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Wednesday, July 30, 2014

Sesamoid Fracture with Chronic Symptoms: Email Advice

Dr Blake,
     Thank you for offering to help folks out via email/blog!  I was diagnosed almost 10 years ago with a sesamoid tibial stress fracture in my left foot. It was via x rays and he mentioned a specific x ray was the only one to show the fracture.  I think it was a view into the front of the foot.  Is that a typical x ray view done? 
Dr Blake's comment: Probably was what is called the Plantar Axial xray which is a crucial one for sesamoid injuries. 
 I was in a boot and healed great as I had no issues again up until 8 months ago. 

      I am a very active person and exercise on a very regular basis. I moved to a different city so I saw a different doctor (podiatrist).  At the time, I was not sure if this was even the same foot as before.  He took x rays, said no fracture and plastered both of my feet for orthotic inserts - he did something to the inserts to lessen the stress in the area.  He also gave me a shot of cortisone.  
Dr Blake's comment: And we can assume that this helped resolve the situation at that time. 

     A week or so ago I started having intermittent sharp stabbing pain and then more moderate pain sometimes when walking.  The very sharp pain comes sometimes when pushing off foot to stand and start walking.  It is like level +7 pain.  I reached back out to the first doctor's office and confirmed this is happening in the same foot as the prior fracture.  I am not sure what x ray views the current doctor took and wondered if he might have missed a repeat stress fracture.  Could I have gone 8 months with that? 
Dr Blake's comment: You seem to have weakness in that area. Xrays are less than 50% accurate in diagnosing sesamoid fractures, since they can look irregular forever. You would need a bone scan or MRI to make the diagnosis of what is happening now. If you have been doing well, you have not been walking around on a stress fracture for these 8 months!! The flareup now can be a new injury, or an aggravation of this chronic sesamoid disease. Again MRI first, and if positive, CT Scan to 3D visualization of the whole joint. 

      I saw a great orthopedic doctor for a knee issue in January.  I think he has a partner in his office that is more focused on feet/ankles.  Do you think I should see an orthopedic doctor and should I have more x ray views taken or MRI to correctly determine what is wrong? Does a re-fracture happen often?
Dr Blake's comment: Get the MRI from the doctor you are seeing. If it is positive, ask for a CT scan. Then get his/her advice. If everything sounds logical, and no surgery is being recommended, stay the course. If not, get a second opinion. Never tell the second doc what the first doc said since you want as honest and unbiased a 2nd opinion as possible.
Thank you so much - Angela (name changed)

Monday, July 28, 2014

Sesamoid Fracture: Email Advice

     I am 23 years old, I am currently in the Air Force and I am dealing with a fibular sesamoid fracture. I have ran my entire life and grew up in a small town where sports were everything. I played everything from basketball, volleyball, softball, track and cross country and I never had issues with my feet. 

     In December 2013, I gradually started to feel a small pain in my foot and ignored it, I self diagnosed myself with metatarsalgia. I dealt with the pain for about 5 months thinking it would subside overtime, but to make a long story short, it got to be unbearable. 

     I had an x-ray taken sure enough it was a fibular sesamoid fracture, which is puzzling to me. I didn't hit the ball of my foot hard on anything and I do not run nearly as much as when I was in High School. I was placed in a cam boot for a month, and then I was referred to a podiatrist.

     The podiatrist told me I would be placed on crutches for a period of 3 months with 60% chance of healing. I am stressing myself out looking for success stories of how I can still be hopeful to maybe be normal again. If I do need surgery why must they take the bone out creating a chance that I will have to have both removed someday and the possibility of having my toe fused together. Therefore,  surgery does not seem like a solution.

      I have also heard that the surgery can lead to Bunions and Turf Toe. I am an active individual and this doesn't seem like it is an easy thing that I can continue dealing with. Has this always been the temporary fix? I am open to suggestions; books, running differently, walking differently, inserts, chiropractic advice..... anything I don't want to remove the bones...

Dr Blake's comment:

     Thanks so very much for your email. My blog is so full of posts on this injury. I am very happy with the results of conservative care, but you will see it takes alot of work. Crutches add to the swelling (pain) and demineralization (poor bone healing). So, see if you can get in a position of protected weight bearing with crutches and orthotics with dancer's pads. Fight the swelling with 2 icings and 1 contrast bathing daily. Fight the demineralization with calcium 1500 mg per day, Vit D3 1000 units per day, and protected weight bearing. I have included my previous blog posts on this injury which I hope will be helpful. Let me know if I can help more. Rich

Saturday, July 19, 2014

Nerve Pain and the Loss of Right Left Discrimination

I was just purchasing the laterality cards for one of my patients who does not use the internet from when I saw/remembered that they have an app. So I downloaded it and thought I would spread the word. When you have nerve pain in your foot you can lose the ability to discern if you are looking at your right foot or left foot. It is the brain trying to avoid pain, and as this process of avoidance gets rooted in your nervous system, it is hard to reverse. Laterality flash cards demonstrated by the app below, and purchased for around $50, can be for feet, hands, knees, etc. Depends where the nerve pain is. It is extremely helpful at preventing the nerve pain rewiring that is devastating to many. It is part of a process called graded motor imagery. 

                               Is this the right or left foot?

Short Leg after Hip Replacement: Email Advice

This AP Pelvic Standing Xray is not that of the patient in question
Recently had THR (total hip replacement) surgery and experiencing severe Short Leg Syndrome - Should I go to my surgeon and suggest correcting this asap?


Dr Blake's comment: 

     Thanks so very much for your email and I am sorry for your predicament. We experience a feeling of one leg being longer for many reasons which include tight muscles, weak muscles, pelvic tilts, limping from pain, and true short legs. A slight short leg structurally can be magnified in feeling by one or two of the other problems produced by the surgical treatment. I relie on the Standing AP Pelvic xray in normal stance to give me as much information on the structural difference in hip heights that your body must deal with when you walk, and the pelvic tilts, including any sacral base unevenness at the base of the spine. You take this information and combine it with the data collected from a physical therapist on muscle tightness and weakness patterns to further get a strong picture on what is going on. Then you ascertain if gait is influenced by pain, weakness, tightness, or spinal sway above. Spinal Sway places severe stress on the operated hip and documented as limb dominance to one side. In summary, most of my patients I see following hip replacement have a combination of structural shortness and functional shortness (related to muscles, scar, pain, scoliosis, etc). It can take a good year post hip replacement to gradually work out the problems. As a podiatrist, I can measure things, and make observations, but relie on PTs and physiatrists, chiropractors, and osteopaths to help me in treatment. Surgeons are smart, but you really need a non surgeon spine specialist to help you work through the functional part before imparting on perhaps hasty and unnecessary surgery. That being said, you must start at the beginning with a standing AP Pelvic xray and get that interpreted. Hope this helps you. Rich

Pack a Back Fundraiser: A Good Cause for the Kids

Thursday, July 17, 2014

Followup on Alcohol Shots for Morton's Neuroma: Email Advice

Hello Dr. Blake,

Well, after 8 shots with the alcohol my MN still remains. I started at about an 8 on the pain scale (10 being really bad) and I am around a 4 right now, sometimes it goes to 6.

Strange thing is that on shot #7, when administered, it was NOT painful and I felt relief very quickly. Then 2 weeks later when my podiatrist gave me shot #8, it really hurt when he administered the shot and of course it made my MN hurt more afterwards. 

Throughout the course of my alcohol shots, it kinds of was the same way. When he administered the shots, if they hurt during the administration, then my MN hurt for that week. When the shots didn't hurt, my MN improved. He used an ultra-sound during each injection to help guide the needle. My theory on this is that he somehow was getting "too close" to the nerve and injured it during the injection and this caused more nerve damage. Of course this is only my unprofessional theory on it.

At this point I am in a waiting pattern to see what I will do next. I have the foot inserts, met pads, and I wear slippers with met pads while at home which helps a lot with the pain. If I go bare foot, especially on tile, it starts to hurt. I am going to try some cold laser therapy, although I know this is not promising, it's worth a shot. I don't want to do the surgery but living in constant pain every time I walk is no fun either. 

Paul (name changed)

Dr Blake's comment:

     Thanks for your feedback on the alcohol shots. You want the shots to hurt during to know that you are at the nerve layer. Your gradual reduction in pain is a good sign. Stop the series at 10 shots, give yourself 1 month off, and try another series of 5. I believe you told me that you were only getting 4%, so try to beg for 6 or 8% for the next round. When you did not feel pain, he/she was missing the nerve and you were only getting the numbing effect of the local anesthetic. Even though this feels good, it is guaranteed not to help you in the long run. Rich

Severe Foot Pain from Trauma: Email Advice with Patient Response

Dr. Blake,

Thank you so much for your blog.  It is very informative and helpful.  It is easy to see that  not only do you love what you do, but how much you truly care about people too.

I have a situation in which the aftermath of injury is more complex than the initiating injury.  My toddler pulled an object off the dining table and it did a nose-dive into the top left of my foot, below and between the fourth and fifth toes.  I immediately went to my bed and hollered for ten minutes straight.  I never knew such pain.  This was followed by an attempt to walk, which I soon gave up and dropped to hands and knees in order to get around.  Unfortunately, my foot had already borne the weight of heavy limping in places it’s not supposed to.

The beginning was really tough-the first two weeks of healing were like having the flu, being crashed in bed most of the time and sleeping as much as possible.  Physical response included extreme fatigue, severe swelling, pain, severe discoloration (deep purple/bright red/pale), throbbing, severe skin temperature fluctuations, inability to walk or tolerate pressure (not even a bed sheet!) A few weeks later I noticed a soft, squishy lump inside the bottom of my heel that made me feel weird, but when I tried to check it again, it was gone.
Dr Blake's comment: This may be what is called neural over-reaction or Complex Regional Pain Syndrome. 

Due to certain circumstances, the medical care I received at the start was not very adequate.  No one knew what happened to my foot and I heard different things from different doctors.  Even the same doctor told me at one visit, while looking at the x-ray, that my foot was broken right “there” (AAYYY!) and at the very next visit said no, it’s not broken and there’s no evidence that it ever was (what evidence was he looking at??)  I was completely off my foot for about 10 ½ weeks due to pain and swelling, but did manage to pull my over-sized foot out of the aircast, stuff it into a tennis shoe and hobble without crutches before he released me.  It was around a similar time that I could (finally!) place my bare foot (with no weight) flat on the ground.  This was around three months post-injury.

Six months later I still had a constant limp, swelling, discoloration, pain, wrong temperature (usu. too cold), lack of function, stiffness, tingling nerve, and I went back to the doctor (different one this time).  I’ve been working with her now for about four months.  I’ve seen some improvement first in function and circulation, second swelling, and improvement in pain is much slower going.  My primary pain points are the heel, arch, across ball of foot, sesamoids and big toe.  Swelling always causes pain to increase.

Over the past thirteen months my diagnoses have been described as:  possible bruised bone, no one ever agreed on whether or not my foot was broken, sesamoiditis, callus, plantar fasciitis, varicose veins, medial hallux neuralgia, IT band syndrome (both legs, from limping too long), and lumbar strain (for which I had to go to another dr.)  Treatments have included a short aircast x 5 wks, Powerstep orthotic (all the time), steroid pack, several applications of Unna boot, a below-knee compression sock, and PT including iontophoresis and Graston technique (left foot and both legs), and of course icing (with a cold pack). Back treatment also included some anti-inflammatory meds.  A flare-up of anything (left foot-legs-lower back) has the potential to aggravate the whole system.

So here are some of my thoughts-
Will I ever be able to run, jump, tiptoe and stand in the shower?  Return to normal function?
Will I ever be mostly pain free/able to bear full weight (esp. sesamoids, big toe, and across ball of foot)?
Why do I still have pain and swelling?  Occasional swelling inside the compression sock?
Can I get orthotics for my ice skates if I ever make it back onto the ice (non-competitive)?
How long do I stick with PT?  Current doctor?  Get a second opinion?  Which medical discipline?
What can I expect long-term?  Will my foot ever feel ‘normal’ again?  How do I exercise?
How do I keep the system in balance and not aggravate opposing-injury cycle?

If I lived anywhere nearby, I would definitely set an appt. to see you.  I am truly blessed to have found your blog and thank you for any input you are able to give me.

Marie (pseudo name)

attached are a couple of pictures

The swelling and redness are common parts of some presentations of CRPS. It is called vasomotor insufficiency. 

Dr Blake's comment:

     Marie, I am so sorry for your problems. It sounds like you have a version of Complex Regional Pain Syndrome. There are so many treatments for this, and you need to be in the hands of a podiatrist and pain management specialist in your area who are knowledgable about this disease. If that diagnosis is confirmed, my blog is full of many ideas on treatment. I hope this is helpful to you. Rich

Marie responded several weeks later: 

Dr. Blake,
Thank you so much for your reply.  I saw a local pain management doc and a diagnosis of CRPS / RSD has been confirmed.  I am very grateful because without your input, there is no telling how long it might have taken me to get an accurate diagnosis.  It does not seem to be very well known among doctors.  Now I have the opportunity to move forward with treatment / management.  My question is:  what role does a podiatrist play in treating CRPS?  My current podiatrist does not appear to be familiar with it at all.
I'm including a few photos from three weeks and nine months (last photo) post-injury, in hopes of educating people on what CRPS can look like.  Perhaps someone else will have the opportunity for a much-earlier diagnosis.
Thanks again for your help.
Forever grateful,

Dr Blake's Response:

     I am so happy to have helped since making the diagnosis is crucial to getting the right treatment. You will see from my blog that treatment should be a Team of people, with a podiatrist helping. A sympathetic block is typically important now, but oral medications can crucial. If you see my checklist of treatments for CRPS, you will see how creating a nerve non stimulating environment is crucial. The podiatrist, if knowledgable on this condition, will be invaluable along the way. Also, definitely check if you have a Calmare Pain Therapy center near you. Let me know how I can help further. Rich

And here is info from an article I am writing. 

4. Lessons learned from the treatment of Complex Regional Pain Syndrome

I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a very difficult topic, and one I have known for a while I needed to present somewhat on my foot blog. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, and others, you are scared. The doctors and therapists who treat you are scared for you. The quicker the response that better, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling comorbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

The Mainstays of Treatment are:

·       Identifying Source of Pain
1.      MRI/CT Scans
2.      Bone Scan
3.      Diagnostic Injections (local or back)
4.      Nerve Conduction Studies
5.      Lab Tests
§         Sed Rate
§         CBC
§         Free T4 and TSH
§         Vit B12 Levels
§         HgbA1c
§         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle
1.     Mechanical Means
§         Roll A Bout
§         AFO
§         Crutches
§         Tibia Wt Bearing Braces
§         Activity Modification
§         Custom Made Orthotics to stabilize an injured area

2.     Oral Medications
§         Anti-Seizure (ie Lyrica)
§         Anti-Depressant (ie Nortriptyline)
§         Others through Pain Management Specialists

3.      Topical Medications/Applications(should be gels for ease of application)
§         Warm Compresses
§         Non Painful Massage
§         Parafin Wax
§         Chinese Herbs
§         Lidoderm Patches
§         Neuro-Eze
§         Multiple Compounding Medications which include (usually not all of these):
ü      Ketamine 10%
ü      Clonidine 0.2%
ü      Gabapentin 6%
ü      Baclofen 2%
ü      Nifedipine 2%
ü      Lidocaine 2%

4.     Alternative
§         Biofeedback (Thermal to increase circulation)
§         Hypnosis
§         Meditation
§         Accupuncture (can be to opposite limb or ear)

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

·       Rehabilitation of Limb Function
1.      Lower Extremities (keep strong as long as painfree)
2.      Core (support feet and legs from above with less pressure on feet overall)
3.      Cardio (improve overall circulation and health)
4.      Whole Body (must address physical, emotional, spiritual sides together)

·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal Faster
1.      Part Time Work
2.      Volunteer
3.      Projects

·       Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration
ü      American Chronic Pain Association
ü      American Academy of Pain Management
ü      Reflex Sympathetic Dystrophy Syndrome Association
ü      How To Cope With Pain blog

Tuesday, July 15, 2014

2nd MPJ Plantar Plate Tear: Email Advice

I'm a professional Rugby League player in England and have recently ruptured my Planter Plate Ligament under my 2nd toe. The toe keeps coming out of joint and under the 2nd metatarsal head is very painful. I have 8-10 games left of the season and would like to play in the remaining matches. i can have a local anaesthetic for games but during the week when training i can't. I've tried all sorts of taping trying to keep the toe from coming out of joint and pulled down toward the floor but haven't found a suitable one that allows me to train properly. I wondered if you had any advice on taping techniques or some kind of splint that may help me get through the next few weeks. I'm having orthotics made to offload the pressure on the 2nd met head.

i hope you can help


Dr Blake's comment: Glad to try to help. Please try to Budin Splints. You should get the single, double and triple loop ones and experiment. For the Single Loop, you can put the loop over the 2nd only, or over the 2nd and 3rd toes combined. With the double loop, you can try 2nd and 3rd or 2nd and 4th. With the triple loop, you only have 2/3/4 possibility. You can also first try taping the toe down (I found a picture for the first, but you would do 2nd in a similar fashion) and then using the splint.  I also have found adding 1/4 inch adhesive felt over the top of the toe before you put your sock on can help push the toe down when you play (could not find a quick image of that). Many times you also have to put as much metatarsal arch under the 2nd and 3rd metatarsals as possible to lift up the metatarsals while pulling down the toes.I like the small longitudinal medial arch Hapads for this purpose. And then probably, if there is any more room in your shoe, to add a float to accommodate the 2nd metatarsal head at weight bearing.  Hope this makes sense. Rich

Hapad used for metatarsal support with an extra piece to the side of the sore area. When you use these Hapads, I use the right on the left and the left on the right. Go to for ordering.

Besides hapads for metatarsal support, accommodative padding of various forms and amounts can help off weight the metatarsal head.

Here a single loop budin splint is seen which can be put over the 2nd alone, or both the 2nd and 3rd toes combined. You can tape first. Please check out

To prevent the toe splint from moving place a small piece of tape between the elastic band and the toe. 

Even though this shows the first toe, you can easily do the same for the 2nd. Use Kinesiotape, Rocktape or 3M Nexcare Waterproof tape.