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Friday, January 31, 2014

Friday's Patient Problem of the Week: Dislocating 2nd Toe

This nice patient had her 2nd toe going over the first slightly after injuring the area playing soccer. The pain was isolated to the 2nd metatarsal-phalangeal joint for several months before the 2nd toe started to noticeably drift towards the first toe. Taping of the second to the third (sometimes even to the 4th) toe and using a medium gel toe separator has held the toe joint in the right position and allowed a dramatic reduction of pain. MRI has documented a ligamentous tear under the 2nd met/toe joint and the patient is discussing surgical options with several podiatrists on my recommendation. She may however stabilize this area over the next 6-12 months and do well without surgery for now. I have also added Hapad metatarsal arch pads to off weight the sore area and she ices for 10 minutes 3-5 times a day when she can sit still long enough. Eventually she will need to be able to do metatarsal doming exercises to rebuild the toe and metatarsal strength. 

Thursday, January 30, 2014

Thursday's Orthotic Discussion of the Week: Pouring the Negative Cast and Building the Anterior Platform for the Inverted Technique

Dear Dr. Blake,
Thank you very much for your blog and for this post ! I've read with great interest your post from Podiatry Arena and, as a self educated person [in my country doesn't exist podiatric schools] I want to tell you that your post is one of the best, expecially from a practical point of view !

 I have a question which maybe seems stupid for you and I apologies for this. I personnaly have difficulties with anterior platform building so I kindly ask you to give me some instructions regarding the composition of the pink plaster from photos. In my practice I make it either too fluid or too rigid and simple I didn't succeed to build the anterior platform in the way you have described here !

I'm expecting with great interest March, when you'll post your manual !
Thank you for your kindness !

Robert (name changed)

Dear Robert,
     I am always honored by getting emails and compliments, and especially from so far. Thank you so very much and I hope I can help. Here are some photos that I hope will help. More questions are encouraged.

Here is the initial set up for pouring of the negative casts to make them a solid positive cast. The most important part of the photo is my coffee cup since it is 6:30 am on a Saturday morning. One basin is for the soap solution and one basin is for the casting plaster to be used in making the positive cast. 

For 2 feet I am pouring the plaster to make a positive cast I use 5 cups of plaster and 3 cups of water. There is the 1 cup volume rubber pouring bowl. For 2 pairs of feet, 4 total, I will use 10 cups of plaster and 6 cups of water. The basin I use holds up to 15 cups of plaster. 

This is the Casting Plaster I use with 30 minute Set Time. 

It is also called Red Tag 30. 

I use a one cup bowl, but you can buy these bowls that hold 5 or 10 cups at once to make life easier at times. Here the plaster is in the bowl and will be emptied into the basin to begin the process. 

I have fillled the basin with 10 cups of plaster good enough for 2 averaged sized pairs of feet. If both your casts are for sizes 12 or greater, consider 12 or 13 cups of plaster. The water ratio is still 60% approximately the plaster amount.

I buy a soapy concentrate and dilute with water 50%. This is poured into the negative cast to saturate the bottom and sides. Any extra soap is allowed to drip out and returned to the bottle. This makes it so much easier to get off the negative casting material once the positive is dried. 

Here are the negative casts after having been soaked thoroughly with the soapy solution and then being tipped over to allow the soap to drain. 

The negative casts are then leveled so that the heel bisections stand perfectly vertical when poured. This is done with every cast so that the top of the cast represents a parallel with the ground. 

Here my talented brother Bob is pouring water in a 60% ratio to the plaster with some colored dye to make the plaster solution for pouring. One pair of casts typically need 5 cups of plaster and 3 cups of water. 

The plaster (mud!!) is mixed thoroughly to get out any clumps of plaster so that the solution is a uniform consistency. 

Plaster clumps are completely broken apart

Then the very smooth consistent liquid plaster is poured into the balanced to heel vertical negative casts.

My great brother Bob skillfully pours the plaster to make the positive casts set a heel vertical.

Here the negative casts sit after the plaster is poured

Typically you can pour up to 3 pairs of casts in one basin. That basin would have 15 cups of plaster and 9 cups of water.

Once the negative casts are poured, it is important to recheck the heel bisection to make sure it has remained vertical. 

After pouring, sticks are placed into positives to minimize breakage with the high pressure vacuum press. 

Once you remove the casting plaster, the first and fifth metatarsal areas are marked to define the anterior platform borders. You find the contact point on the first metatarsal (lowest point) and then place the line 15 mm closer to the arch. I like to then even the 5th metatarsal platform with that line, but the fifth metatarsal is normally a little shorter. The vertical lines are in the space between the first and second metatarsals and the 4th/5th metatarsals.

Here you can see the proximal line 15 mm from the contact point. This will be where the plastic of the orthotic device ends. You do not want the plastic to run under the weight bearing surface when walking or running. 

Here the nails are placed on the platforms to make the angle for Fettig Modification of the Inverted Technique. Here the medial nail under the big toe joint will set the overall inversion and lateral nail under the fifth metatarsal head for the forefoot valgus correction.

When I am working with plaster, I typically have 2 or 3 bowls going at once. The plaster has to be right, not too runny and not to solid, to apply and shape. It takes time to learn your plaster. I try not to stir it much, for stirring will make the plaster harden faster. I try to pour off the excess water once the bubbles stop, for too long with excess water makes the plaster to take forever to dry. 

I use wooden sticks soaked for 10 minutes or so for making the transition from anterior platform to the medial arch fill more solid during vacuum press. The high pressures can break the platform away from the medial arch without the sticks in place.

After the nails are in place, and the plaster the right consistency, place a piece of paper down to make the anterior platform. 

Gently stir the plaster to check the consistency

It is so important to play with the plaster and know it's consistency

and play some more!

And more

I place dye into the plaster to make the various parts of the positive cast stand out

Mix it in well

When the plaster is ready, place it on a piece of paper and press the positive cast gently down. It is important not to push too hard to distort the nails. It is important not to push too lightly and lose the angle set by the nails.

Here the anterior platform area of the positive cast is coming in contact with the plaster mound

Gently, but firmly, I press the positive down into the mud

Then I use a spatula to make the medial and lateral edges straight up and down.

It is important to check your angles, if off from what was ordered, immediately knock off the platform and start all over again.

This photo is out of order but shows the positive casts, after being poured, drying for 1 hour in the sun. 

Here the wooden stick is placed into the anterior platform to set further strengthen the area before pressing. The total length of the stick coming out of the platform and into the arch will be 1 and 1/2 inches in general.

Another view of the stick

The platform is being formed following the lines on the positive cast.

When cutting the anterior platform, keep the spatula moist with water to allow easier trimming.

Do not lose focus on the shape of the platform desired and outlined by those lines 

The medial and lateral sides will still need to be trimmed to go straight up and down from the positive cast.

Another view of the 20 degrees Inversion with 6 degree forefoot valgus in the Fettig modification of the Inverted Orthotic Technique.

Trimming of the sides with scrapper

Final product with anterior platform with medial and lateral expansions.

Wednesday, January 29, 2014

Wednesday's Article of the Week: Possible Future of Synthetic Cartilage Injections in the Big Toe Joint for Hallux Limitus/Rigidus

The article below discusses the complex world of research around Synthetic Cartilage injections for Hallux Limitus/Rigidus. Every Podiatrist is waiting anxiously for approval of a synthetic substance to act like a new cartilage pillow within the big toe joint when injured. In this proposed study, intra-articular Hyaluronan (Synvisc) would be injected into every other patient and sterile saline (salt water) into the other 50%. Everything else would be equal. It would be the only treatment for a 6 month period. Patients would be evaluated many ways:

  • pain levels
  • function levels
  • pain with walking and at rest
  • amount of stiffness in the big toe joint
  • amount of measured big toe joint dorsiflexion
  • plantarflexion strength across the big toe joint
  • global satisfaction to treatment
  • overall health related quality of life
  • magnitude of symptom changes throughout the day
  • use of pain relieving medications
  • changes in measured pressures in walking of the ball of the foot
Data will be collected at baseline, 1, 3 and 6 months
Up to 3 shots will be given each patient based on symptom relief
Data will be analyzed using the Intent to Treat Principle and other common forms of objective testing.

Dancer's Pads used to off weight Hallux Limitus/Rigidus when it is sore to put weight on the big toe joint.

Tuesday, January 28, 2014

Tuesday Question of the Week: Fractured Fibular Sesamoid under the Big Toe Joint

Dr. Blake,

Thank you so very much for your willingness to hear my story!  That alone means more than you know.  Here it goes.

I picked up running in 2011, ran my first half marathon in 2012, and did two more by May 2013.  I started having slight discomfort from the arch of my right foot up to my big toe (mostly when I flexed it) in December 2012. It felt like a sore muscle, so I chalked it up to bad shoes (changed them) and ran through it.  I never expected to be told there was a fractured bone in my foot.  The discomfort was intermittent at best, bothersome but not very painful.

I finally saw a podiatrist in September 2013 as a precautionary measure before training for another race.  He took x rays and told me my fibular sesamoid was fractured

The sesamoids are two little bones under the first metatarsal head in the ball of the foot that consistently get injured. In this MRI image (not this patient), you can see how they stand between the ball of the foot and the ground. The arrow is pointing to a bursitis (fluid sac) which was misdiagnosed as sesamoid pain. 

 I was put in an aircast for 6 weeks.  At my second follow up appointment he told me the bone had healed and cleared me to run and wear heels again. 
Dr Blake's comment: Rarely, maybe this fast, but typically 3 months in removable boot, and 1 to 1 and 1/2 weeks to wean out of the boot into protective orthotics and shoes. 

 He gave me no instructions regarding how to safely get back into running. I tried to ease into it slowly by run/walking short distances with a stiff soled shoe insert he gave me and an ace bandage with a gel cushion under the ball of my foot. 
Dr Blake's comment: I like dancer's pads much better, minimal under the sore bone, and more under the 2nd to 5th metatarsals. 

 That was late October.  I ran a little here and there throughout November and early December 2013.  The dull discomfort was less noticeable than before the boot, but it came back after I'd run a mile or so.  I stopped running and decided to see a different podiatrist.

The new podiatrist took x rays the week of Christmas 2013.  She could tell the bone was cloudy looking but couldn't say whether that was calcification or something else.  She suspected avascular necrosis and ordered an MRI.  Upon reviewing the radiologist's finding (my understanding is that she never reviewed the actual images), she said the bone was beyond healing and that my options were surgery removing the bone now or surgery later, whichever was more convenient for me.  She told me to run my heart out and that it would eventually bother me enough to want the surgery.
Dr Blake's comment: It is so hard to make that ascertain. I would start you on a bone stimulator from Exogen, get your biomechanics in order, and see how the next 9 months went. 

To get another opinion, I saw a well-regarded orthopedic surgeon in Dallas on Jan 23, 2014 who specializes in foot injuries.  He took an x ray and said the bone looks unhealthy.  He also reviewed my MRI but mumbled something about the cuts being 4millimeters apart and not terribly helpful.  He said that unless I stop running entirely, surgery is likely inevitable.  He said I could go back to running now because I won't make the situation worse (what?! how is that possible?).  He gave me no instructions for caring for the injury and said to call him if/when the bone bothered me enough for surgery.
Dr Blake's comment: Yes, you can make the problem worse. Fractured sesamoids can produce damage to the underside of the first metatarsal leading to a hugh mess, and a longer recovery time. Spend 2014 trying to get this injury healed with activity modification creating 0-2 level pain, orthotics to off weight, bone stimulator daily, icing twice daily, contrast bathing once daily, spica taping when you are going to be athletic to protect, 1500 mg Calcium daily, and 1000 units Vit D3. 

Dr. Blake, I have never experienced the pain many of your patients have.  My pain is minimal at best, and basically non-existent at this point, as long as I'm not running on it or wearing heels.  Surgery seems dramatic and it scares me, both because of the initial pain involved post-op and the unpredictable nature of the outcome.  But I miss running, and being inactive is weighing on me.  
Dr Blake's comment: The athletic part of your rehab program should not emphasize impact sports or too much toe bend. But, you should run every other day with good orthotics and dancer's pads, even if it is only 5 minutes to develop a baseline. You must stop running if the pain comes on during the run meaning you hit the threshold of injury. Pushing through that type of pain can injure you further. Cycling, swimming, and swimming should all be good, with a little modification if necessary. 

My questions for you are:
  1. What is your assessment? Dr Blake's comment: Listen to your body for we need to protect these bones. I am happy to look at your MRI by mailing to Dr Rich Blake 900 Hyde Street, San Francisco, CA, 94109. 
  2. Can a sesamoid bone with supposed AVN be healed?  If so, how? Dr Blake's comment: An AVN is still fixable if the bone does not collapse. Bone collapse can be helped with bone stimulator, pain free protected weight bearing, calcium and Vit D3, contrast bathing and icing daily. 
  3. Will a bone stimulator help at this point? I had not used one before seeing any of these doctors, but a co-worker offered to lend me her Exogen device.  I started using it 20 min-daily a few days ago. Dr Blake's comment: Definitely 2 sessions of 20 minute with the Exogen for the next 9 months.
  4. Even though the doctors say I can go back to running, I have chosen not to in hopes that my bone just needs more time/care.  Is there any benefit to be gained from staying off my foot, or am I wasting my time with a dead bone that will not heal? Dr Blake's comment: I will try not to discuss Lazarus from the Bible, but no one can be certain that this bone is dead. Treat it as if it were dying due to lack of blood flow and go from there. As long as the MRI shows that the bone is not fragmenting and degenerative, you have a good chance a saving it.   I downloaded the xray image below and it showed a fracture, but the MRI will be a better way to interpret. The radiology report of the MRI talked about AVN (dead bone) and fragmentation, so let me see how severe. 

I have a hard copy of my MRI disk that I am glad to send you.  The report is attached, as are the x rays I have from the first doctor who suspected a fractured sesamoid in Sept 2013.  I can request the most recent x rays from both follow up doctors if you'd like to see them.

Thanks again for your time.  It is much appreciated.

All the best,