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Saturday, July 20, 2013

Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,

First let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.

As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have. 

Now here's my story...

I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray, and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day I couldn't stand. And my foot was purple.

Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a lisfranc ligament sprainThe doctor seemed to pay little regard to the lisfranc injury - saying that a sprain isn't serious. 
          Dr Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, 
          with a high  percentage needing surgery.  
Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non weight bear for 3 weeks (in a remove-able walking boot), use a dancers pad, then see another doctor (doctor #3).

I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weightbearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)

So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it, and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.

Unfortunately I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weightbearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site. 

Also my whole body seems pretty out of whack (my hips have a very strange turn out right now...).
          Dr Blake's comment: Typically this out of whack feeling is part of any cast regimen.
           It is helped greatly by using an EvenUp on the side without the cast, 
           and never going to one crutch. It should be 2 
          crutches or no crutches, since one crutch and sometimes canes
          throw your back and pelvic into strange tilts. 

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...
          Dr Blake's comment: For what I know, this is all normal for your injury and
          being in a cast and non weight bearing for a while. You are gradually
          progressing from the Immobilization Phase of Rehab to 
          the Re-Strengthening Phase. During this phase you need a lot
          of physical therapy guidance to work on the remaining swelling,
          and increase range of motion, strength, flexiblity, and balance. There is a
          lot of hard work ahead.  
2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?
          Dr Blake's comment: For these injuries, you never push the toe bending
          part of rehab. You let that 
          come naturally. It is always fun to measure the range of motion 
          with each stage if you have a therapist  you will be working with. 
          Typically you come out of the cast with almost no motion in the motion, you  
          start doing some of the self mobilization movements on my blog
          under Self Mob for Hallux Limitus. You can 20-30 degrees as you 
          begin to walk normally, and another 20 degrees as you begin to run. 
           Keep the joint pain free when you are working on it, you never 
          know if more healing is still going on it there.  

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait...
          Dr Blake's comment: Core and other lower extremity strengthening that does
          not hurt the injury can normally be started right after the injury.
          There is benefit to riding a stationary bike with one foot and 
          no tension when you foot is in the boot. There are so many core, hip,
          knee, and ankle movements that you should be doing right now,
          and that is why a PT or Personal Trainer can help. The stronger the 
          core, the normal you are lifted off the foot, and the faster
          the rehabilitation goes.  

4. This lisfranc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed? 
          Dr Blake's comment: Lisfranc Injuries are big deals. You need to wait 3
          months from your first MRI  to get a repeat MRI to document healing.
          I treat all Lisfranc Sprains very seriously with a 2 year 
          committment to orthotic devices, arch taping, and a gradual progressive
          re-strengthening program on all the important intrinsic and extrinsic
          muscles/tendons that support the arch.  

The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a boney bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this lisfranc thing?
          Dr Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you
          are weight bearing, get a orthotic ASAP to stabilize that area and learn to
          tape your arch (I have arch taping videos on this 
          blog). I am not sure what the boney bump is. You could send me
          a photo of you pointing it out, and
          another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non weightbearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?
          Dr Blake's comment: Yes, but 16 weeks of immobilization means 32
          weeks minimum more to get your foot healthy again. Go slow, go gentle,
          but persist. You are still in the hands of the docs for 
          direction, but PTs and Personal Trainers and Athletic Trainers
          should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend to help this? Mostly the middle of my foot. What about Superfeet?
          Dr Blake's comment: When you get custom made functional foot orthotics from
          a sports podiatrist, they are always made in pairs. Consider seeing Drs Karen
          Langone, Dr Robert Conenello, and Dr 
          David Davidson in New York. You can also see the AAPSM website
          for all the New York 
          members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?
          Dr Blake's comment: The bone stimulator has a 3 inch penetration. You can aim
          the beam from the top of your foot where you do not have tape, and it 
          will still work. That way you can tape also. This is  at least my understanding
          of the Exogen bone stimulator, but check with the local rep. 

8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately they don't take my insurance (GHI/Emblem)
          Dr Blake's comment: See my recommendations above. Even if they are a distance,
          it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from beginning of May? I would love to know your thoughts.
          Dr Blake's comment: Yes, Dr Rich Blake, 900 Hyde Street, San Francisco, 
          CA, 94109.  

Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged. 

Any thoughts/advice would be so greatly appreciated. 


Jill (name changed)
          Sorry one last question!! 

          I've been using 1/4" adhesive felt applied directly to my foot for the dancers pad. Is this correct for use in             a boot? 
          Dr Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog
          I have an example of this. Get working on your orthotics ASAP and then just
          place that in the boot. I sure hope this 
          helps you. 



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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.