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Thursday, December 31, 2015

Happy New Year!!!

Dear Dr. Blake,

Knowing that we are now published poets,
has served me quite well,
wouldn't you just know it,
I've another poem yet to tell!

"Ode to the Podiatrist & A Happy New Year!"

January 1st is coming,
kicking off another year,
may your feet keep you walking, running,
and joy produce your only tear,

Healthy feet are a treasure,
both right and left,
they have you dance with good measure,
while carrying your heft,

Ode to the great Podiatrist,
who keeps them healthy and strong,
this warm gratitude you can't miss,
for it would just be all wrong,

Stand tall as tree,
but never forget,
your healthy feet support thee,
Here's to the Best Year Yet!

Happy New Year Dr. Blake!  I hope you and your family have a wonderful 2016.


Please enjoy Adele's new song: Water Under the Bridge

Sunday, December 27, 2015

Accessory Navicular: Email Advice

Hi Dr Blake!

I'm a young adult with flat feet, extreme high arch and accessory navicular.
It all started 6 years ago when I had pain right at the extra bone. I did ballet at the time and soon after, the pain was unbearable to the point of sharp pain at the bone every step I took. At that time, my treatment was icing, taping, ankle guards, orthotics and pain killers everyday. I even had 3 sessions of physiotherapy every week for 2 years. I experienced numerous ankle sprains through walking in a day where my feet either sprains inwards or outwards (even while wearing ankle guards and orthotics) and was literally unable to run. I even tried chinese healing to reduce the swelling. It got to the point where I'm  so used to the pain because I experience it with  every step i took. I saw an orthopedic surgeon who failed to pick up the accessory navicular problem and thus did nothing with it.
Dr Blake's comment: High Arch feet when unstable can be extremely difficult to treat and need an expert in making podiatric custom orthotic devices. 

I stopped ballet 2 years ago and the pain at the bone got better. I stopped wearing ankle guards a year ago. I've been on orthotics and very expensive arch support shoes for 5 years (24/7) but I notice that my ankle still severely slops/falls inward when walking. There is also some pain involved. So I'm  wondering if it's  time to consider surgery if this is a problem that may continue for the next 40 to 50 years.
Dr Blake's comment: Glad you are feeling better. Yes, surgery to remove the accessory navicular should be an option to give you a stronger arch. But, it is complicated, and requires that you find several surgeons and get their opinions on whether it will help you. I am hopeful you are doing a daily home strengthening program for your arch, especially the posterior tibial tendon. Also, if you have a complication with the surgery, is that a risk you are willing to take? 

Lastly, Sorry for the long question and i appreciate  your time taken to read and answer my question.
Thanks and Regards,

Thursday, December 24, 2015

A Podiatry Christmas Poem

 'Twas the eve before Christmas
and Dawn took a look,
she took a look at her cold bare foot,

You see, the stockings had been hung by the chimney with care
and this made Dawn's foot to be chilly and bare!

Alas, the report she sent Santa, Doc Blake and all,
was that her foot was healed, heel, toe and all!

Dear Dr. Blake:

Merry Christmas to you.  You had asked me to send you an update in December.  This might not be in the format you expected....but none the less the foot is fine.  Thank you so much for your excellent care.

Dr Blake's Christmas Response:

Thank you so very much Dawn
As I am watching the rain green up my Lawn
Thank you so very much Dawn
This poem will surely make you Yawn

Your great news brought tears to my eyes
I could tell that they weren't mere lies
And for this I will take note and Rise
Yet, I know with your feet, this is probably not goodbyes.

Love, Rich

Wednesday, December 23, 2015

Possible Hypermobility Problem: Email Advice

This was an email I just received as I am catching up on emails as a Christmas present to myself (sick I know, but somehow therapeutic to my soul). Merry Christmas and Happy Holidays to all my readers. Rich

Dr. Blake: 
I was on the and saw your comment on the hypermobility of the first ray joint. 
I have bilateral foot pain for many years.  My left foot has the hypermobility more so than the right.  I have a bunion on the left.  I have had many orthotics made within six years none of them really helping.  The first podiatrist I went to in 2007, made this huge orthotics and made me wear motion control sneakers with them.  I was told that my feet were not to move in the sneakers, I feel this was a big mistake.  Perhaps this made the problem worse.  I never had this problem until I started wearing orthotics.  I also have a problem with my left hip (weak hip, core and pelvic).  My gait has is really off. 
It was not until last year when I visited an orthopedic doctor who said I have a lot of hypermobility in the forefoot and that my ligaments and tendons are too weak to support my weight.  After visiting at least six podiatrists, not one of them ever mentioned this problem with my feet.  The orthopedic doctor wants to fuse the bones in my feet.  After getting a second opinion from another orthopedic (Mass General) who said absolutely no to the fusing and not knowing how to help.  I really don’t know what to do.  My feet literally throb from pain and I feel as I am grasping the ground and my big toe joints hurt so much as they are being pounded into the ground.  I have been everywhere looking for help and cannot get the help I need.  I visited a foot doctor in Worcester and he could not figure out what to do, except offer me another pair of orthotics, but he never mentioned the hypermobility of the first ray joint. 
I have been on Dr. McClanahan’s site and purchased a pair of correct toes and have followed him on getting out of orthotics and going to minimal shoes and exercising my feet.  My feet are in so much pain from exercising and they are not getting any better.  I am so discouraged and just cannot believe no one can help. 
I was wondering if you would know of any foot doctor in the Boston area who would have been the expertise to helping me get out of pain without surgery or orthotics. 
May I ask you would strengthening the feet help with the hypermobility or am I wasting my time.  My lower legs, calves hurt so much, I have been told that the certain muscles are not functioning, as well as my glutes.  From being an athletic person to not being able to walk without pain is very discouraging.
I would appreciate if you could possible help finding a doctor who could help. 
Thank you. 

Dr Blake's response: 
     Thank you so very much for your email and I am very sorry for your struggles. There are many types of hypermobility, from mild to severe, from static to functional. Sounds like you have a severe case, although at times mild cases just spin out of control. Typically when rehabing a patient with hypermobility you find you need longer immobilization, longer periods of re-strengthening, and it takes longer to return to activity. It is a careful balance. Not too many podiatrists or orthopods believe that hypermobile patients should go without orthotics and learn ways of joint taping or splinting that helps. I have never had a hypermobile patient had a joint fused, and I am not sure what that would do to the stresses on all the other joints in the lower extremity. I would find a local PT who deals with Ehlers Danlos patients to help you first, and they may have a suitable podiatrist for you. To me, orthotics devices are crucial, although not with motion control shoes. You should see if by orthotic devices, activity modifications, anti-inflammatory measures, and perhaps assistive aids, you can re-establish a pain free environment of 0-2 pain levels. Then, spend the next year getting your feet stronger, not be walking in minimalist shoegear, but by a calculated home/gym strengthening program done daily under the instructions of the PT. I sure hope this helps you. Rich

Big Toe Joint Splint for Hallux Rigidus/Limitus Pain

Recently a patient was getting some considerable amount of pain relief with this device for her Hallux Rigidus pain. Hope it helps some of you. Rich 

Hi Dr. Blake
Thanks for working with me this afternoon!   I am looking forward to have better working feet! 

Here is the info about the toe guard.  This is the one I ordered from amazon.

here is the company ..they have  a variety of items.  EVOSHIELD

take good care and have a happy new year!

Sunday, November 22, 2015

Sesamoid Injury: Email Advice

Dear Dr Richard Blake,

I have been experiencing pain for about the last 12 months. I have recently seen a podiatrist who referred me onto an orthopaedic surgeon. They have determined that I have a fractured sesamoid but are sending me for an MRI to confirm (Plain x-rays show an abnormal appearance of this lateral sesamoid, which is lying in two pieces. The fragments are not rounded which tends to suggest that it is not a typical bipartite sesamoid.). I do not know a cause of a potential fracture and cannot remember injuring it at any point. There is no swelling around the joint. When I have a couple of days where I am not too active the pain relieves itself and only hurts when pressure is applied such as going on tiptoes or bending my toe back when walking. When I have been on my feet quite a bit it gets quite painful. My doctor has suggested that I try a steroid injection and possible excision of the inflamed sesamoid fragment. I am a bit worried about having surgery on it as I have heard it can cause even more problems and pain. My question is, as this happened over a year ago is this too late to try relieving pressure and hoping that the fracture would heal itself, or is surgery the only option? What would you suggest in this situation?

Apologies for the question but I would be really grateful for your help as I am quite worried about the whole situation.

Kind regards and thank you,

Dr Blake's comment: Definitely get the MRI and see what it says. You can always start the 3 month removable boot Immobilization even after a year. If you have a possible fracture, definitely no steroid injections. With no swelling, you either do not have a fracture, or the fracture is pretty healed. I know that patients can have pain for many months after the complete healing, since they still have to walk on it. Check out all the many treatments for this conservatively. Hope this helps. Rich

Monday, November 16, 2015

Sesamoid Fracture: Email Advice

Dear Dr. Richard Blake,

First I would like to express my gratitude: you have been very special by sharing your knowledge, by motivating, and by being very clear to all of us who live far from you.  

Let me try to be concise with the injury: After 2.5 months under small and constant pain, I got both X-Ray and MRI to check that out following doctor's prescription:  "Vertical fracture line in the medial sesamoid in its central portion.  Associated with edema and inflammatory process, probably from stress.  No evidence of Avascular necrosis".  I believe it happened due to a combination of factors, first bumped my foot while bicycling, then overused it while climbing with a tiny climbing shoes, and from there on just wearing cowboy boots and all that... I got the diagnosis 2 weeks ago and so far I have been doing all what the doctor prescribed to a conservative treatment.      

I have 4 questions that hopefully will also help the understanding of many  readers/patients:

1) A lot of us have been wearing boots, cast, or even orthopedics pads, so the question is, what about the baruk shoe, don't you think it may be a better option to avoid the contact of the ball of our foot on the ground?  What about if I get to be on wheel chair for 1-2 months to avoid the contact of the entire foot, wouldn't that be good idea to heal the bone faster? I attached a picture of the baruk shoe then you could gently share with your readers.
Dr Blake's comment: Thank you very much for this comment. I am very much into weight bearing for swelling reduction and bone mineralization, but there is a place in the course of treatment for the Baruk shoe or Darco Orthowedge to totally off weight the area at times. It is all about maintaining the 0-2 pain level. I believe in weight bearing an injury for the bone and muscle strength, along with swelling reduction.

2) Do you think swimming can be a good exercise to release tension as well as to enhance blood flow in the area?
Dr Blake's comment: Definitely, without pushing off the wall with the injured foot. 

3) Do you think warm/cold contrast bath can be good?  If yes, how would you propose us to do: how many minutes in each warm/cold bath, and how many times in total in each session? Dr Blake: see link below.

4) We know each one of us has a unique injury, where healing time will be processed differently due to many factors, but if we take an average, how long would take to heal from a general stress fracture? 
Dr Blake's comment: 8-12 weeks to allow the fracture to heal, and another 3-6 months to remove the nerve sensitivity and swelling. Some depends on whether you have to walk on the fracture area which definitely increases the symptom longevity. 

 More than that, do you think we can really get healed without surgery?  It seems impossible to find a successful story, making me very sad.
Dr Blake's comment: Sesamoids heal 95% of the time. Good odds. I really need to push my patients who get well to tell their stories. Only 1 in 20 go on to surgery. 

I wanted to thank you in advance for your help, and coming to the Bay I will make sure to get an appointment with you.


Thursday, November 12, 2015

Plantar Heel Bursitis: Email Advice

Hi there, 

After seeing your video "Physical Examination of Heel Pain" and reading your "Plantar Heel Bursitis: General Treatment Thoughts", I strongly believe this is what I am suffering from and wanted to get your advice.
I have suffered from heel pain in both heels for around 4 years now, and it has gotten worse over time. My pain is directly under the heel and I can feel some sort of lump that can be moved by pressing it. I have been to 2 different podiatrists, they both told me I have plantar fasciitis without really checking anything or asking any questions. I had 2 different custom orthotics made and modified many times as well as having tried many many insoles. None of that helped. I tried the recommended stretching, icing etc, didn't help. I also had shockwave therapy done, didn't help. Then I had an x-ray and dignostic ultrasound done and they didnt show anything, but I was recommended to go to physiotherapy. I went to physio and they did several things including manual therapy, more shockwave, laser therapy, etc. None of that helped. Then I went to my doctor who referred me to a specialist who sent me for MRI, which again showed nothing. Now I am taking NSAID's which dont seem to be helping. The specialist also assumed I have plantar fasciitis and when I asked about infracalcaneal bursiitis she didnt seem to know what that was and said "there's no bursa under the heel."
She was going to give me corisone injections after I asked for it, but I ended up changing my mind and not getting it since if I really do have bursiitis, then perhaps the injection should be put in a different place?

Theres a few reasons I think I have bursitis and not fasciitis:

1) My pain is directly under the heel and not where the plantar fascia attaches.
2) There is a noticeable lump under each heel that can be felt and moved with pressure.
3) My pain isn't in the morning but hurts after being on my feet for some time and gets worse the longer I stand.
4) None of the usual plantar fasciitis treatments have helped at all or only very little.

So the issue i'm faced with now is that I can't seem to find any practitioner in my area that is familiar with bursitis or even knows what it is in order to tell me whether I have that or not. None of the doctors I've seen have even seemed to be sure if I have plantar fasciitis or not. I'm wondering if I should just go ahead with the cortisone shots even if the doctor is giving me shots thinking it's plantar fasciitis or should I try to find someone who can diagnose me first?

I live in Toronto so if you know anyone in the area that you could recommend that would be greatly appreciated. Or if you have any other advice that would be great.

Dr Blake's response: 
     I am so sorry. Plantar heel, or infracalcaneal, bursitis is extremely common in sports. You have described the place and symptoms perfectly. I typically design an insert to transfer weight to the arch and soften the heel. Yet, I can use OTC inserts, especially Sole or Powerstep, and with a little modifications get this weight transferrance to work. Then, I start the patient doing rolling ice massage 5 minutes with a frozen sports bottle twice daily. If after 2 weeks progress is not being made, 2 times per week PT of Ultrasound, deep friction massage, and EGS with ice is started. Cupping recently has been added to my protocol. The PTs are told to focus on the bursitis, which everyone can feel, and nothing else. If they are not causing the bursa to shrink, I will definitely start the first of 3 cortisone shots (some only need one or two). I use a mixture of 1 ml of 0.5% Sensorcaine and l ml of Kenolog 10. You need to stay away from the plantar fascia attachments and the skin. Each part of this treatment can be essential, so I rarely break that routine. Hope this helps you. See the docs in Toronto from my beloved AAPSM.

Tuesday, November 10, 2015

Sesamoid Injury Prolonged Swelling Post Healing: Email Advice

Hi Dr. Blake,

I saw your blog and I am praying you could help me.  I've been suffering from a sesamoid fracture for about 10 months now and I believe I need some guidance as my local podiatrist has not been much help.  I have not had pain my foot for over 7 months, but I have a HUGE issue with swelling.  I have decided to try non-weight bearing for 4 weeks, and I feel the foot has not improved.  Simple trips to the kitchen, or bathroom in crutches agitates and causes my foot to swell and feel uncomfortable.  I see that in your post you talk about actually walking and rehabilitating it and I never thought of that.  An MRI was performed and the bone seems to have healed, but I still get inflammation constantly.  I'm prescribed 500mg of Nabumetone twice a day, but that doesn't seem to help either.  I'm wondering if I should try to rehabilitate my foot by walking in an air cast, or some other method or not. If so, I was hoping you could point me in the direction or create a recovery schedule.  Any help would be much appreciated.  This injury has spun me into depression since I do not see any light at the end of the tunnel, and I am in fear I'll never be able to walk normally again. I hope to hear from you soon with any guidance or suggestions. Thank you.

Dr Blake's response:
     This is not that unusual, but surely very frustrating. There are many reasons that this can occur which can point us to the appropriate treatment. First of all, non weight bearing increases swelling, weight bearing without pain decreases swelling. So, you need to be walking, within reason, to help more the swelling out of the area. Secondly, prolonged nerve hypersensitivity can cause swelling (sympathetic overload). So add massage, as deep as you can comfortably, of arnica, NeuroEze, biofreeze, etc three times daily for 10 minutes to move the swelling. Massage always from the sesamoid area back into the arch (towards the heart). Get some Tubigrip, typically size B or C, from the PTs, and wear 24/7, from the toes to just above the ankle bones. Too high can actually cut off the circulation. Every hour pump your ankles up and down, and wiggle your toes, 10 times to move swelling. Never have your fee on the ground, even small amounts of elevation can really help if consistent. Once a day do a full 20 minute contrast bath, and after drying off your feet, put on the Tubigrip and lay on the ground, placing the foot up on the wall or a couch. For the next 20 minutes, do repeated ankle pumps, 3 every minute, to get the fluid out of the tissue. Let me know in one month how this is going. Rich

Sesamoid Injury in Ballet Dancer: Email Advice

Good afternoon, Dr. Blake,

I noticed you helpfully answered a question regarding a young dancer a couple of weeks ago, and I'm hoping you can shed some light on my daughter's situation, as well.

My daughter is a 16-year-old classical ballet dancer at the pre-professional level. She dances 5 days a week, between 3 and 6.5 hours a day (depending upon the day). About half of this dance time is done en pointe. She is hypermobile with flexible pes planus (diagnosed around age 11 by a pediatric orthopedist), and has developed very strong feet and high arches through dance.

About four weeks ago she developed mild pain beneath her big toe on one foot, but kept dancing because it wasn't bothersome to her. One evening it suddenly reached a level where she could not dance on it. Through visits with a PT and to a orthopedist/foot & ankle specialist who treats dancers, and after a normal Xray, she was diagnosed with sesamoiditis. We placed a dancer's pad on an orthotic within a solid running shoe. After two weeks off and ultrasound therapy, she was beginning to make great progress--no pointe work and no jumping, but a gradual easing back in to barre and center exercises.

Last week she had a couple of great nights and was pain-free (still no pointe or jumping), taking things carefully during her classes. She was instructed that she could dance if the pain was below a 3, and she followed those instructions. That night she iced and elevated her foot preventively but did not have pain.

Apparently that was too much. The next morning, she woke up and had visible swelling and pain upon walking. It was like she was back to square one, or even square zero. We went back to the orthopedist, who confirmed her diagnosis but ordered an MRI just to be safe. She is now on crutches until she can walk without pain and will have the MRI at the end of the week.

Though I know it's impossible to predict the healing process, I wonder if you can recommend any practices or products beyond PT and ultrasound that might promote healing. She has numerous performances coming up, which we realize she will probably miss, and very important auditions for summer and year-round programs in January. Needless to say this is causing her a great deal of anxiety.

She has never been injured before, and there was no one event or accident (such as a hard landing) that triggered this pain. The only contributing factor may be walking about 2 miles from school after a switch in shoes--she had been wearing Birkenstocks in the warm weather, then switched to a less-supportive boot (with no orthotic, yipes!) about a week before the pain began.

Thank you for any light you can shed on this frustrating condition, and for your blog. I'm glad I found you!

Dr Blake's response:
     I am happy to help. It sounds like you did everything right. Definitely from this point on when dancing she should have dancer's pads and some medial Hapad arch support, and when not dancing orthotics with dancer's pads. Keeping her dance shoes as stiff in the arch also helps. She should be icing for 10 minutes twice daily, and do the full 20 minute contrast bath as a deep flush every evening. Glad the xrays were negative, so we will see what the MRI shows. I would rather she in a walking boot with orthotic/dancer's pad, than non weightbearing, since no weight bearing always increases the swelling. She should be massaging the tissue 3 times daily to de sensitize the nerves that can get real protective, also adding to the pain. And, there is always more of that with the first injury a dancer's has, especially one that may interfere with career goals. Use arnica, biofreeze, etc to help with the massage. Of course, any bone injury needs bone strength, so make sure dietary or supplement she gets 1500 mg calcium and 1000 units of Vit D. Have her continue to do floor and barre exercises, figuring out what she can or can not do this week, testing weekly if she can add to the routines. Center work can do be done when she can walk comfortably and initially avoid jumps. Releves can be so much more stressful, than actual pointe work, thus barre workouts can help us know what she can or can not do. Since there can be a stress fracture, avoid ultrasound treatments with a passion right now. Hope this helps some. Rich

Prolotherapy for Achilles, Plantar Fascia, and Osgood Schlatters Article

Thursday, November 5, 2015

Chronic Forefoot Nerve Pain: Email Advice

After baffling yet another Doc with my condition, I returned to the internet in search of a sport medicine podiatrist and came across your blog.
If you could offer any advice I would certainly be grateful. My situation is as follows (if you are able to help I can provide more detail J):

·        57 year old male – was active and in good health.
·        While recovering from bilateral quad tendon issues I injured both forefeet in 2012 while hiking for 2 days in a caved area with stairs and slopes. To protect the quads I went up many, many stairs using my feet and calves (think of it as doing 4,000 calf raises).
·        Result was bilateral stinging pain on the balls of the feet, the metatarsal marble sensation and sharper pain with dorsiflexion of 2 and to a lesser extent 3 and 4. No issue with great toes. And no foot issues whatsoever prior to hiking.
·        Upper body issues have been ruled out – very confident on that.
·        Failed treatments over 3 years have included: cortisone shots, orthotics, regrettably a right foot bunionectomy and shortening osteotomy on 2 along with pinning 3. Did PT and then was sent to a pain clinic. Next Doc focused on the left foot and performed a 2/3 neurectomy. No relief and told cannot treat if cannot diagnose.  Indicated I had no serious issues such as cancer, etc.
·        Current status is broad ball of foot stinging sensation that escalates with use (now constant), marble sensation on metatarsal heads (left 2 and 4; right 4), and toss in some stiffness and numbness from the surgeries! No swelling. No toe drifting on the left foot; slight pulling down of 3 on the right foot. Aggressive stretching = stinging, sometimes on a delayed basis – i.e. the next day.
·        I have had 3 MRI’s (generally unremarkable according to Docs, but may provide some insight) and 1 diagnostic ultrasound (identified micro tears on the plantar plate).
·        I have been wrestling this for 3 years and feel my condition is deteriorating while my activity level is very low.
·        I buy into your concept of getting to a 0-2 pain level and then progress from there – but could use assistance  developing a course of action.

If you are willing to help, I can get my hands on the MRIs and ultrasound reports or answer any questions you may have.

Thank you for considering my situation.

Dr Blake's response:
     Thank you so very much for your email. It sounds nerve related more than plantar plate, at least this would be the area to explore. Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):
  • Neural Flossing three times daily (find out if sitting or laying techniques more productive)
  • Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness,  so you would wait on this right now) etc 
  • Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
  • Heat over ice
  • No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
  • Oral meds (start with evening doses only of Lyrica, Neurotin, or Cymbalta). 
  • Epidural injections into L5 nerve root
  • Soft based orthotic devices like Hannafords
  • See if there is a Calmare Pain Therapy center near you 
  • Sometimes TENS and Capsacin is helpful (but you have to go through 14-20 days of more pain first)
Hope this points you in the right direction. Rich

Wednesday, October 28, 2015

Sesamoid Fracture in Dancer: Email Advice

Hi Dr. Blake,

My daughter is 11 years old.  She's been a dancer for 6 years, 4 years competitively.  This year, she enrolled in a more intense program that includes, per week: 5 hours of ballet + 9 hours of other classes (strength and stretch, hip hop, tap, Lyrical, Acro, competitive dance routing practice).  This year also involved a new studio with new floors.

A few days after an intense weekend of dance "turns" with an out of town choreographer, she said the ball of her foot hurt.  Then next day, she was walking on the side of her foot.

So, that evening we took her to a podiatrist (orthopedic surgeon).  He felt her foot, took x-rays, one of the injured (right) foot which showed a separation of the sesamoid bone.  He then took an x-ray of the left foot to compare it against the right one to see if it might be a bipartite sesamoid.  The left foot was normal.  This was on a Tuesday.  He said he wanted an MRI done on the affected foot because .  He asked her if she wanted a hard shoe they had on hand and told her that crutches would be useful.  He also told us that our daughter might never dance again.
Dr Blake's comment: There is no place for this comment in that situation!! I apologize from the rest of the medical profession. 

It wasn't until 11 days later that our daughter had her MRI and 14 days after this initial consultation that we got the MRI results.  Also, since the 6th day of her pain, she has had no pain.
Dr Blake's comment: Good starting taking such a short time to get in pain free. Now, you have to keep it between 0-2 pain as you gradually work her back. 


Osseous structures and articulations:
There is a linear low signal extending transversely through the medial/tibial sesamoid at the first MTP join (sagittal images 4 and axial series 7 image 15).  There is mild adjacent bone edema.  This has the MRI appearance of a subacute or chronic sesamoid fracture.  There is no significant separation of the fragments.  There is also a mild edema involving the lateral sesamoid at the first MTP joint.  There is a small first MTP joint effusion.  The other regional bones and joints are normal.  The Lisfranc ligament complex is normal.  The MTP joint plantar plates are intact including the great toe plantar plate complex.

Muscles & Tendons:
The regional muscles and tendons are normal.  The visualized portions of the planar fascia are normal.

The regional neurovascular structures are unremarkable.  No regional soft tissue masses.

The day we got the MRI results (I went to pick them up in addition to the results sent to the initial doctor), I decided the take my daughter to a pediatric orthopedic surgeon.  This doctor did not see the MRI images (due to insufficient time between the time I gave them the CD and the time of our appointment - minute apart) but he read the report noted above.  He took x-rays as well.

He could not conclude that there was a stress fracture, a fracture-fracture, sesamoiditis...).  He put her in a long walking boot and told her she didn't need crutches.  He also sent us to get carbon fiber shoe inserts for when she eventually transitions into shoes.  He scheduled an appointment in 3 weeks to take more x-rays to see what changes have occurred, if any.
Dr Blake's comment: So the MRI showed stress to the sesamoids with bone reaction (edema). You have to treat it as a small stress fracture (worse case scenario), even though it could be a bone bruise with sesamoiditis. Conservative protocol would be to immobilize with the walking boot for 6-8 weeks, and then take 6-8 weeks weaning from the boot into normal shoes (hopefully with orthotics and dancer's pads). Since it is a removable boot, she should do contrast bathing (see other posts)daily to flush out the deep swelling in the bone and in the joint. 

So, I have questions...

1) What is a chronic sesamoid fracture?
Dr Blake's comment: As a sesamoid heals, it can look like your daughters for a long time, with some swelling (healing response). It is about timing. A chronic sesamoid fracture would be at least a year old or so. A subacute stress fracture signifies that the acute phase is over, or never happened. It can look like that between 6-9 months or so, so just after a bone bruise that never broke. This is what I hope she has. 

2) Do you think based on the MRI report that she has a stress fracture, a subacute fracture, a chronic sesamoid fracture?  Are MRIs 100% conclusive?
Dr Blake's comment: Based on what you have said, she either has a small stress fracture (which can get worse if not protected) or just a bone bruise (sesamoiditis). She is not in the subacute or chronic stages yet. 

3) Is there any way that she could really have bipartite sesamoid with sesamoiditis?  (Wishful thinking, as this seems the least problematic.)
Dr Blake's comment: This happens all the time, so why not now.

4) Is it correct that our daughter wasn't put in a cast (totally immobilized)?  That she does't need crutches with her boot?  Is this the right course of action for any sesamoid issue?
Dr Blake's comment: No matter what any one says, you and your daughter need to do what it takes to create that 0-2 pain level. If that is not happening within the boot, someone has to build an accommodation or orthotic in the boot to create that. You definitely want to weight bear if you can create that pain free environment. Non weight bearing typically causes more pain, swelling, hypersensitivity, and bone demineralization. You use crutches initially if you can not obtain a 0-2 pain level without them. 
5) How long will the healing take?
Dr Blake's comment: So much depends on how fast she goes through the stages of normal rehabilitation. She needs to be pain free in the removable boot for minimum 2 weeks, then it is a minimum 2 weeks to go from boot to no boot (into shoes with dancer's pads minimally). Then 2 weeks to increase walking to all day, with floor bar all along this course. Then slowly 2-6 weeks getting back into shape with no increase in pain, etc. 

6) Is the fact that she's had no pain after the 6th day a good sign? GREAT!!!!!
7) Do children heal quicker than adults? 
Dr Blake's comment: Definitely, but have a poorer sense of good and bad pain, which can be a major issue. 
8) Do you think my daughter will dance again?
Dr Blake's comment: Yes, silly goose!!! I love that saying. Your job is to be her ombudsman, her protector, and make sure she is keeping this pain free, without walking on the outside of her foot, as she moves from this point on. 
9) Are there any questions I should ask the doctor?
Dr Blake's comment: Who will make her orthotics and dancer's pads? Can she go to physical therapy to help safely progress her through the rehabilitation? Can her pain and function progess allow her to avoid xrays (basically can she avoid xrays if they really do not show much and she is improving). 

Thank you, in advance, for your response. You are Welcome!! Good luck!!

Sunday, October 25, 2015

Soft Tissue Injury Treatment and Running Shoe Concepts: A Lecture for the California School of Podiatric Medicine

Soft Tissue Injury Management: 
20 Golden Rules of Foot

                                        by Richard Blake, DPM

1981   We each ran 125 miles during that week
I am the goofy one above the T.

Patients present to your office with various injuries. These injuries have many general principles of treatment that I will call Golden Rules of Foot. These are rules I live by. This particular lecture focuses on soft tissue injuries, including sprains, strains, contusions, bursitis, and nerve injuries.
General Definitions:
  • Sprain is an injury to a ligament
  1. First Degree: overstretching of ligament
  2. 2nd Degree: partial tearing of ligament (will see some ecchymosis/bruising)

  1. 3rd Degree: complete tear of ligament (sudden swelling, impressive bruising seen)

  • Strain is an injury to a muscle or tendon
  1. First Degree: over exertion or over stretch of the muscle or tendon
  2. 2nd Degree: partial tearing of the muscle or tendon
  3. 3rd Degree: complete tear of the muscle or tendon
  • Tendinitis vs Tendonitis: both acceptable spelling
  • Tendinitis vs Tendinosis: Tendinitis is inflammation of the tendon (first degree strain), whereas tendinosis means their is some injury to the tendon (osis means condition of) not inflammatory
  • Tenosynovitis is inflammation of the tendon sheath (peritendon)
  • Stenosis tenosynovitis means that there is scarring along the sheath interferring with normal tendon function

  • Contusion to direct trauma (single blow or multiple blows) to the body causing injury to skin minimally, and as deep as the bone and everything in between

  • Bursitis is inflammation of bursae that protect bony prominences like posterior heel, lateral hip, etc

  • Nerve injuries can be local to the foot or referred from above the foot or systemic like CRPS (complex regional pain syndrome aka RSD).
Patient with left foot CRPS!!

You also have acute injuries (like a sudden fall) and overuse injuries (from chronic repetitive motions) like most tendinitis.

Golden Rule of Foot #1: As you treat patients, listening to their stories, examining their injury, you should develop a checklist of treatments that could help them which include:
My Daughter In Law Clare in the San Francisco Marathon
  1. Activity Level Allowed
  2. Type of Anti-Inflammatory Measures Needed
  3. Appropriate Stretches
  4. Appropriate Strengthening Exercises
  5. Any Bracing Needed
  6. Dietary Help 
  7. Shoegear or other Equipment Changes
  8. Inserts to Purchase
  9. Need for Testing (x rays, etc)
  10. Followup Needed (office visit, email, telephone call)
  11. Logs to Keep (training, stretching routine)
Golden Rule of Foot #2: 98% of all sports medicine lower extremity injuries are non surgical. Therefore, your skill set in non surgical approaches to treatments should be developed.
What are 7 General principles in Stretching?

How do I pad the removable boot for a sesamoid injury?

What is the best shoe for a patient's problem?

Golden Rule of Foot #3: With each office visit, you make changes appropriate to your checklist, based on the patient's response.
  • Activity Level
  • Anti-Inflammatory
  • Stretching
  • Strengthening
  • Bracing
  • Shoe Inserts
  • Diet
  • Shoes and Equipment
  • Testing
  • Followup
  • Logs

Golden Rule of Foot #4: The 3 phases of injury rehabilitation that the patient goes through (sometimes in the wrong direction with 2 steps forward and 3 back) are:
  1. Immobilization/Anti-Inflammatory Phase
  2. Re-Strengthening Phase
  3. Return to Activity Phase
You may have to take an athlete 9 months post injury who keeps hurting him/herself and place them back into the Immobilization Phase. Many times athletes who come into your office seeking 2nd opinions have never been treated appropriately for the phase they were in. 

What are the common ways you strengthen a body part? The various categories of strengthening are:
  • Active Range of Motion (with or against gravity)
  • Isometric (no change in length of muscle)
  • Isotonic (weights--no change in amount of resistance)
  • Progressive Resistive Exercises--variations in resistance (therabands).
  • Functional Exercises--strengthening whole groups at once

Golden Rule of Foot #5: During the treatment of an injury, the athlete will exist within the 3 Phases of Rehabilitation at the same time, although primarily in one phase. The art world I love to dwell within.

Golden Rule of Foot #6: Any time you are treating a superficial soft tissue injury, remember that the true cause of pain can be deeper, or referred from elsewhere. 

This patient's Anterior Tibial Spasm was related to a bone spur in the front of the ankle.

Chronic Ankle Tendinitis (achilles, peroneal, etc) can be related to Cartilage issues
Bunion Pain can be related to arthritic spurs

Neuromas can be related to Low Back Issues
Heel Pain can be related stress fractures

So, always think deep or referred as you work on the soft tissue components. 

Golden Rule of Foot #7: There are 3 sources of pain that patients experience in an injury each with different treatments---mechanical, inflammatory, and neuropathic. Any injury can have all 3 components at one time, with one type primary. The primary source of pain may change during the course of treatment. Typically inflammatory pain is always treated, but mechanical and neuropathic pain ignored completely or inadequately treated. 

What are common treatments for each source of pain?

Golden Rule of Foot #8: For an Acute injury, think PRICE.

  • Protection 
  • Rest
  • Ice
  • Compression 
  • Elevation

PRICE is 5 individual components of treatment that must be changed or at least discussed with each visit.

  • Develop a Pain Free Environment (0-2 pain level)
  • How long is it needed? 
  • What is the best form?
  • Can strengthening be used to take it's place?
  • A 4 Letter Word for most of our patients
  • Develop a Pain Free Environment (0-2 pain level)
  • Activity Modification 
  • Keep up leg tone, core strength, cardio 
  • Typically 96 hours post injury ice alone
  • Then add heat in some form like contrast bathing
  • Continue icing after irritation of injury

  • As long as swelling remains (can be months)
  • Pressure greater towards toes and less as move up leg
  • Patient needs to be able to remove or loosen
  • As long as swelling remains
  • Does not have to be above heart
  • Ankle Pumps and Circles and Toe moving as long as not painful
  • Super Elevation with body on ground and foot up on couch (especially after contrast bathing) once daily

Golden Rule of Foot #9: With any injury whether in the acute phase, subacute phase, or chronic phase, always attempt a pain free environment while rehabing (0-2 pain levels). This is the level of pain that a patient can have and still heal. 

This is how you determine the amount of protection needed, activity levels recommended, the need for icing, NSAIDs, etc. This is crucial in your treatment and the patient may or may not want to follow this. 

Acute Injury: Just happened (PRICE initiated)
Subacute Injury: 2 weeks to 3 months (with active treatment and cause reversal initiation)
Chronic Injury: Over 3 months

Golden Rule fo Foot #10: Rehabilitation is a balance between 0-2 pain levels and a gradual increase in Activity Levels. 80% better is your initial goal in treatment of most injuries. 80% better means you are back to full pre-injury activity level, and you are keeping your pain level between 0-2. It can take 4 times longer to go from 80% to 100% than it took to go from injured to 80% better. 

Golden Rule of Foot #11: With any injury (even if surgically produced), it is crucial to move as much as possible (highest level of activity within 0-2 pain) and begin strengthening the area as soon as possible. Our knee surgeons typically have a muscle stimulation unit on the patient when they wake up in the recovery room. 

Golden Rule of Foot #12: For any injury, seek 3 causes from the obvious to the "I am a great podiatrist" less obvious. This crucial in all overuse injuries, and still very important in some acute injuries. 

Law of Parsimony: The most common cause of an injury is most likely the cause now.
  • Achilles Tendinitis--tight achilles/calf
  • Plantar Fasciitis--tight plantar fascia
  • Posterior Tibial Tendinitis--excessive pronation with arch collapse.
But constantly train yourself to look deeper!!! For example, a patient with a foot stress fracture doing an activity alittle more intense than normal. Initial cause of injury is overuse. You can stop looking. But, why a stress fracture vs tendinitis vs something else? 

Law of "Weakest Link in the Chain": If there is an abnormal overload to the body, the weakest link in the chain will complain first. If a patient who over does an activity breaks a bone, do not just blame it on overuse, look for reasons that they broke their bone vs not strain a tendon, and why that particular bone. I have typically found 4 or 5 reasons that an injury occurred and in helping those reasons can prevent further injuries in the future. 

What are some reasons that a runner who break their heel bone? Think in deeper and deeper layers.

Golden Rule of Foot #13: Podiatrists own the world of preventative sports medicine as we evaluate the causes of injuries, and make decisions to initiate cause reversals. 

Claim it!! But it takes time

How does a tight achilles give you metatarsalgia pain?
How does weak quads give you 4th or 5th metatarsal stress fractures?
How does excessive supination cause medial knee pain?
Which is more likely to cause achilles tendinitis: pronation without heel valgus or pronation with heel valgus?

Golden Rule of Foot #14: With any injury, look at the common mechanics involved for causality or aggravating factors. 
  • Achilles Tendinitis--too tight, too loose, excessive pronation
  • Plantar Fasciitis--too tight, excessive pronation
  • Tibial Stress Fractures--excessive shock, excessive pronation with tibial torque

Golden Rule of Foot #15: The 8 common mechanical causes or contributing factors in lower extremity injuries that can be seen in gait or sport specific evaluations are:
  1. Excessive Pronation
  2. Excessive Supination (also called Underpronation)
  3. Leg Length Discrepancy
  4. Poor Shock Absorption
  5. Tight Muscles
  6. Loose or Weak Muscles
  7. Improper Sport Specific Techniques
  8. Miscellaneous Gait Findings
As we perform gait evaluation, and technique evaluations for specific sports, we look for mechanical problems that may need to be corrected. 

Still working on understanding the mechanics of mud running!!

We need to make sure this ballerina stays in neutral and does not over pronate (winging) or over supinate (sickling)
Cycling is one of those repetitive motion activities that we can greatly influence with subtle mechanical changes.

And then add other causes of stress/overload on that tissue to the mix.

Golden Rule of Foot #16: Besides mechanical causes of injury, there are so many other causes of injury including:
  • Equipment Faults

  • Training Errors

  • Psychological Factors (ie. negative addiction, inability to appreciate correct pain levels, desire not to stop competing, etc)

  • Dietary
This is why it is typically easy to find 3 causes of any particular injury.

Golden Rule of Foot #17: KISS rules!! It is okay to start slow in most cases, but the patient has to be with you on this (and most are). So much depends on the level of pain the patient is experiencing when you see them. 


Golden Rule of Foot #18: For any treatment modality or area, develop expertise in treatments from Simple to Complex. 

Short Leg Treatment: Heel lifts to full length lifts to shoe additions

Orthotic Therapy: OTC to Custom Made to Speciality Orthotics

Anti-Inflammatory: Ice, NSAIDs, Contrast Baths to Physical Therapy, Oral Cortisone, Acupuncture

Golden Rule of Foot #19: Use the mnemonic BRISS for tendinitis treatment.
  • B----Biomechanics
  • R----Relative Rest
  • I-----Ice or Anti-Inflammatory
  • S----Stretching
  • S----Strengthening 
Golden Rule of Foot #20: Treat what you see as directly as possible (and be persistant)!!  
  • Swelling (work on reducing the swelling)
  • Ecchymosis (evaluate for tearing--2nd or 3rd degree injuries--an treat with immobilization and strengthening, along with soft tissue mobilization to reduce scarring
  • Stiffness (work on soft tissue and joint motions)
  • Hypermobility (work on strengthening with protection as needed for activities)
  • Gait Findings (Gait Evaluation is the key to understanding how the patient moves, and if there is problems with that movement)

The 2nd Part of this lecture is on Running and Running Shoes. Let us go to my power point presentations on these subjects.