inflammation process, a sign of healing. You should be creating your pain free environment with the least immobilization as possible. Right now, if the joint is swollen, contrast baths, no NSAIDS, bone stimulator if your insurance will allow, spica taping, orthotics, dancer's pads, Vit D3, Calcium, occasional boot, stiff shoe, rocker shoes, etc.

6. I am now trying to follow the advice on your blog and create a pain free environment - spica taping, icing, contrast bathing, orthotics inside my aircast boot. Yet my joint is visibly still quite swollen and I believe the aircast boot my even aggravate it from rubbing. Would you advise removing the boot whenever sedentary?
Dr Blake's comment: The swelling will be there for a long time, and immobilization makes it worse. Base your treatment on gradually increasing activity, while you protect the joint, and keep the pain level between 0-2. Do not base your treatment on swelling. Good luck my friend and so sorry for the delay in responding. Rich

The saga of my foot injury has brought me quite low. And I am quite devastated to learn after all this time that there has been a fracture lurking. I hope that by following your advice I can finally access some real healing.

Many, many thanks,

Cecilia (name changed)

On this view, like the above X-ray changes within the tibial sesamoid suggest a tibial sesamoid stress fracture. The tibial sesamoid is closest to the skin, the fibular sesamoid is closest to the 2nd metatarsal. See the dark area in the center of the first metatarsal head suggesting bone remodeling. This area is highlighted in the T2 image below which emphasizes swelling. 

This is really why you hurt. You can see that the tibial sesamoid is lighter than the fibular sesamoid suggesting some fluid retention, but healing uneventfully. The center of the first metatarsal is full of intense swelling signifying cartilage or bone injury to the metatarsal head. You will not feel a lot better until that inflammation goes down with further healing.

Here the sesamoid and the first metatarsal look fine, however injury is noted in the distal phalanx (under the toenail) with inflammation seen on this and the next image.
Normal middle of the joint from the side

You can see the center of the first metatarsal head is still remodeling. Definitely here looks like a slow healing fracture.

Here there is a suggestion of bone edema into the first metatarsal shaft away from the sesamoid area.

You can see the old tibial sesamoid stress fracture that is in one piece. You can get some symptoms, but the injury to the first metatarsal head is worse, and still has aways to go to stop giving you symptoms.

This is a hard image to read but implies normal sesamoids

This is another great image showing that the sesamoids at this stage are not your problem, but the swelling above it.