Total Pageviews



Wednesday, August 28, 2013

Basketball Shot wins Free Tuition

I am sure he was in very stable orthotics to be able to make this impossible shot! LOL Congratulations!! 

Saturday, August 24, 2013

Severe Ball of the Foot Pain: Some Points to Consider

Posterior Tibial Tendinitis: Some Key Points

Algorithm of Treatment for Posterior Tibial Tendinitis from diagnosis to immobilization to re-strengthening to return to activity. 

Posterior Tibial Tendinitis: Some Key Points

 Posterior Tibial Tendinitis: Key Points

 ■ This tendon moves the ankle, prevents over pronation, and supports the arch
 ■ Treatment of this tendon at times requires stabilization of all 3 areas with ankle bracing, inverted orthotic support, and arch support
 ■ As soon as treatment is started to immobilize the injured tendon, both anti-inflammatory and some form of strengthening should begin
 ■ MRI should be used initially to rule out an actual tear, or if the treatment seems to hit an impasse

Thursday, August 22, 2013

Walk In My Shoes: A Powerful Short Video!!

We daily envy the good fortunes of others which brings our spirits down. We are all incredible gifts, and I realize that life is unfair! This short but powerful video will be analyzed by everyone differently, but it's point is to get us thinking. We need to have a heightened appreciation of our gifts, not failures, our successes, not shortcomings. We do need to walk in another's shoes to really understand them. We will never understand them if we are only thinking about ourselves all the time. I think I could watch this video 10 times, in 10 different emotional places, and get 10 different responses because it is that powerful. 

Walking Stairs: A Great and Natural Exercise, and very underrated!!

Walking is one of the safest and natural activities that produces great health benefits. It is very underrated. If you build up your walking legs, look at some of the adventures you may have!!

Wurzburg , Germany
Pailon del Diablo, Equador

Chand Baori fountain in India.
These steps lead to a huge fountain built in the tenth century to collect rain in the region and accumulate them in temporary lakes.
The structure has a total of 3,500 steps and down to a depth of 30 meters.

Elbsandsteingebirge stairs in Schsische Schweiz, Germany.
Some steps are cut directly into the rock of these mountains.
Dating from the thirteenth century and were eroded by wind and water, but it remained being used daily by tourists. 487 steps, which have been restored in the eighteenth century to facilitate transit.

Crack of Guatape in Antioquia, Colombia.
Corner stone is a genuine monolith with a height of 220 meters.
Cement stairs were built directly on the rock, filling the crack where the sides support the structure.  To reach the top, you must climb the 702 steps.

Haiku scale in Oahu, Hawaii.
This extraordinary scale spanning 3922 steps, climbing and descending a hill of 850 meters. It was created to facilitate the installation of antennas in 1942. Largely made of wood, was modernized in 1950 with metal, but closed to the public since 1987.

The Inca road in Peru.
An ancient trade route that connects Cuzco to Machu Picchu town.
There are miles and miles of stairs in some very unsafe places, such as for example the famous floating stage.

Wayna Pichu at Machu Pichu, Peru.
Some steps cut into the rock which crown an ascent of 360 feet above the main city of Machu Pichu. In some sectors, the ascent is complicated, passing through narrow portions with small eroded steps.   They allow only 400 tourists to climb daily, and shuts down access at 1 p.m.

Cross Road ladder in Bermeo, Basque Country, Spain.
This network connects with endless steps where Rocky is a small church dating from the tenth century, it seems to be of Templar origin. To reach the hermitage of San Juan de Gaztelugatze must climb 231 steps and there are gaps between steps are identified to be the footprints of St. John, which are assigned certain curative powers. For example, sit on them for healing, or touch the hat to cure headaches.

Scale worm Taihang Mountains on the border between
Shanxi and Henan provinces in China.
This scale worm of approximately 100 meters was recently installed with the intention of attracting thousands of tourists to the beautiful Taihang mountains. Before climbing visitors are asked to sign a form assuring that are no heart or lung problems.

Tuesday, August 20, 2013

Fractured Sesamoid with Surgical Complications: Email Advice

Hi Dr. Blake,

I have been reading emails after emails on your site trying to find a similar situation to mine. I have been through 6 doctors in the last 5 years and I have hit a wall. I will tell you I am only 26 years old.

I fractured my  lateral sesamoid in 2008 of my left foot. I was casted multiple times,placed in a boot, fitted for orthotics, and had many cortisone shots. After 3 doctors I had my Lateral sesamoid removed in 2011. I got pregnant in between so I had to wait the year. My foot didn't hurt when I was pregnant but the moment my foot unswelled it was back.  The doctor who removed my sesamoid used porcine graph without my permission, I was allergic and it caused a HUGE mess. The doctor vanished on me. I found another doctor and she went in and cleaned out what the prior guy did 1 month later. My incision was infected, I had a hole in my foot. I got it cleaned out and now there is a thin layer between my bone of the foot and skin on the side from incisions. You can literally feel the bone. They say if i every get cut there it would be directly on the bone.  If anything touches it, it hurts right away and even makes my nerves crazy sending shocking sensations up my toe. That is the least of my problems.
Dr Blake's comment: I am so sorry.

Since that seaamoid was removed the pain had not improved. I was still unable to walk correctly or pain free. Over the course of 1 year my big toe starting turning in and the pain was increasing.
Dr Blake's comment: It is hard sometimes to know if the pain is coming from the sesamoid which is in the joint vs some other arthritic process within the joint like Hallux Rigidus (although you are quite young for that). 

My doctor suggested transferring the tendon and fusing my big toe. She said this would alleviate all my problems. I had that surgery in Jan-13. I have had nothing but more problems. Pain in my arch, above my toe joint, ball of my foot and now my toe hurts from the screw. I got orthotics and more cortisone shots. The shots no longer work.  Her next step is to lengthen the tendon. I would rather not have surgery on my foot again so I decided to get another opinion and changed doctors.
Dr Blake's comment: When they fuse the big toe joint, they typically fuse for a slight heel. The bend in the toe produced forces more pressure on the sesamoid area underneath. 
My new doctor did an MRI and x-rays. My medial seasmoid is fractured now and I have fluid in my tendon as well as chronic edema and arthritis in the joint.  This doctor casted me for 2 weeks after finding that out. If anything, this increased the ball of my foot pain drastically but the pain directly over the sesamoid is gone. I had NO pain when I was casted. With every step now I hear a cracking noise. This doctor says the tendon is not healing around the sesamoid. (That entire tendon hurts all the way up my calf, ankle. I saw a physical therapist and she had me in tears just from barely pushing on it). He is out of options on what to do other than remove the remaining sesamoid. He feels a Plasma Rich Platelet injection may do the job and heal everything in my foot. Well, my insurance denied that and I can't afford it right now. I am frustrated and extremely upset that I will never be able to walk normally without having pain. I can't hold a job that requires standing or walking. I can hardly go grocery shopping. The zoo? Mall? no way! I am in tears in the middle of it and at the end my foot is very swollen and I can not bear weight, it feels like my entire foot is broke. I am out of options and do not know what to do. I have been rubbing the essential oil lemongrass on the ball of my foot and arch and toe for 4 days now hoping it will work. Please help me! What can I do? What is your advice or opinion on this situation?

Thank You!

Dr Blake's comment: 
     Thank you so very much for your email, and I am so sorry for the problems. I have more questions, then answers, so while we try to get some direction, place yourself into as pain free environment as possible. This is probably with a removable boot with accommodative floating of the big toe joint with an EvenUp on the other side. 
Sesamoid fractures take minimum of 3 months of casting and the cam walker should do that. We need to protect the other sesamoid as well as possible. I am sorry that I have no experience with PRP to help you with that decision.
     The fusion should have taken care of 2 of the 3 sources of pain in a bad big toe joint: the pain produced by pressure in the joint and the bend produced by bending the joint. This leaves the 3rd source or the pain produced by weight bearing on the area. This is where temporarily (2-3 years with your problem) you need to off weight the area with various forms of arch support and dancer's pads.
     If you are working on the mechanical aspects of pain, you have 2 other areas to deal with: inflammatory pain and neurological (neuro-pathic) pain. For the inflammation I would be icing every several hours for 10 minutes placing an ice pack on the bottom of your foot. For the neuropathic pain, I would see a pain specialist. It can take you 2 or 3 to find one that really gets it for you. But, I would start working on that right now. 
     The nerve person, pain specialist, will have topicals, patches, oral meds, and other tricks. If you read some of my posts on "Complex Regional Pain Syndrome" you can get a feel for what that speciality has to offer. You will also read that is it important to be touching the area gently AMAP as long as it does not hurt to desensitize the area. 
     I am sure hope this starts pointing you in the right direction. You may have to have the metal removed, since that could be a source of irritation and only needed until the joint fuses at 12-15 weeks post surgery. Typically, they wait 1 year to let the area calm down after surgery before removing the hardware. Rich 

Hi Dr. Blake,

Thank you for writing me back. I never thought about visiting a pain specialist as the pain is bearable when sitting but once I step on my foot it sky rockets and doctors pretty much just cross me off the list and are unable to help me any longer.  I guess I dont understand why my foot is unfixable. My body has automatically compensated so I walk on the side of my foot. My physical therapist says its the weirdest thing. I can only do that barefoot or in flip flops though, but being barefoot hurts as well on the side all my weight is on. When I wear a shoe it no longer allows me to walk like that, which is why the doctor gave me orthotics but those still cause pain at the ball of my foot and arch. I seriously can't wear a shoe to walk, it hurts the worst! I know its bad to wear flip flops but it is the only way I can get around. I have done a dancer pad in the past ( first sesamoid injury) and it did not heal it. I can do one this time to see if it helps again. I did read about lipstick on the ball of my foot, I will try to do that as well. I do apply ice and apply heat, I do not feel it helps. It brings down the swelling temporarily but then when I walk it swells right back up. I have been using Voltaren gel 2-3 times a day and I am unsure if that helps either. I continue using it in hopes one day it will. 
Dr Blake's comment: Orthotic devices can be designed to put your weight on the outside of your foot with some inversion force. Many orthotic lab offer various techniques to start, and then the podiatrist/physical therapist has to do some in office tinkering. But, it can be done to get you into shoes. You can also invert/varus cant the outersole of a shoe to get your to the outside of your foot. This is so much better (for the next 4-6 months) than having you have to do it with gait changes and abnormal muscle contractions. Nothing will cure this in the short term. You need to use 8-10 things that each seem to make some difference. By putting them all together, you may get at least 50-60% better. 

To be more specific my most recent surgery in January was: Hallux Interphalangeal Joint Fusion with Screw Fixation with Jones Tenosuspension of the Left Foot.  She said I had first metatarsophalangeal joint capsulitis as well.  The pain is a lot worse after this surgery than with the first. I wish I would have never got it done!
Dr Blake's comment: I am so happy they did not fuse the big toe joint, best news you told me all day!!! The Jones tenosuspension I never see, so what did they do? Please make it as clear as you can. Even a copy of that paragraph from the op report. 

My MRI findings say: Postoperative changes. Moderate osteoarthritic changes and moderate disc space narrowing involving first metatarsophalangeal joint. Mild T-2 weighted increased signal involving the lateral sesamoid at the plantar aspect of the distal first metatarsal. Flexor Hallucis longus tenosynovitis. Fluid within distal flexor hallucis longus tendon sheath
Dr Blake's comment: Definitely want you to send me a disc of the MRI so I can see. Send to Dr Rich Blake 900 Hyde Street, San Francisco, California, 94109. Sounds like some arthritis in the big toe joint which has not been addressed yet, and maybe why you continue to hurt!!?? Hope??

The MRI is my most recent diagnosis. After that I was casted and now I am still in pain unable to bear weight if not it worse after casting which he thinks is from tearing the tendon now... Did I say this already? 
Dr Blake's comment: The MRI did not talk about torn tendons, so that is good. Alot of patients hurt so much worse after casting since the immobilization allows for stiffness, weakness, fluid retention, bone demineralization,etc. Get into the removable boot with accommodation and start putting some weight on it gradually. Massage as painlessly as possible, and as often as possible. You need protected weight bearing and mobilization, and anti-inflammatory for the next 4-6 months. 

I just realized I was backwards on my sesamoids-sorry- I had the medial removed and I still have my lateral?   I just know my outer seasmoid closest to the right foot was taken out and I still have my inner sesmoid closest to the left pinky. 

Any other advice? Does that added info help you any?

Have you seen improvement in ultrasound therapy or the electronic shock therapy? My doctor also mentioned a bone growth simulator, but thinks that is a 1-5 chance of working. 
Dr Blake's comment: These toys are all about timing, and it is really hard for me to assess that right now. 

I feel like I just need cushion at the ball of my foot, can they do implants or anything of that nature? I know, that may be a crazy thought. 
Dr Blake's comment: Have your doctor look at the Hannaford orthotic design on my blog, perhaps his lab can make something similiar. Dr Suzanne Levine in New York is injecting collagen for cushion into feet. She can advise if possible in your case. 

Did I read that you suggest wearing a boot for 2-3 years? Maybe I interpreted that wrong? 
Dr Blake's comment: The goal is to create a pain free environment and then gradually wean from it. If that requires a removable boot for 2-3 years, then that is what you do. Hopefully not, for that would rack havoc on the rest of your body. 

Also I can still move my big first big toe joint which is painful at the joint and ball of the foot. I have limited motion of that joint. When I move my big toe down my entire foot shakes.  My big toe is also up like a hitchhikers toe but not as drastic.  I have used a JAS system to regain motion but it really aggravates things and makes it worse as does Physical Therapy.
Dr Blake's comment: You really sound like some arthritis is in the joint causing a severe pain syndrome. The MRI will help me understand you better. You need to move the toe, but painlessly. Get small gains very week. Only a few physical therapists can do this. See my video on Self Mob for Hallux Limitus. Thanks for all your clarifications. 

Thank you for taking the time to read this.

Monday, August 19, 2013

Severe Heel Pain (in a friend!): More than just Plantar Fasciitis

Hey Rich
Just saw your You Tube video on Facebook.  I KNEW  I should have called you when
I had plantar fasciitis in July 2012.  

I have been limping around with severe heel pain in my left foot for over a year. Sometimes
both heels if I've been standing in one place for a period of time.  Grandma must be getting
old !!!

My friend and I had been walking for about 3 miles every day until one day I woke up
and couldn't walk.  My friend told me what was wrong as she teaches anatomy at the med
school here.  

I used a wooded thing over which I would rub my foot back and forth and then soak in a bucket
of ice water for about 20 minutes or... until I thought I would pass out ... which ever came first.

The plantar part seemed to get better but the pain in the heel is particularly bad when I've been sitting,
especially with my legs elevated in the recliner.  Ouch !!!

When I get up I limp around for 2-3 minutes until it works itself out.   

Is there anything you can suggest that might help?

I'm so glad that you have developed something that is helping others.

Many blessings,

julie (name changed)

Hey Julie, It is so wonderful to hear from you. I miss seeing you my dear dear friend (our friendship goes back almost 40 years!!!) Definitely let us take this 2 weeks at a time. First of all, if you can not get an MRI to make the diagnosis of a possible plantar fascial tear (good possibility due to the length of time and the severity of the pain), then we should just treat it like that for the next 3 months. I will send you the link to order an anklizer boot and EvenUP. Start wearing and continue icing. There will be enough time out of the boot that you will know that you are healing. Continue icing 3 times daily, but stop all plantar fascial stretching for now. We will put all other conversation on this same post. Love, Rich

Sunday, August 18, 2013

Plantar Fasciitis: Email Advice

Hi Dr. Blake,

    My name is Stacey (name changed) and I just recently came across your website.

I have been suffering pain in my feet for about 9 months now. 
The diagnosis is plantar fasciitis and i have seen several different podiatrists who suggested different methods of treatment which have been unsuccessful.

I had custom made orthotics which I have worn now for about 5-6 weeks.
I work in a pharmacy so I am on my feet for 8 hours a day and am finding it painful with the orthotics. I was told this is to be expected and that the average person will see results in 15 weeks.

I am very worried I may be doing more harm than good and fear I may never rid myself of this awful condition. I find it very stressful and wonder if I should stick with the orthotics.
I am now considering reducing my hours at work or taking long term leave.

I would greatly appreciate your advice.

Regards Stacey

Dr Blake's comment: 

     Thank you so very much for emailing me. Plantar Fasciitis can be a very stubborn entity, but most patients can get it under control. On my blog I have so much advice regarding plantar fasciitis, that I hope you can find some further answers. 

     The most important thing is to make sure you do have plantar fasciitis. MRI scans are the most telling, and may help direct treatment differently. Typically, you initially get an MRI of the worse foot, and start with that. 

     The treatment for plantar fasciitis is lumped into 3 primary areas that can fluctuate in their importance from month to month. All three areas should be treated daily, and changes in each category made to help find what works. The 3 areas are flexibility (stretches), anti-inflammatory (icing, PT, meds, etc), and mechanics (off weighting, arch support, avoiding negative heel positions, etc.)

     I will assume you are icing for 10 minutes 4 times daily, wearing your orthotics which transfer weight to your arch, avoiding barefoot walking at home, taking many sit down breaks as your employment allows, stretching the plantar fascia hourly as long as the stretch does not hurt, taking 2-3 advil 3 times daily unless their are stomach issues, and have a few PT visits scheduled unless their is insurance issues. If you are not doing this, try to get it accomplished. 

     Read everything on my blog on plantar fasciitis so you can have as meaningful as possible conversations with your treating physicians. See if they will prescribe an MRI, PT, night splint, etc. If you do not have a well organized plan for home, taking time off will not help. You must start over, and reset your goals biweekly. Orthotic devices alone will never get the job done when you have pain for this long, and you may need a very special soft orthotic (like the Hannaford) just for standing. Orthotics feel the best jogging, second best walking, and worse standing. There goal is primarily to change how you walk. 

     I hope this helps you. Please keep me in the loop. Hopefully, your job will allow some moderation. Good luck Rich

Orthotics causing Back Pain: A Common Problem with various Solutions

Dr. Blake,

I had posted about sesamoid problem after bunion surgery, and thank you so much for answering my questions.

I am on second pair of custom orthotics and my back was so irritated that I could not function, missed one week of work, could not even stand long enough to make a meal.  I had times that my right side foot and leg just wanted to give up. Went to see a podiatrist hoping for help, he took the time to look at my x-ray before and after surgery, and told me the surgery was well done, except the first metatarsal bone was longer than it's supposed to be, which caused all my other problems.  He said surgery should be the last option, instead we should try pads.
Dr Blake's comment: Functional Foot Orthotics are just that----functional. They make a functional change in your body, and as podiatrists, we ask the rest of the body to please accept the change. When designing orthotic devices for sesamoid pain, two common problems can occur leading to back pain. The orthotic device places your weight too lateral, making you over supinate, leading to back pain. If this is the case, you should feel that the weight is going to your baby toe as you walk through your foot, or even worse, feel like you can sprain your ankle. Typically, the orthotic devices make you straighten your knee too much, and if you have tight hamstrings, the pull on the low back causes pain. These are easy things to change if recognized. Sometimes a simple adjustment can be made to allow you to be more centered or slightly more pronated. It is up to the prescribing provider to recognize what is going on when they watch you walk. Sometimes a whole new orthotic device is necessary. But, it is important to know what most likely caused the problem in the first place, so that you do not repeat the same mistake. 

This is what I felt ever after the surgery but you cannot do much to change the fact and it is affecting so much of my life now, I am horrified to think about another surgery, but other options seem to be running out.
Dr Blake's comment: If the metatarsal is too long, and it is causing all these problems, a temporary fix with orthotics should be able to be made. A long first metatarsal does potentially 3 bad things: supinates you too much (that can be corrected with orthotics), blocks your ability to roll properly through your foot jerking your low back (that can be corrected with orthotics), and straightens your knee too much by limiting normal arch pronation (that can be corrected with an orthotic device). I would always recommend trying to accomplish an orthotic fix for the problem first to make sure everyone truly understands the source of the problem. Then, if surgery makes sense, go for it. 

Your blog taught me more than all of the orthopedics surgeons told me, I really don't know what to do next, my big toe and the rest of four other toes simply don't land on the same level, and I felt the function of nerves and muscles are all affected.

I will seek other doctor's opinions locally, but I am so concerned about loosing foot and leg functions. Do you think correcting the bone(surgery) would help with sesamoid issue long term, or is it even possible to have surgery with sesamoid issue present?
Dr Blake's comment: You need information based on function not x rays right now. Go to a good sports medicine physical therapy that watches you walk. Do not influence them by previous conceived notions. Let me try and tie together your gait and back pain. I am assuming that the orthotic devices corrected for the sesamoid but lead to the back pain. Right? This is so common, I can not tell u!!! But, it may be an easy orthotic fix. Keep me in the loop. 

Thank you so much for your time, and how I wish I lived in California!

Further response from patient:

Thank you so much Dr. Blake!

I had one Acupuncture Dr. and one Orthopedics Dr. both suggested simply try Dr. Schol's full-length gel pad, which I did, I cut out some felt pads according to your website instruction, simply trying to level other four toes with the big toe, and a cutout to accommodate the sesamoid area. So far, have not had any bad pain yet.

I so appreciate your time.

Thursday, August 15, 2013

Sesamoid Fracture: Email Advice

This email was received 8/15/13. 

Hello Dr. Blake, I just contacted you through your website but wasn't sure if it went through. I also forgot to add that I'm 35; thought that might be important to the osteoarthritis diagnosis. Here is my message again, please forgive if you already received it:
I've been using your blog as my go-to guide for the last 3 months. I sustained a stress fracture to the sesamoid bone closest to the outside of my left foot while coming down stairs wearing wedge heels.
Dr Blake's comment: This is called the tibial or medial sesamoid.
My first podiatrist diagnosed it as sesamoiditis and ignored my repeated phone calls saying I was in immense pain. Time to switch doctors. My current podiatrist took x-rays, by this time it was 24 days after injury, but found them inconclusive and ordered an MRI. In the meantime I was put on crutches. 10 days later, after insurance finally approved it and the results came in I got the news that it was indeed a stress fracture and was told I needed a plaster cast. I bargained my way into getting walking boot with the promise that I would treat it as a cast, sleeping in it and never walking on it.
Dr Blake's comment: I always try protected weight bearing since the cast holds in so much fluid that you need some weight bearing to drive the swelling out of the injured area. Protected weight bearing is with 1/4 inch layered adhesive felt to protect the area while allowing pain free weight bearing on the non injured parts of the foot. You can purchase a roll of 1/4 inch adhesive felt padding at 
I've been a model patient and recently went back for my six week check up. (During this time I did take calcium, magnesium, vit d, and vit k, but only for one week as it caused stomach upset.) The doctor stressed the fact that this injury is very slow to heal and that if I move my big toe at all it impedes healing. He pressed on the ball of my foot and I yelped in pain. He said it wasn't healed. He said if it was healed I would have no pain at all. I thought this strange since I broke the big toe on that same foot 9 years ago and can remember being in pain for a few months after it healed. Surely this bone would hurt for a while even after healing! (Sure enough, reading your blog confirmed this!) So, he ordered another round of x-rays. I did question this since the fracture was found through MRI and not x-ray, but he said he wanted to order a bone stimulator and insurance would require a new set of xrays. I consented.
Dr Blake's comment: For many injuries, like sesamoid, pain to palpation can be present almost forever, and it a poor indicator of healing. Functional pain, the pain you get from advancing from non weight bearing to weight bearing, and from weight bearing in a cast to weight bearing in a shoe with protected padding is more important. 
For one of the images I had to get down in a runner's stretch, completely pulling my toes back. (I did have to do this with the first round he ordered, but this was before we knew what the injury was.) Since he had just said moving my big toe would impede healing, I was wondering why in the world we were doing this, but I knew I needed the bone stimulator and had to do it. The tech and I had to bend my toes back and forth repeated trying to get mobility back in them so that I could get them back far enough for a good image. This maneuver left me in pain for several days afterwards.
Dr Blake's comment: Sports medicine as a discipline evolved around the concept of protected weight bearing, sensible motion to keep things moving as best as possible, and anti-casting as much as possible. I love to move things, weight things, touch things. The more normal the stimulus, the faster healing back to full function occurs. For every day you completely immobilize an area, it can take up to 4 days to get the area back to function. And, returning to a function state can be painful, but not a sign you are not healing. 
The results of the x-ray was that the sesamoid bone now has osteoarthritis in it. He said it was due to the fact that the bone is receiving no impact through walking in order to build it. He ordered the exogen bone stimulator and said to stay on crutches and come back in 2 weeks.
Dr Blake's comment: Osteoarthritis takes a long time to settle in, but the changes in the bone could be related to the fracture healing and the demineralization from non weight bearing. It is almost impossible to predict what this means in relationship to the final outcome. 
I go back in 5 days and insurance still has not approved the device. Fortunately a friend had one and I've been able to use it twice a day for the past 4 days. I also switched brands and have been back to taking calcium, mag, vit d, and vit k for the past 9 days.
Dr Blake's comment: Remember the goal standard is 1500 mg of Calcium daily (diet and supplement) and 1000 units of Vit D (unless you know your blood levels). 
I called the doctor yesterday and told him I did not want another round of x rays. He said he wasn't planning on ordering any, just performing another physical exam (presumably to see if it still hurts when he presses) and at that time he would consider ordering another MRI.
Dr Blake's comment: The first MRI is the baseline. The second MRI should be minimum 3 months (and up to 6 months if you are doing a bone stimulator). I hope you do not feel pressed into a quick solution!!
He did say removing that sesamoid left me in danger of developing bunions later on and that surgery would be a last resort. In the meantime, I've been on crutches for 8 and 1/2 weeks and have lost so much muscle in my calf and foot. My foot even has muscle spasms now, which from my very scientific research on the internet seems to be coming from loss of muscle integrity.
Dr Blake's comment: Unfortunately you are developing "cast disease" or "cast rot". If you want to calculate your road to healing, take the amount of time it takes to get you to full weight bearing without a cast, and crutches, and times by 4. At that time, you will have recovered from the damage caused by the cast. This is why I always say that a cast is a "necessary evil". When needed, it can allow something to heal, but it sure takes a long time to get your foot back, grossly and subtly also. 
In your opinion, what should be my next move? In reading your blog, it seems like it should be continued use of the bone stimulator, vitamins and supplements, and transitioning to walking in the boot for 3 months. But can I just "start walking" after not touching my foot to the ground for 3 months and losing so much muscle?
Dr Blake's comment: No, inside the boot you will need cast accommodation with 1/4 adhesive felt or an orthotic that off weights the sesamoid. You need to continue daily icing 10 minutes 3 times, learn to spica tape, and perfect the orthotic you will be wearing out of the cast. The rest of what is said is true.

I really appreciate any help and advice you can provide. Thank you for making your blog available, I would have been lost without it!
Dr Blake's comment: Great, I am glad it has been somewhat helpful, and good luck finishing this healing. 

Sunday, August 11, 2013

Please Respect Our Elderly Patient's Right to Walk Safely On Our Streets: Patience Can Be Necessary

Injured Sesamoid: Email Advice

This email was received 8/11/13 for time reference.

Hi Dr Rich

I have been following your blog for some time, as I have an injury to my tibial sesamoid bone on my right foot for 8 months. Like many people with this injury it I have spent a long time looking for positive information online, and yours is the most helpful source of advice on sesamoid injuries. I was hoping I would never have to email you but as time has gone on I would really appreciate your thoughts on what I do next. My story.

  • December 2012- I suffered a fall from a 1.5 ft height and my foot was very sore/I was limping. I could bear weight and doctors saw nothing obviously wrong. 
  • February 2013- my GP commissioned an XRay which showed nothing
  • March - I referred myself to an orthopedic foot and ankle surgeon  who suspected sesamoid injury - I googled it and freaked out (!), visiting a podiatrist who confirmed the diagnosis and told me  takes 18mths-2years to be totally pain free.
  • Had an MRI showed no edema. Dr Blake' comment: Edema means swelling, which is a sign of injury and the body's healing response. I believe it is impossible to have a fracture without bone edema, so perhaps you do not have a fracture. 
  •  Surgeon diagnosed bone bruise but commissioned a CT scan - the report said there was a small area of cortical break involving the plantar surface of the medial sesamoid. Dr Blake's comment: Not sure what it looks like, but the plantar surface can be normally irregular and look like a cortical break (just a possibility, and hope!!)
  •   I asked about a boot/crutches and was told if he had seen me originally at the acute phase he would have put me in a boot, but now there would be little point. He told me it would heal in time and suggested 6-8 weeks of offloading using dancers pads. I decided to be more cautious and asked his opinion on a podiatrist (I didn't want to go back to the first one) and he referred me to a colleague. This podiatrist was positive - told me he could almost guarantee in 3 months I would get better and told me to do calf stretches three times a day (apparently I have super tight calves) and I was given temporary orthotics and told to walk with a heel strike
  • In the meantime I followed your advice - taping my foot, icing/contrast bathing, ensuring proper vitamin supplements as much as I could. I cut out running, heels (the most upsetting part for me as I am only 5ft) and rested as much as possible. I sought out stories of people who had this injury too - a professional footballer who had this injury from impact too and after three cortisone injections considers himself healed. I also spoke to a former model who broke her sesamoid bone in half through wearing heels but finally saw a recovery after 2-3 months using a bone stimulator (wanted to include these stories in case it helps keep others positive). My surgeon was very conservative about cortisone but did say a small amount via ultrasound guidance might be sensible down the line
  • April - I received custom orthotics. These raised my arches (I was told my feet pronate and are flat, aggravating the sesamoids), but actually stopped right behind the ball of my foot - something which I always questioned. I was told the weight was being offloaded down the metatarsal head. 
  • May - No real improvement - pain would start up as soon as I walked any distance - My surgeon offered cortisone. I asked him about  bone stimulators - he confessed not to be an expert/use them, but said they would do no harm. So I managed to source an exogen express from the ebay and used it for 3 weeks. I then contacted a sports orthopedic surgeon who promoted the use of exogen for as a second opinion. My new doctor commissioner a new MRI - he said he was immediately skeptical of the diagnosis (said if you stared at a scan too long you can convince yourself of non-cortical fractures). Dr Blake's comment: I agree so far!
  •  I went to see a physio therapist who said  I had modified my gait to protect the sesamoid, She told me to try and walk from heel to toe, exactly as I did with my other foot and strengthen the foot with glute and balancing exercises and walk barefoot as much as possible. I did this, but the proper walking aggravated the injury.Dr Blake' s comment: What ever I tell a patient, if their body tells them differently, it is always best to listen to your body and the signals it gives out. 
  • June - my new doctor studied my new and old scans for a long time. He also asked a radiologist colleague to do the same separately. They both concluded there was never a fracture, but that sesamoiditis/inflammation had built up over time. He suggested cortisone to break the cycle of inflammation and told me to stop using the bone stimulator as it would counter-balance the cortisone. He also referred me to a different podiatrist who said my orthotics did nothing to offload the sesamoid area 
  • July - I had the cortisone injections (20mg in two joint areas) and started to wear new orthotics -  modified to include a forefoot dancer's pad
  • The cortisone has made some difference, but I still have pain when I walk if I don't wear trainers (especially when I try to walk 'properly' - its like a constant toothache in my joint, along with occasional sharp pains down the joint at the side of my foot . My foot  lack a lot of strength and I often feel pain in my little toes, side of foot and ankle too - I feel like I need to click the joints often etc. I emailed my new doctor and he has suggested another injection. I've also been going to the gym in the last month to try and build up strength through cross-training.

Sorry this is a long email - but I wanted to give you the full history in the hope you might be able to give me your expert thoughts on some questions.( I would love to send you my scans but whilst I have them on CD I don't have the software to open them on my computer):
Dr Blake's comment: Just ask the place to give you a copy with a reader for a PC. You can mail to me at 900 Hyde Street, San Francisco, Ca, 94109. 

1. Was my first podiatrist right? Does it just take a really long time to recover? And have you actually seen people  recover fully if they have a tiny hairline fracture/bone bruise?
Dr Blake's comment: I would have not expectations at you not healing. You do not have an injury that tends not to heal well. However, being a specialist in biomechanics, I do know you could have a difficult foot to get the right orthotic for that truly off weights the area well. If that is the case, then you keep re irritating things over and over again. See who in your area is great at orthotics. 
2. As Dr's disagreed with the diagnosis but not the treatment - I still have a niggling doubt there is an resolved tiny fracture and was I wrong to stop bone stimulator? Could I restart this or is this out of the question now I have cortisone in my system? If so, would there ever be a time when I could?
Dr Blake's comment: Please try to heal without cortisone if possible. I would prefer you to ice and contrast daily and take NSAIDs then to use cortisone. It can mask pain too much. Short acting cortisone is fine, and the initial shot to get ahead of the problem/inflammation was fine, but I would not go there again. I love the bone stimulator, but sounds like no fracture, so there is no place for the stimulator. The bone stimulator actually stimulates the bone, important for fractures, but stimulation can also increase bone inflammation and pain/sensitivity. It could actually keep the bone sensitive to pressure that you do not want.
3. My second doctor said I could have up to 3 injections - I know you are no fan of cortisone, but icing/taping/orthotics have given me no obvious improvement - its been only thing to push me into some form of recovery (if temporary/misleading) - would a second shot be a bad idea?
Dr Blake's comment: Just remember how long it can mask pain, and give you a false sense of security. What are your other options? Physical Therapy with cortisone in iontophoresis? Acupuncture? Better orthotics? More daily icing/contrast bathing? I would feel more comfortable with cortisone if your orthotics were perfect, and you had no other options. As you walk, do you feel that the orthotics take weight off the injured area 0%, 50%, 90%, or 100%. You want the weight in the middle of your foot and off the sesamoid area. Put lip stick on the ball of the foot under the sesamoid, carefully put your foot in the shoe, walk down the hall or outside, take the shoe off, does it look like the weight is off the sesamoid. I know alot about orthotics, and it can still take me many attempts to design the best orthotic for this function. 
4. Is walking barefoot/foot balancing helpful or should I offload wherever possible- it doesn't hurt at the time, but can afterwards.
Dr Blake's comment: I find no purpose in walking barefoot. My blog is loading with foot exercises to get the area strong. One of my patients sent a great video recently on FHL eccentric strengthening which looked great. The exercises should not hurt during or after. You have to experiment. Try rearranging books to stand on for single leg balancing where you float the big toe area. Ice after any exercises to calm down the irritation for 10 minutes. 

 Any thoughts you have would be really appreciated and I will of course make a donation to your blog.
Dr Blake's comment: Thank you so very much and I sure hope this helped some. Rich

Please do not comment on the stomach rolls!!! I am doing sit ups every day!

Thanks so much (if you could keep me anonymous that would be appreciated)

Sesamoid Fracture: Email Advice

This email was received August 11th, 2013 for time reference. 

Hello Dr. Blake,

My name is Michael (name changed)  and I am in my early 20's. I have been a runner for the past 5 years and I love it. Back in December 2012, I tripped over my big toe (not while running) and knew right away that something was wrong. I went to the doctor to get it x-rayed but, since the metatarsal bone was not broken, my doctor told me nothing was wrong and to ice/rest for a couple of weeks. I did this until the pain was much better and the swelling went away and then slowly returned to running, biking, yoga, and all of the other things I love to do while still incorporating stretches and strengthening exercises I had found online for my foot. 
Dr Blake's comment: I would have to say that from the sounds of things that your original injury definitely healed. 

The pain was almost completely gone (would just have some issues from time to time) until I decided to skate one day in June. I pushed out and immediately felt a sharp pain in the ball of my foot where I had injured it before. After putting it off for a couple of weeks, I finally decided to go to the podiatrist. He x-rayed my foot and immediately found that one of my sesamoid bones was fractured. I have now been in a boot for 4 weeks and have two more to go and when I went back for my half way check up the fracture was still there and I am now on cortisone pills for the swelling and inflammation.
Dr Blake's comment: A fractured sesamoid should be immobilized for 3 months, while an off weighting orthotic is being designed to help with the gradual weaning process of boot to athletic shoe. That process along can take 2-6 weeks. Whatever happens, as you begin to wean out of the boot, you can not have more pain. Hopefully the boot has brought the pain level between 0-2 while you are walking in it. 

Now that you know my story I have a couple of questions. I read on your blog, when used properly, cortisone pills can sometimes help inflammation and pain. This was great to hear and we shall see how they work for me on an individual basis. My main question is this: do sesamoid fractures usually heal and will I ever be pain free again? I am having a very hard time physically and emotionally due to the fact that I am so young and am normally very active. I miss working out and I have not read the best recovery stories about this injury. I want to avoid surgery if possible and my podiatrist is on the same page. I like that is seems you have the same ideas about surgery. I am really just looking for some words of encouragement from an outside source or any positive feedback that you have gotten or seen from a sesamoid fracture recovery. 

I thank you so much for taking the time to read my email and for creating a blog that allows for me to further research what I am going through.

Sincerely, Michael

Hope you will be back running soon!! 

Dr Blake's comment: Sesamoid Fractures are very tricky, but sound principles and patience can get most patients through without surgery. All guidelines to treatment are close approximations/generalizations. You can still heal even if you are an exception. What are the most important points for you right now? 

A) Listen to your body and do not accept more pain as you go from stage to stage.
B) Bones need Calcium and Vitamin D3 to heal, make sure your diet is good.
C) Swelling is your enemy, even deep swelling in the bone which you can not see, it cuts off healing circulation, so icing and contrast bathing daily is extremely important.
D) Typically at 3 months post injury you are getting out of the cast, and 6 months after the injury you are beginning a walk run program, so go slow with each stage.
E) Your podiatrist can begin making an off weight bearing orthotic device now, or modify your present ones, so when you begin to wean out of the cast, you are protected.
F) Avoid all anti-inflammatory meds after you finish the cortisone pills, since many slow bone healing.
G) Even with the boot, you should be riding a stationary bike, swimming, and other core activities that do not put stress on the sesamoid, or force bending the big toe joint. 
H) Ask the podiatrist if you are a candidate for a bone stimulator.
I) Ask if a baseline MRI can be taken, in case you need one in 6 months to check on healing.
J) Learn spica taping and how to make dancer's pads (also called Reverse Morton's).
K) Find out when you should start re-strengthening your foot (met doming, single leg balancing with a hole for the sesamoid, inversion/eversion therabands, etc). 

I hope this all helps Rich