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Tuesday, October 28, 2014

Fractured Sesamoid: Email Advice

Hello Dr. Blake,

I was told 18 months ago I had bipartite tibial sesamoiditis.  

About 3 months ago, based on an MRI, I was diagnosed with a fracture in my right foot of one of these tibial sesamoid bones.  

I was in a boot and the physician (in retrospect) was loose in his treatment of me (athlete that wanted to get back out there).  I was allowed to hike after 3 weeks to see how it was and it hurt.  So did 2.5 more weeks in boot.  Again, still painful but interestingly, the ball of the foot wasn't the primary pain spot.  Instead, the joint between the metatarsal and the great toe esp on dorsiflexion was painful.

A second opinion diagnosed that a fracture was still present.  He only did an x ray and didn't seem to think it was just bipartite bone.  

My question is, how do you differentiate between bipartite bone and ongoing fracture via x ray?

I do have the images if you wanted to see them.


Dr Blake's comment:  Here are some xrays of my patients with sesamoid injuries. 
This is the common plantar axial x ray to evaluate with sesamoid injuries. You are looking at the remodeling of the bone as an indicator of injury (fracture instead of just bipartite). You can see the sesamoid on the right side has more opaqueness to it indicating new bone internal formation. The sesamoid on the left shows a greater distinction between the more density bone on the bottom of the sesamoid, and the darker (less dense) bone on the top of the sesamoid. This is the more normal appearance of a sesamoid. 
The x ray above shows the typical fracture appearance of a sesamoid. We are looking at the fibular sesamoid, the one closest to the second toe. The separation between the 2 parts is sharp, irregular, not rounded.

Here the fracture line of the tibial sesamoid is sharp, distinct, irregular.

Here is one I needed an MRI. The 2 bones making up the tibial sesamoid are rounded like bipartite, but the junction is sharp and irregular suggesting some trauma. In this case, a bipartite sesamoid fractured across the junction, only documented by MRI.

If you follow sesamoid fractures via xray, you normally have x rays every 2-3 months, and you watch for the gap to lessen or fill. Since the healing is internal, the x rays can be months and months behind the actual healing. And well after the sesamoid has internally healed and is strong, it remains very sensitive still. This always plays mind games with the rehabilitation program. 

Monday, October 27, 2014

Ganglion: Source of Years of Symptoms

Hi Dr. Blake. I know you must be very busy but i was wondering if you could help me.

I'm a 32 year old female.

I have been seeing a podiatrist for about 4 1/2 years, Initially with big toe pain which developed into chronic plantar fasciitis, eventually resolved in one foot by ESWT, the other foot being managed by orthotics only.

 I should mention that i am a radiographer and have access to xray/ MRI at ease (although not very good quality for feet as we don't have that particular piece of equipment) and referral to ESWT (not from my podiatrist), a colleague told me they had it and it helped- and it has.
Dr Blake's comment: ESWT stands for Extracorporeal Shock Wave Therapy. It is the ultrasonic blast that is used to break down kidney stones. I am familiar, and have had patients whom have had it, but I no personal experience. Like PRP injections, I consider this on the fringes of treatment, but would definitely recommend prior to surgical treatment for plantar fasciitis. 

I also have a completely ruptured ATFL in my right foot, i believe caused by rolling my ankle once in the orthotics initially prescribed for me, and excruciating peroneus brevis tendonosis requiring a cortisone shot (different podiatrist now) (PB eventually got better now pain is only occasional- ankle instability to blame probably).
Dr Blake's comment: So, a lot has been hurting, but you tend to respond well to treatment. Good sign!! The ankle ligament tear should be coupled with daily ankle strengthening--theraband for the peroneals, and single leg flatfoot balancing. 

On several visits i mentioned pain near the fibular sesamoid right foot but more towards the the distal phalanx in the meaty space between the big toe and second toe, it was getting worse and worse,(three podiatrists all said capsulitis) eventually i got a colleague to refer me for an x ray. it basically showed nothing except a small bony bit near the fibular sesamoid not really visible on previous x ray a few years prior. So i was concerned about it (no idea whether it was a fragment or osteophyte formation but convinced it must have something to do with my pain).
Dr Blake's comment: I am assuming it is the original big toe pain that started these pain symptoms.

It was getting so annoying i pulled apart my orthotics and removed the tear drop shaped dome between the 1st and 2nd MTPJ for capsulitis. This gave some relief. I showed the podiatrist and at first he thought it was a sesamoid fracture until i showed him the MRI. MRI showed ganglionic cyst extending from tendon sheath, first and second toe.
Dr Blake's comment: This is why I love MRI so that all the bone and soft tissue is evaluated. 
Although not this patient, the MRI is able to clearly show the soft tissues of the sore area.

The much bigger ganglion has a long stalk to the first toe. i then had a doctors referral to get aspirated and injected with steroid. The second toe was too small/tricky to aspirate (a little bubble sandwiched between two tendons). After two/three weeks pain started coming back- albeit not as bad as before. After two months i got another referral for aspiration and cortisone, however they couldn't see under ultrasound enough of the one under the first toe to do anything, and the second toe- could only inject around it and not in the ganglion or the tendon sheath.
Dr Blake's comment: You have to hope that this means the cysts are calming down.

At this point in time i am trying to increase my level of exercise- and have been enjoying doing so as it has been such a chronic limitation for me these past four years. I have weight to lose and i want to start a family (i'm 32) . I feel it is important for me to fix this once and for all. At this stage it isn't so bad but feel it when walking, after increased exercise it aches, i'm scared its just going to get worse again.
Dr Blake's comment: Ganglions are common, and can re-occur post shots, but are actually not that common to remove. The shots can be repeated if bad. Surgery to remove can be a complete success, but can have complications more serious than the cyst. Now that you have identified the source of pain in this area, and you have at least a temporary fix, you can follow this closely. 

About 14 years ago when i was 18 (this might be relevant) i saw a podiatrist for pain in this area, i was prescribed orthotics under the impression it was some sort of tendon issue between first and second MTPJ- pain never really resolved- i was just putting up with it (no imaging done at this time).
Dr Blake's comment: So much depends on how long you think this has been disabling to you since you have had the shots. Definitely you want to watch over the next 2 years, have some orthotic devices made that off weight the area, get a few more shots if warranted, and ice daily to keep the inflammation under control. You are not wrong if you just have it out due to the overall time, but if you desire, you still may be able to avoid surgery.

 I am wondering what i should do next.

I was thinking orthopedic consult with view to removal because this has been such an ongoing saga for me that took forever to diagnose until i did the mri. The pain to me seems where the ganglion arises from the tendon sheath.
The thing that worried me is that both my podiatrist and radiologist injecting the cortisone seemed to not think my pain came from the ganglions (well believe me i'm not making it up!). Can you shed some light on what is going on in my foot and what i should do? Is that bony fragment anything??
Dr Blake's comment: I will try to make time to read the MRI (Dr Rich Blake 900 Hyde Street San Francisco, Ca 94109), but if the first shot into the ganglion eliminated the pain for a while that is a great sign the sesamoid is not the issue. Also, now that you have had 2 injections, how is your return to activity going?

Also i have a ganglion in my left foot too under the second proximal phalanx too (just because i felt similar pain there but much milder and got them to have a look.

I thought i was going crazy for so long because none of the podiatrists believed there was something there. I was relieved when i found the ganglions to explain the pain.
Dr Blake's comment: We doctors all function on some form of tunnel vision. What is never wrong is your body. Golden Rule of Foot: Listen to Your Body. You knew something was wrong, and it was. You have a body that heals and talks. It depends if what it says can be interpreted. 

Any advice and thoughts would be helpful because i cannot find much about ganglions under the MTPJ area anywhere except your blog (which is wonderful).
I have xray and MRI images available if required. I am not sure what to do next. Is removal the answer? Dr Blake: Maybe your best choice, and I can hear the frustration loud and clear in your words. 

Thank you if you have the time to respond,
Marie (name changed due to climate change)

Sunday, October 26, 2014

Soccer Cleats improved with Shock Absorbing Insoles (SAIs)

I have a pet peeve about soccer cleats for young kids. They are so poor at both support and shock absorption that kids seem to be always in some form of pain. This new article from the Journal of the American Podiatric Medicine Association links foot comfort to shock absorbing insoles when adding the extra stressful hard surface of Artificial Turf to the game of soccer. 

Tips for Breaking in Orthotic Devices

Tips for Breaking in Orthotic Devices

Breaking into full time wear of custom made functional foot orthotic devices should occur over a period of 10 to 14 days.

Picking Up Your New Orthotic Devices
On the day you pick up the orthotic devices, wear them for 1 hour if tolerated.  This hour should only include active walking or standing.  Do not count sitting time.  Therefore, 1 hour of orthotic wear may actually occur over 2 to 6 hours in real time.  If even 1 hour is difficult, attempt (2) 30 minute sessions, or (4) 15 minute sessions, with an hour off between the sessions. So much will depend prior use of orthotic devices, the amount of change of structure built into the design, the weakness of your intrinsic or extrinsic foot and ankle muscles needed to adapt to the change, and the nerve sensitivity or hypersensitivity to this new pressure sensation on the bottom of your foot.
The breaking in process continues by adding 1 more hour each day until you are up to 8 hours of wear by the 8th day.  Of course, due to many factors, it may take more than 8 days to build up to these 8 hours.  Once you are at 8 hours, you should be able to go as long as you desire on any given dayRunners should run 1 mile longer with the orthotic devices each day (starting at 1 mile on the first day).  Other athletic activities, like baseball, etc., should progress in 30 minute intervals daily (starting with 30 minutes the first day).
The doctor/therapist prescribing the orthotic device should dispense them, watch you walk and/or run, and attempt to make the devices stable and comfortable.  This is the perfect time to learn power lacing.  Power lacing is a must for orthotic devices. You can find my Youtube video at drblakeshealingsole power lacing in the search engine at Youtube.

Handling Discomfort
If you get discomfort anywhere (foot, ankle, knee, hip or back) while breaking in the device, immediately remove the device, and leave it out of your shoe for the next 2 hours.  If there is still time later in the day, you can try to re-wear them if you have not met your time allotment.
It is important during the adjustment period to always have the regular shoe inserts with you in case you have to take out your Orthotic devices for this 2 hour period. The accommodation period is partially for foot comfort, but mainly for knee, hip, and back adjustment to the new positioning of the body and the new use of many muscle groups. Plus, there can be a sensitive area in your knee,  etc, that we will find only by placing a new pressure on it. Lucky us!!

Golden Rule of Foot: Always blame any new ache or pain on the new Orthotic devices.  Never push through any pain.  The breaking in process must be pain free.

Adjustments May Be Necessary
Normally, patients are told to get used to the orthotic devices and to return in 6 weeks. I love when they bring in some old and new shoes to check how the inserts fit and function in gait. However, 30% of patients return to the office in 2 weeks or so since they are having some problem with the devices.
Adjustments are normally routine, and part of normal office visits.  Occasionally, the orthotic devices or impression molds must be returned to the laboratory for further fine-tuning. Sometimes I can predict which patients are going to need adjustments, and sometimes I can not. It is common to recommend different shoes at times, and there may be problems with fit. Many patients need an intermediary pair of orthotic devices, before the final pair is made, since the correction needed is too severe.
The prescribing practitioner may use his/her judgment in allowing some discomfort, if further adjustments may lead to loss of stability.

Wearing Socks 
Wear socks with orthotic devices if the devices have no smooth top cover.  Some practitioners dispense only the plastic device.

Squeaking Orthotic Devices
If the devices squeak with certain shoes, remove the orthotic device from the shoe and apply powder (any type, although corn starch is the best) to the inside of the shoe.  Rub the powder along the sides of the inner liner where the orthotic device will be in contact with the shoe.  This normally takes care of the squeaking for several months.  Some of my patients slip hose (thin nylon) over the orthotic devices which accomplish the same function. Others spray a silicon based sealant or rub on Body Glide.
When the orthotic device has a top cover, occasionally a noise will be created from an air pocket developing under the material at the heel.  Carefully pull up the top cover if possible in the heel area.  Use Barge cement to initially glue both sides needing glue.  Let air dry for 15 minutes.  Then apply ample dabs of Superglue or one of its knockoffs to the bottom of the heel and the side walls.  Place the top cover back down, and hold for one minute to let the top cover reattach.

Maintenance Routine
When given orthotic devices with a top cover, it is helpful to check the device bimonthly to reattach any loose sections with Superglue with or without Barge cement.  The practitioner may not tightly attach the top cover initially since multiple adjustments for improved function and comfort may be necessary. Monthly application of foot powder to the top of the orthotics and inside of the shoes utilized and biweekly removing the inserts from the shoes can prevent fungus from colonizing.   
If the shoe utilized has a removable insert, and that insert has some form to it, remove it completely.  You want the orthotic device to sit down in the shoe as low as possible for stability.  However, if you need more padding, apply a thin insole to the full foot or just the forefoot (like those sold in Dr. Scholl’s foot care areas of pharmacies or Spenco product in athletic stores). 

Dress Shoe Orthotic Devices
When receiving dress orthotic devices, you need some short insoles for the front of the shoe in order to hold your foot from slipping out of the heel in some shoes.  The orthotic device itself should not be wider than the shoe because this pushes the shoe away from your foot.
Dress orthotic devices normally require little time to get used to, so breaking it in is quick.  However, listen to your body and remove the orthotic device for at least 2 hours if you have any discomfort.  If you find that you need to grip with your toes in order to hold the shoes on with the inserts, more front padding must be used, or you just can not use this shoe.