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Sunday, June 30, 2013

Fitness Tidbit of the Day from Lisa Tonra

Fitness tidbit of the day:

Gals: are your thirties well behind you? (I'm right there with you!) Have you noticed that your knees seem to be moving a bit more towards each other, perhaps even looking somewhat knock-kneed? You might 'need' to look a bit more south, towards your feet! It's always wise to check with your podiatrist to rule out more serious conditions and those requiring orthotics or other external support, but a few simple exercises performed in bare feet can make all the difference in knee health. Try this simple routine:

1. Warm-up: While standing, lift all ten toes off the ground and lower them. Now lift all ten toes off the ground and spread them as far apart as possible. Finish with lifting one heel off the floor at a time, rolling from one side to the other. Repeat each move for 12 repetitions.

2. Heel Raises: Standing on both feet, raise your right heel and then set it down. Do the same with the left heel. Now holding onto a firm surface, such as a counter top or chair back, rise up onto both heels simultaneously. Do one set of each movement for 12 repetitions.

3. 'Domers': Standing with feet flat on the floor, lengthen toes along the floor as broadly as possible, then pull them inwards towards you while keeping them on the floor. Try to keep your toes straight rather than curling them under your foot. Return toes to starting position and repeat 12 times.

Strengthening these small-but-mighty muscles of the feet will help increase your foot and lower leg strength, enhance your awareness of foot mechanics and give your knees a big positioning boost! Good luck!

About Lisa:

Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here:

Peroneal Subluxation/Dislocation Syndrome: Video Presentation

Video on Importance of HbA1c Test for Diabetes and Stability of Diabetes

Morton's Neuromas: Success with Alcohol Shots

Excellent article about Morton's neuroma which has plagued me for six years. Had some success with alcohol injections, but my podiatrist moved to Kansas before completing series of shots. Replacement podiatrist doesn't believe in their value. Can you recommend another doctor in Wilmington, NC? The pain is severe after 45 minutes of hiking which is my passion.  Prefer NO surgery.  Also, your search function on my iPad keeps taking me back to the same article when I try to access potential treatments you recommend.  Thank you for any help with identifying a doctor who,shares your values and expertise.  

Dr Blake's response:

     There are the podiatrists in North Carolina from our national Sports Medicine Academy--AAPSM. They are normally the best place to start.  

Christopher J. Gauland, DPM2140 West Arlington Blvd.
Ste. D
William J. Johncock, DPM - Fellow828-327-3029419-B 2nd St. N.W.HickoryNC28601
Robb A. Mothershed, DPM3057 Trenwest Dr.Winston SalemNC27104
Jeremy Thomas, DPM
919-851-3435204 Ashville Ave Ste 40CaryNC27518

There are some of the other articles on Morton's Neuromas, but many more throughout the blog. Sure hope this helps. Rich

Foot Possible Stress Fractures: Email Advice

hi doc,

i'm a former patient (i can't remember when exactly, but it has been a while). at the time i was seeing you, i had problems w/ stress fractures in both feet (revealed via MRI). you had me do contrast baths, taping, wearing orthotics and i had to wear a walking boot at one time or another on either foot.

during a recent tennis match, i was forced to make a shot which had me land a bit awkwardly on my left foot. i felt "something" right away, but it wasn't enough to prohibit me from playing the remainder of the match. since then, i've felt some things that make me think (more like know) that my left foot is broken. i've had the same type of throbbing at night that has kept me awake at night on the top and bottom of the ball area of the foot. there is no swelling, only slight discomfort when walking - pain in the 3-4 range that varies during the day - and the pain is not constant.

i've been able to play tennis, but i've been taping my foot (amazing how i remembered to do it just like that!) for support.

think it's best to actually come in or do you think i can just tape and immobilize for a while to see if that has any positive effect (or possibly no effect)?

very truly yours,

Dr Blake's comment:

     Ralph (name changed), thanks for the email. It is so difficult to play tennis (or most sports) with a stress fracture, that you either have a small one, or just a sprain of the ligaments. I agree that it sounds like a stress fracture however by how sudden it came on. These scenarios are always stress fractures until proven otherwise. Stress fractures always give swelling, but with some of the deep ones, you can never see the deep swelling. Small stress fractures, if given time to heal, normally take 3 months to heal. So, you can wait the 3 months, and if you are not appreciably better, than let's take some xrays. Read my blog post on Good vs Bad Pain, and avoid bad pain. No limping or sharp pain while playing or you will hurt something worse like your knee. If wearing the old removable boot during the work day makes it feel a lot better, I would do that (even for 4 hour periods can rest the area and help healing). Remember to get 1500 mg Calcium and 1000 units Vit D, check the foods you eat for average amounts and supplement if you have to. If tape helps, tape daily for 2 weeks longer than you think you need too. 3 times daily work on the inflammation with 10 minute ice packs and/or contrast baths. I sure hope this helps. Rich

Hallux Rigidus: Email Advice

Hi Dr. Blake

I'm an active 52 year old female with end stage hallux rigidus. My condition was caused 27 years ago when my big toe was jammed into the joint playing soccer.

Each year I would assign a percentage to inconvenience the pain disrupted my daily life. Once the bump appeared about 2 years ago the percentage went up to 90%.

In the past 6 months I've had 3 opinions. Podiatrist wants to clean the joint then a joint replacement in 10 years, orthopedic 1 wants a fusion, orthopedic 2 (top doc in major east coast city) said joint destroyed and severely arthritic. Fusion is my only option.

Your blog is incredible and helped me ask great questions. No one offered spica taping which I just tried a few days ago with great pain relief.

I haven't seen much on what the risks would be if no action is taken. I understand the disease is progressive. Can the joint break.
Dr Blake's comment: No the joint can not break. It is gradually self fusing, but that produces both bone and soft tissue inflammation. The soft tissue inflammation can be controlled with icing 2-3 times per day, occasional cortisone shot or oral cortisone burst, contrast baths 3-4 times per week, spica taping to limit the bend of the joint, NSAIDs occasionally, bouts of PT or acupuncture, and activity modification. 
The bone inflammation is also helped by contrasts baths, possible off label use of a bone stimulator, physical therapy, off weighting the joint with orthotics and dancer pads, and occasionally use of removable boot, stiff hiking boots, carbon graphite plates. Hang in there and see if the above can help you get this calmed down. You were good to get the opinions, of course, if you have any surgery, you would have to get an MRI and possibly CT Scan to analyze the present situation better. Rich

I'm very hesitant to fuse. Although I was told its self fusing. Is it ok to let the body self fuse. I can tolerate the daily pain for the most part.

Thank you for dedicating your time to helping those of us living with this crazy condition.

Saturday, June 29, 2013

When Working Out: Understand the Laws of the Environment You are In

When you are feeling rushed and in a hurry, 
maybe it is time to stop and appreciate the wonder all around you.

These photos are from Centurion in Pilanesberg Game Reserve, South Africa .

The guy in the car was honking, trying to get past the elephant. 

Road rage, it affects us all...

Should we Cool Downafter Exercise?

New York Times article on whether or not we need to cool down after exercise sent by one of my patients.

Cipro and Prednisone's Negative Impact on Tendons

Hi Rich,

A friend said I should tell you I'm finishing cipro (for stomach bug) and was on prednisone recently (related to shingles) in case that makes me more prone to a tear or injury. I guess that happens with some corticosteroids and antibiotics.

I'm taking it easy. Let me know if this changes anything.

Thanks very much.   Dr Blake's comment:   Hey Nakima (name changed), You are suspectible for 2 weeks after stopping Cipro to injury tendons. Please finish the medications, wait 2 weeks, and then increase activity and exercises. You have a double whamy with both those meds. Lucky you. rich

Friday, June 28, 2013

Achilles Tendinitis: Avoid Cortisone Injections

This was a comment posted today on 6/28/13.

First I want to say that I've had Achilles tendonitis in both ankles for the past 5 years. I've had cortisone injections every 6 months for the first 2 years from my local Doctor then went to a Physiotherapist and had 6 months of Shock Wave treatments that didn't help.
Dr Blake's comment: Please try to avoid any type of cortisone injection around the achilles tendon. I am so hopeful that ultrasound guided injections will be the wave of the future, but it will take many years to prove that any injection of cortisone around the achilles tendon is not potentially dangerous. Remember health care providers: do no harm. Use physical therapy, acupuncture, body work, orthotics, stretching, strengthening, etc to help the achilles. 

 I then went to a Specialist and received more injections which only helped for about a month each time and then I was back again for more. Then on the 24th September 2011 I sprained my ankle as I was getting out of bed - yes, before I even touched the floor with my foot. I heard a very loud crack and it hurt really bad - even my husband heard it! It started swelling and aggravated my Achilles tendonitis to the point where I couldn't wear my shoes.
Dr Blake's comment: This is probably a partial tear of the tendon causes or aggravated by the cortisone. 

 I had to buy a pair the next size up if I wanted to go somewhere. It stayed very sore and swollen for months until I had a intensive set of cortisone injections in February 2012. It helped (until now) and the ankle swelling and tendonitis went away but I still have a strange swelling on the top of my foot. It starts where my toes join and then goes up the foot almost to my ankle. It swells and hurts more if I'm on my feet a lot or even just a few hours so I'm going to try your hot and cold bath method to see if it helps.
Dr Blake's comment: This was a comment from the contrast bathing post.

I still have the Achilles tendonitis (in both ankles now again) and was referred back to a different Physiotherapist. After 5 treatments he said I had too much inflammation in my body and couldn't treat me - the more he and I worked on it, the worse it got. The strange thing is, all my doctors etc. have told me doing The Negative Heel Stretch is the only way it will help it but in one of your videos, you say they should be avoided.
Dr Blake's comment: Here is the video associated to that comment.

 I've tried doing them (because my doctors have told me) but I had excruciating pain and had to stop. It only makes my problems worse and for some reason they don't believe me. Anyway, I'm going to follow your advice with the calf, ankle and foot stretching instead and hope it works.
Dr Blake's comment: Definitely push to get an MRI so that we can analyze the 3D of the tendons. Please stay away from cortisone and let the MRI put us into a specific direction. 

Thursday, June 27, 2013

Surgery of the Future??

My wonderful friend Kenn sent me this great video highlighting one Israeli company and there great advances in non invasive surgery. I love the Star Trek reference, because this is what I dream about for the surgery of the future!!!

Golden Rule of Foot: Keep It Simple Stupid

Golden Rule of Foot: Keep It Simple Stupid

     Yes, the famous KISS principle applies here as in most aspects of life. So, it is a great start to the Golden Rules of Foot that podiatrists live by. For every treatment plan, there are simpler and more complex modalities. Patients can help you decide if you go for the big guns or start slowly. I make mistakes all the time being too simple when more complexity is needed, and too complex when simple will do. So, I allow my patients a vital role as we discuss options. It is the nature of a sports medicine practice anyway for the doctor/therapist and patient to team up to work together on the problem(s) at hand.

     One of my patients today just injured her posterior tibial tendon. Because of many factors, including the fact that she ruptured the other posterior tibial tendon 15 years ago, I immediately ordered an MRI to know what direction to go towards. This would be considered a more complex approach, instead of a more simple xray, with course of icing, anti-inflammatory medication, and ankle brace. But, the seriousness of possible missing a tear and immediately treatment thus I could not take a chance. The more one uses an MRI you see when and where it really makes a difference. No KISS Principle today.

     One of my new patients today was in for a second opinion regarding big toe joint surgery. Very serious stuff, but her conservative care was very lacking, and the surgery suggested very complex with joint replacement. I started her icing 3 times daily, spica taping to hold the joint still, Cluffy wedge to place weight on the first toe, and dancer's pads to further off weight the big toe joint. Simple stuff to start for a serious problem. She is to call or email in a month and also send me her MRI done 6 months ago. Here I am starting with the KISS principle since it seems helpful and direct.

     One of the interesting factoids I have learned is that complex is exciting, interesting, and seemingly professional to most doctors, therapists, and doctors. They expect treatments to be something the patient do not do on their own. Add a laser into the discussion and everyone gets excited. Medical schools and seminars emphasize complex treatments and testing. And this is how the KISS Principle gets ignored, violated, battered, and destroyed daily in most medical practices. Students who rotate occasionally through our office seem bored with simple solutions and definitely are not taught this stuff. I rarely see a bunion patient with toe separators by their podiatrist as an example.

     I am internationally known for my orthotic designs, yet I use OTC orthotics routinely when KISS applies. I always prefer icing and contrasts to oral medications or injections. If a patient said that they would rather have surgery than to ice 2 times a day for the rest of their life, I would have a vigorous discussion of why that may not be prudent. The KISS principle can be boring, time consuming, and non-flashy, but 90% of the chronic pain patients I see have a very inadequate KISS based conservative program of treatment when I first see them. These are patients that have seen up to a dozen of health care providers. I also give credit for this dilemma to the patients for not following through on simple treatments, or implying to the health care provider that it sounds too simple (the provider hears that as an attack that they are "simple minded.") How often are simple treatments ended because they only gave 20% pain relief when 5 simple treatments additively could give 100% pain relief.

     When you are going through treatments, find what works even partially, and stick to them for 2 months longer than you need to due to pain. Make your treatments additive (One from Column A, One from Column B, etc). Add complexity when needed, but if the treatment complexity seems more than the seriousness of the injury, ask questions. And if the treatment simplicity seems not enough for the seriousness of the problem, ask more questions. I sure hope this thought process is helpful. Dr Blake

Wednesday, June 26, 2013

Smart Socks: They are on their way to Help Athletes and Diabetics

I am so excited about the future. These two videos give a little look into why I am so Happy!! Socks to help me treat my runners and socks to help me treat my Diabetics. 

First Metatarsal Position: Important to Know with Metatarsal Problems

One important measurement that bio mechanic specialists evaluate is the relationship of the first metatarsal to the second metatarsal head. The foot should be centered under the ankle joint (therefore not pronated or supinated). One thumb on bottom and index finger on top grab the second metatarsal head and stabilize it. This will be the reference point. With the other hand, grab the first metatarsal head also from top and bottom. See where the first metatarsal head lies in relation to the second metatarsal head when the thumb fingernails are parallel. Then move the first metatarsal head up and down noting the overall motion and position. The motion is ideally 5 mm up and 5 mm down. In this patient, the left first metatarsal moved only 2 mm total (4 mm down and -2 mm up). This is called a stable plantar flexed first ray. Ideally the first and fifth metatarsal heads are lower than their adjacent metatarsals.

On this patient's right foot, the first metatarsal rested 3 mm above the second metatarsal. The overall motion with 6 mm (6 mm up and 0 mm down). This is called an elevated first ray or metatarsus primus elevatus (I love to talk like I am smart!!) This is an unstable first metatarsal that will not hold up the arch, and causes instability in the foot. It can be the cause of bunions or produced by the formation of a bunion. When recognized, orthotic modifications like the Cluffy Wedge or Morton's Extension  can be used, and if surgery is being done, corrections for the elevated bone can be done. With an elevated first metatarsal, the weight goes more to the second and sometimes third metatarsals leading to pain syndromes like metatarsalgia, capsulitis, neuromas, and hammertoes. 

Tuesday, June 25, 2013

Non Healing Sesamoid Fracture: Email Advice

Hello Dr. Blake,
I am glad to see that you are taking emails again. I hope you are well. I have been immeasurably blessed by your blog. I have learned so much and have passed your site on to my fellow foot sufferers. Who knew there were so many of us? Being in the fitness industry, I am concerned about the high and increasing occurrence of foot injuries. Never again will I take foot health for granted.
Dr Blake's comment: Sounds like we are in this together to help with foot health. Thank you. 

If you get a moment I would appreciate any thoughts you might have regarding my sesamoid fracture. I have become weary---I was so determined to get this puppy healed but sadly it is not cooperating. I am somewhat distressed that surgery may be looming.

     I am a 53 year old female.
I teach elementary P.E. (I agree with your post regarding kiddos and increased exercise btw) and I am a certified Zumba Fitness Instructor. 

     In August 2012 I doubled my Zumba Fit classes from 5/week to 10 per week.
Dr Blake's comment: Golden Rule of Foot: 10% increase per week is safe, more than that we are at risk for injury. 
     In early October I began to have discomfort in the left ball of the foot with minimal swelling on the top of the great toe joint after Fitness classes. Additionally, I regularly wore high heeled platforms every weekend to church, events, weddings,etc. I attended a wedding late Oct. and danced in said heels at the reception. At the end of October I recall a sharp pain in my left ball joint while teaching Z Fitness---doing a heel toe move.

     Thereafter, I began having chronic discomfort and swelling coupled with acute pain after fitness classes. I had x-rays  with an unclear diagnosis; the possible beginning of both a bunion and arthritis. Dr. advised foot rest, no Z classes, shoe inserts and come back in 4 weeks. I called the 3rd week and requested the specialist to look at my X-rays as I was not improving. When that did not happen I went to another Podiatrist. He looked at my Nov. x-rays and said I clearly had a sesamoid fracture.
Dr Blake's comment: It is good to get a second opinion when not improving, even when you plan on going back to the original treating physician. Health care providers just got to get over it!!! It is best for the patient in many ways--physically, emotionally, spiritually.

     He put me in a walking boot to be worn 24 hours daily. I began using an Exogen bone stimulator 2xs daily. My next set of x-rays showed no change.  I upped my calcium--Vitamin Code Grow Bone and Ezorb. Icing 2-3 times daily and contrast bathing. I went to crutches and a knee scooter for 6 weeks. Major swelling and pain continued.
Dr Blake's comment: Immobilization tends to thwart any reduction of swelling hoped for. The major swelling reduction comes with weight bearing, elevation, painfree massage, and motion. I would expect however the pain to be subsiding.  

ua I went to a TuNai therapist who aligned my ankle and foot. We watched the swelling go down in that session! Amazing!! Continued 1 weekly TuNai therapy for  4 weeks. Got a custom orthotics boot. X-rays every 3-4 weeks showed little to no change.
Dr Blake's comment: After the first 6 weeks or so, the xrays lag behind the healing, and may not be very reliable. By this time, they are a waste of radiation in general. Best to go by symptoms. 

      I slowly weaned to walking with custom orthotics in my athletic shoes and have been wearing them to date. I occasionally wear Ugg converse sneakers with purchased orthotics. I added Vitamin Code D3 and a supplement called Repairzyme. I had quit drinking diet soda and caffeine back in September for other health issues.

     I had an MRI: Radiologist report:'..medial sesamoid bone...indicating edema. An irregular, jagged cleft btwn 2 portions of medial sesamoid....seems to be a small tear in the intersesamoid ligament and probably the plantar plate btwn the intact flexor hallucis longus tendon and the lateral sesamoid.  Osteoarthritis of the great toe MTP joint...some arthritis spurring along the inferior  surfaces of the 1st metatarsal head.' 
Dr Blake's comment: It is the osteoarthritis in the joint that I am most concerning with. It suggests you have a healing medial sesamoid fracture (in some stage of healing), and arthritis in the big toe joint that may be chronic.

    I began having slightly increased pain and swelling in the last 2 weeks. I went last week 6/20 to TuNai therapist and she painfully pulled my big toe joint into place and I have had relief. I have 2 more sessions scheduled. I continue to ice and I have increased the Exogen to 3xs daily.  I made an appointment to consult with an orthopedic surgeon. My reasons are twofold; to get a 2nd opinion and to consider surgery. Waaa! I have been adament about avoiding surgery. I am not so adamant now, but do not relish the idea of my bone removal. I am concerned about life post surgery--teaching P.E. and Z classes. No more cute wedge shoes (I know--so ridiculous) but cute converse Uggs just don't quite cut it at church and weddings (smile). 
Dr Blake's comment: Surgeons tend to be blind to the arthritis when they are dealing with bunions and fractured sesamoids. Do not have your sesamoid removed unless you are sure it will not continue to heal and you are convinced that the arthritis is not the major cause of your pain. Arthritic big toe joints cause swelling to collect around the sesamoids, which make them hurt on physical examination. 

What do you think? Is there any chance of healing at this point (outside of a miracle?)?  I understand it can take up to 1 year to fully heal and I would wait if that was happening. But shouldn't I be seeing some healing at this juncture? 
Dr Blake's comment: I will feel better giving you advice seeing the 6 month MRI comparison of sesamoid bone edema and first metatarsal edema. 

I value any input you might have Dr. Blake. 

Attached are recent x-rays.
Attached are images from MRI.  

I truly appreciate your valuable time and expertise of my dilemma.
Thank you.
Be Blessed.

Dr Blake's comment: So, I think the sesamoid is healing enough to warrant another MRI at 6 months. You need to go back and do what you can creating a pain free environment. You should have several conversations about the possibility that the sesamoid is healing and you really may have Hallux Rigidus/Limitus joint pain. I hope this helps you somewhat. Rich

Tibial Sesamoid Fracture showing sesamoid fracture line and line extending into the first metatarsal. I would love to see this same image in T2 imaging where the bone is black when healthy.

Bottom slice of the foot showing the normal fibular and fractured tibial sesamoid

Another view of the fractured sesamoid with no break in the cartilage under the first metatarsal head. However you can see that the consistency of the first metatarsal head is irregular with bone cysts suggestive of arthritis.

This is called the Eqyptian Foot with the long first metatarsal--first metatarsal length should be approximately 3 mm shorter than the second metatarsal. Long term stress to the joint occurs with that alignment. See the obvious increase whiteness of the first metatarsal to the second signifying stress. These are joints that get arthritis. 

Monday, June 24, 2013

Icing: How much of a good thing can you do?

Hello Dr Blake:

Is it possible to ice too much? I have a sesamoid injury and I am currently icing 4 times a day for 10 minutes and then a contrast bath. But if I ice, say 7 times a day, would this be more effective?

Dr Blake's comment: 

    Thanks for the email. Ice typically cools the area 4 times longer than you use it for. Therefore, 10 minutes of icing means another 40 minutes of anti-inflammatory action. I love the idea of patients controlling the inflammation with icing every two to three hours. You will keep the area cooled off round the clock. The skin and nerves in the area have to be watched for lasting redness or tingling/numbness. If so, start to back off the icing 50% or give yourself 1 day off to regain status quo. Sure hope this helps. Rich

Sunday, June 23, 2013

Posterior Tibial Tendinitis: Email Advice with Further Response

Dr. Blake,

I have struggled with bilateral posterior tibial tendinitis for a long time.  The first bout I had for roughly three to four years.  It had a devastating impact on my life.  It finally went away for a couple of years, only to come back about six weeks ago.  Since the latest onset, I have done a great deal of research.  Your blog is far and away the most helpful and hopeful resource I have found.  Thank you for taking the time to help educate and inform people about this condition.  Your generosity is apparent when one considers that the vast majority of people reading your blog will never become paying patients.
Dr Blake's comment: Thank you for your kind words. It has been as rewarding for me as helpful for others. It definitely forces me off my butt at night and to sit down at the computer. Please tell me where the pain is in the posterior tibial tendon, and whether that point of maximal soreness is on both sides. This would be the weakest link in the chain. 
Also, what factors do you think helped it go away? It can help in the present rehabilitation. 

The pain is always present on the posterior side of my ankle bone—that is the point of maximum soreness.  The pain creeps a couple inches up the tendon towards my calf.  When it is bad, it goes all the way up the tendon, and around the bottom of the ankle bone into the arch.  The area around the navicular is very tender when you palpate it.

Rest and ice help the pain go away.  I’m currently icing my feet three to four times a day.

I have had a complete work up of my condition through a variety of doctors.  This includes an MRI of the left ankle, and a series of plain films of both feet.  These were done in the last couple of weeks.  Three years ago I had an MRI of the right foot.  I have been through the full panoply of conservative treatment: multiple orthotics, RICE, PT, walking boot, nightly interferential current, NSAIDs, etc.  There also was a suggestion that I might have ankylosing spondylitis, but that recently was ruled out by a rheumatologist.
Dr Blake's comment: I am assuming that your tests were negative. Make sure you get copies of all these tests for your records. What did the reports say?

The May 5, 2009 MRI report is included in the Rebound records I sent you.  I had forgotten that the MRI was of both feet.  The impression of the left foot is:  “OS naviculare edema consistent with os naviculare syndrome.”  Interestingly, that condition was not found in the right foot, yet my symptoms in both feet are generally identical.  The report also indicates on the left foot a peroneus longus tendon partial tear.  My doctor minimized this finding—I think he said it might have been an artifact.

This week I went to a new podiatrist to address this new onset.  The podiatrist said that I have an accessory navicular bone and he saw a small amount of edema in that area.  However, he is perplexed as to how I could have PTT.  He said there is no arthritis in my foot, good joints spaces, good alignment, good arch, etc.  The posterior tendon is intact.  He doesn’t see any reason for putting unusual stress on the posterior tibial tendon.  He also said that I have essentially exhausted all the treatment options he would consider.
Dr Blake's comment: An accessory navicular can give chronic pain at the insertion of the tendon into the arch. Is this where you hurt?

Yes, I do hurt there.  But the pain is more consistently present on the posterior side of the ankle bone.  I apparently don’t have an accessory navicular on the right side, but I have the same problems on the right side.
The rheumatology angle warrants a little more discussion.  I saw two rheumatologists during my first bout with the condition.  The first one said I do not have AS.  I then had a complete work up with an orthopedic surgeon specializing in foot problems.  He finally concluded that I might have some type of autoimmune condition.  So, at his suggestion, I saw a second rheumatologist.  That doctor made a tentative diagnosis of AS.  I was put on a trial of Humera.  The PTT finally resolved some time later.  Whether or not that was related to the Humera, I cannot say.  Now, after the latest bout, I contacted that second rheumatologist only to learn that he is about to retire.  So I recently went to a third rheumatologist.  She is the one that said I do NOT have AS.
Dr Blake's comment: A diagnosis of Ankylosing Spondylitis is made by symptoms and a positive HLA-B27 blood test. What were those findings? Any back pain associated with this pain syndrome?

I do have a positive HLA-B27.  This was re-confirmed recently.  I occasionally have mid-back pain, but it usually resolves in four or five days after I start doing yoga each morning.  Then it won’t come back again for months.  Every several months I have some low back pain, but it also goes away after yoga.  So, I don’t really have consistent back pain.  I’ll get you the records from the rheumatologists.

Part of the frustration of dealing with my condition has been proceeding along the dual track of working up the mechanical tendon etiology vs. autoimmune etiology.  This most recent bout was precipitated by two things.  One, I modified my running style to a short stride and higher cadence.  I’ve since learned this puts more pressure on the posterior tibial tendon.  Second, I went on a very vigorous up-hill mountain bike ride that required a great deal of standing up on the pedals.  I haven’t ridden a mountain bike in 10 years.  It is my feeling that these activities started this new bout.  Therefore, I do think there is some kind of mechanical problem going on.  I also think that I tend to have a higher-than-usual inflammatory response to trauma, which might be contributing to the problem.
Dr Blake's comment: So, are you do anti-inflammatory things to help this recent bout? 
The posterior tibial tendon is an ankle plantar flexor, an ankle and sub talar joint supinator or pronation decelerator, and a midtarsal joint stabilizer. So, you can have normal foot mechanics, but dramatize the posterior tibial tendon by getting off the seat of a bike too much. 

I took two Aleve twice a day for several weeks.  I now take the Aleve only occasionally after the rheumatologist cautioned me about side effects.

I would like to come see you.  I live in Portland which is an easy flight.  I’m going to be in San Francisco on July 22 and July 23.  I could also come sooner which, in fact, I would prefer to do if possible.  What I would like to do is to first get you all the existing imaging studies and chart notes.  I realize that it would probably take you a lot longer than the amount of time you are allotted on a typical new-patient office visit to thoroughly review all the records and then see me.  So, I am happy to pay you for the extra time as you see fit.

Thanks so much for taking the time to read this far.  Please let me know if and when I can make an appointment to see you.  I very much look forward to it.
Dr Blake's comment: I will be honored to see you. Mail all of the images and records to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 and we will go from there. Call my front desk at 415-353-6400 and arrange a one hour appt for one of those days. Bring all your orthotics. Thanks Rich
PS. Please email me with more answers to the below questions. 

Sesamoid Fracture: Email Advice to MRI or not MRI

Dear Dr. Blake,

Thank you for creating this wonderful resource, which helped so much. It's been extremely helpful as I recover from a fractured fibular sesamoid. You often recommend a baseline MRI with follow-up at 6 months to monitor healing, and I'd like your opinion on whether I need one. 

I'm female, early fifties, and was hit forcefully near the ball of my left foot 3 months ago.  I was out of the US, and was prescribed rest, ice and elevation after a fluoroscopy showed no fracture. I had a huge bruise, and swelling at the ball of my foot and base of my toes, which was mostly gone after 3 days. 

After 10 days the pain was minimal, and I stopped limiting my walking. Unfortunately a week later I developed swelling and pain after carrying a heavy bag on the way home.  The x-ray (3 weeks after initial injury) showed a sesamoid fracture and I was put in an aircast with dancer's pad. I'm forwarding them with two later sets in case they're helpful. After 2 months in the cast I'm now in athletic shoes, and am allowed to swim and do more walking as well as the stationary bike. My orthopedist predicts a very slow healing process, but that I won't need surgery.

With the dancer pad I sometimes feel mild aching or burning (up to 2, rarely 3) on the sole at the base of my first two toes, and some tingling across the top of my foot.  So I've started trying just a thick cushioned insole without padding, to remove pressure there. Should I be concerned about this? Overall, pain is 0-1 when exercising.
Dr Blake's comment: No, sometimes with fibular sesamoid injuries, the one closest to the second metatarsal it is hard to not have the edge of the dancer's pad hit the injury when turning, etc. You, however, as you increase your activity, may want to go back to a thinner dancer's pad (under 3rd through 5th metatarsals). 

Thanks to this blog I'll be getting a bone stimulator and bone density and vitamin D tests. However my doctor doesn't see the need for an MRI, and I'm not sure whether having one might change my treatment in any way.  Could there be something important that may be missed without one?  Should I pursue this, by getting more opinions?
Dr Blake's comment: I never regret getting a useless MRI. What is a useless MRI? It is one that someone without an injured sesamoid says you do not need. It is a baseline for another MRI possibly 6 months later if needed. When it is needed, you are awfully happy you got the first one. And we are not just talking about the sesamoid. You had blunt trauma, which can produce more unpredictable problems, so the MRI is even more important in your case.

Further comments by Dr Blake: She was kind enough to send me xrays from 4/13, 5/13 and 6/13. Both sesamoids had irregularities, and the big toe joint itself looked slightly arthritic. This is going to make MRI interpretation more difficult, thus we may be opening a can of worms. However, I still think it is a good test for her to have. The sesamoid injury showed no fracture displacement, so healing so be complete at some time. 

Miami Heat Beat the San Antonio Spurs: Now It is Time for Us to Exercise!

Unknown Author: Thank You

Congratulations to the Miami Heat for winning the Basketball Finals in the NBA 2012-2013 Season!! This photo summarizes beautifully the end. I immediately think of Ray Allen's miraculous shot at the end of Game 6 that kept Miami from going home. But, since I have been watching a lot of basketball, I now need to get out there and exercise more. What excuse can I find today? 

What does this have to do with a podiatry blog you might ask? Plenty. Physical activity is one of the biggest secrets of life. My patients drive themselves to be more active. They continue to challenge themselves, to keep their hearts, lungs, muscles, bones all healthy. 

I mention that it is a secret of life since many of our children are not being taught this secret. Obesity is skyrocketing!! Diabetes is rampant!! And all of the other side effects of not taking exercise seriously. 

Below is a link to the President's Counsil on Fitness, Sports, and Nutrition. Read about the 60 minutes daily of exercise our children need, and the 30 minutes for adults. Yes, 60 minutes!! 

When you are starting a new program, remember it takes 30 days to make a new habit. So, just start moving more, gradually increase, plan to make the whole 30-60 minutes in 3 months. You will feel so much better about yourself, and your health will dramatically improve. If you can not run, walk, if you can not walk, bike, if you can not join a gym, watch YouTube videos on exercise routines. Make no excuses! As a sports medicine specialist, I try to take a patient and give them an athletic mind set whether they are an athlete or not. But, pushing through pain is not being an athlete, it is being an idiot!! Exercise in your comfort zone, gradually push yourself to new heights, and only very gradually set some goals. Goals can be a big reason people get frustrated and stop working out. Be kind to your self. But, Be Active!!!

Foot Strengthening After Multiple Foot Surgeries: Email Advice

Hi Dr. Blake,

I have had quite a journey that I never expected to deal with in my life time. I would like some advice about physical activity based on the surgical procedures I have had. When I was 20 yrs old, I had a routine bunion surgery on my right foot. Due to an ineffective surgery, the bunion returned and even had a bump on the top of my foot causing pain at the site of the bunion. I decided at the age of 30 to fix the problem so I ended up having another surgery where it was determined I had hypermobility and had the head of the metatarsal joint shaved down to fix the bunion. The surgeon also had two screws placed on the top of my foot to help with the hypermobility. Well, that didn't last long even though I was on non-weight bearing cast for 4 months as the problems returned 10 fold. I was running about 33 miles a week and general cross training. At the age of 40, I went to a Podiatrist and he could see several problems going on with my right foot. He determined that I do have hypermobility, hallux valgus and my sesamoid bones were completely destroyed. He had to go in and replace the greater toe joint with a Hemi toe implant, fuse the second toe joint, remove the sesamoid bones and remove the screws as they were causing extensive pain as they rubbed against my shoes. Ultimately after 3 surgeries, my left foot ended up having a collapsed arch and I had to have surgery to fix that with pins and a cast for 2 months. I have a bunion surgery for the left foot next summer (As a result my left foot is now 3/4" longer than my right foot!). So, I have had some problems with my feet you could say. =) I am a really active person, I use orthotics, hapad metatarsal pads, and I did receive physical therapy. So far, my right foot has been feeling good, however, I did have extensive discomfort while it was healing. My right big toe is stiff with limited mobility and it's difficult to move and PT helped in a limited amount. Due to my biomechanics in my feet have changed how my weight is distributed I do see some calluses on the outer edge of both feet, but is very minimal. I have curtailed my running and now use an elliptical trainer, I do engage in weight training and watch my diet.
What kind of activities do you recommend with all of the surgeries I have had? What other kinds of foot strengthening exercises can I do to continue my healing process and any recommendations do you have for me at this time? I have tried to find your blog on metatarsal doming, but with no luck. My podiatrist is excellent but I would like other opinions as well. I appreciate your time in reading about my extensive surgeries and you providing advice on my case. Thank you!

Dr Blake's comment:
Hey, Thank you so very much for the email. You are right to think about focusing more on non impact sports like elliptical, cycling, swimming, and moderate running. Sounds like your orthotics or changes in biomechanics have gotten you to the outside of your foot. Continue to work with the orthotic maker to try to keep you centered. The better your core, the less collapse into your arch you will have. The better your foot strength, the less stress on your bones and ligaments. You could easily improve your foot strength by a magnitude of 2 or 3 by daily going through 3 exercises each evening. I will place in my labels all the foot strengthening posts in a minute. I will also place under this email that I will officially post within the hour. I hope this helps. Rich

Ball of the Foot Pain: Email Correspondance

Dr. Blake,

    I have been dealing with left foot pain for over five months. I was placed in a boot for five weeks for stress reactions in the 1st, and 2nd, and 3rd metatarsals, followed by six weeks of physical therapy. During the physical therapy, the pain on top of the second metatarsal and bottom of the 1st metatarsal got progressively worse and the physical therapist ended up cancelling half of my sessions because of the pain. I also ended up wearing the boot again for two weeks and then a surgical shoe for two weeks during the last four weeks of the physical therapy.

    In the last two months, I have worn athletic shoes full time, minimized the amount of time on my feet, and started experiencing constant swelling over a two inch area down the entire length of the top of my foot. If I spend more than a few minutes on my feet, the pain on the bottom of the 1st metatarsal gets worse and worse. I have also periodically had shooting pain over the 2nd metatarsal when walking.

    I recently had an MRI, which showed marrow edema in the plantar and lateral margins of the 1st metatarsal head and nonspecific marrow edema in the hallux sesamoids. When my doctor initially reviewed the MRI images, he said it looked like I had an extra outer sesamoid. After reviewing other images, however, he decided that this was not the case as he did not see it in those images. There is a black jagged horizontal line through the outer sesamoid in three of the MRI images. Other images of the same sesamoid show no line. Is it possible that this is a partial sesamoid stress fracture? The doctor determined that I have sesamoiditis and told me to wear a metatarsal pad in my shoe for the next six weeks to off-weight the sesamoids. I tried the metatarsal pad, but it has made the pain significantly worse.  

   What do you suggest? 

                                          Thank you!

Dr Blake's comment:

    Hey, thank you so very much for the email. Typically, you have one source of all this pain (say a fractured sesamoid or first metatarsal head) and when treated improperly, the pain and swelling magnifies to involve a larger area. Swelling alone is no big deal since it is a reflection of a healing response of your body. Pain and swelling means you have not stabilized things well enough and healing is being somewhat compromised. Remember stress fractures are tiny cracks in the bone, hurt as much and as long as true fractures, and normally may not be seen other than the bone edema (swelling) noted on the MRI. Thus, the confusion of whether a black line is seen or not probably means stress fracture vs true fracture. Stress fractures on the bottom of your foot take a long time to feel better since first the fracture and then just the resultant bone edema hurt. 

    The things you need to do in the next 2 months are: make sure the inserts have maximal off weight bearing padding (called dancer's pads), make sure you have high and tolerable arch support, ice minimum 3 times a day for 10 minutes to keep cooling down the area, do a full 20 minute contrast bath daily and twice on weekends, learn to spica tape to stabilize the big toe joint, keep your legs strong with biking (you can rest the arch area on the pedal), weight bear to tolerance (all immobilization and non weight bearing can increase the swelling in a foot/weight bearing great for moving swelling, make sure your Vit D and Calcium are normal, eat healthy, use crutches, get a new MRI 3 months after the first, and hang in there for some of these injuries to completely heal can take several years and your job is to create a pain free environment to allow healing. Another 3 tests that could give alot more information are CT scan, bone scan, and CT fusion (which is a combination of the above). If insurance allows, and the way you are struggling, I would try to get more information also with one of these tests. I sure hope this helps. The information on all of this (like contrasts) is all within the blog.