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Wednesday, September 30, 2015

Sesamoiditis: Email Advice

Hi Dr. Blake,

I am so grateful to have found your blog about sesamoiditis. I have had it for three months and I've tried everything (complete rest, ice, anti-inflammatory, physio, acupuncture, custom orthotics, a boot, taping), and I've been five weeks non weight bearing completely. But I still have swelling and pain.
Dr Blake's comment: Any time someone mentions non weightbearing I know that the pain and swelling are going to last longer. When you go non weightbearing, the tissues swells much more, since weight bearing with every step pushes the fluid back towards the heart. Swelling is the body's way of healing, bringing in the right stuff, but it always brings in more swelling then it needs, and the non weight bearing does not allow you to get rid of it. 

I've decided to get a cortisone injection. The doctor said if I haven't had healing from all the rest yet, I need to take  the next step. 
Dr Blake's comment: Cortisone, without knowing what the tissue looks like on MRI is risky. One hopefully is fine to shrink swelling, and diagnostically should tell you if all the pain is actually coming from within the joint. 

My question is how long I should keep my foot off the ground after the shot (to prevent tendon rupture)?
Dr Blake's comment: As long as the joint is within the joint, there is no weight bearing restrictions. You can not run for 2 weeks!!!

Should I go weeks non weight bearing? 
Dr Blake's comment: As soon as you can stop non weight bearing the better, but that has to be your doctor's decision (and you of course). 

And how long before I do some gentle foot exercises? 
Dr Blake's comment: Typically, even if you are non weight bearing you can do met doming, Single leg balancing with shoes and orthotics, posterior tibial and peroneus longus therabands, and achilles stretches. Remember, if there is weight bearing and if the exercise puts too much weight on the injury, you can stand on 3 or 4 books next to each other, with a hole for the injured area. Hope that makes sense. For the achilles stretch, just putting the front of the foot off a 2 inch thick book works. 

When can I deep water pool run?
Dr Blake's comment: Now!

 I'm willing to rest completely for as long as it takes, as this has been the worst experience of my life. I'll do anything to heal. I'm just afraid that this shot is only going to be short lived. 
And in your opinion, is it true that some people never ever heal from sesmoiditis? 
Dr Blake's comment: No, I have never seen a patient not heal from sesamoiditis. I have seen injuries that were called sesamoiditis, but were something else that required surgery. That is why I would even self pay if you have to for an MRI for peace of mind to know exactly what your diagnosis is. 

Thank you in advance. I'm hoping I'll be one of the lucky ones to whon you are able to reply.
Dr Blake's comment: This was sent during my vacation to Spain, so I am 3 weeks late. I hope it still helps. Rich

Tuesday, September 29, 2015

2nd Metatarsal Pain: Email Advice

Hi Dr. Blake!

I'm so glad I stumbled upon your blog today and that you're taking
questions! I have what's been "officially diagnosed" as bursitis on
the top of my left foot at the second metatarsal head and am hoping
you can shed some light on treatment for this aside from
ultrasound-guided cortisone injection.

The backstory:

In July 2014 I suddenly developed pain btw the 2nd & 3rd metatarsals
on my left foot near the toes. I don't recall injuring my foot but I
had been wearing some "barefoot" sandals a lot and having some issues
with my foot sliding around in them, which caused a lot "gripping" of
the toes. (I had already spent many years "barefooting" without issue
in Vibram Five Fingers at this point, but had moved from TX to PA
about 8 months prior and spent a lot of time in slippers/shoes because
of the cold, so simply wearing a minimalist shoe was not the issue.)

My chiropractor did regular ART on my foot over several months but
there was no improvement, so he tried Graston. A few weeks after he
started trying Graston on my foot, in Oct 2014, the pain moved from
the inter-metatarsal area to the joint at the head of the 2nd
metatarsal. The pain became more severe, and by Thanksgiving 2014 I
was unable to walk.

X-rays were negative but MRI in early December 2014 showed a stress
reaction at the head of the second metatarsal as well as inflamed
bursa. I was put into a fracture boot and spent 4 months in it
full-time. I spent another 2.5 months transitioning out of the
fracture boot into running shoes. By June 2015 I was full-time in
running shoes, but still in pain.

Dr Blake's comment: So, my first question revolves around levels of pain from the initial injury to the fracture boot to the running shoes. As you transition, it is okay to keep the pain between 0-2 levels, but not allow greater than 2. 

MRI in June 2015 showed that the bone was 98% healed but there is
still bursitis at the head of the second metatarsal. Orthopedist
recommended ultrasound-guided cortisone injection to address it, which
I haven't done yet.
Dr Blake's comment: I agree with your resistance to cortisone as the bone was still healing. PTs can use transdermal (non injectable) cortisone to shrink the bursitis. The procedure is called Iontophoresis and you typically go 5 times in a 10 to max 14 day period. 

At the beginning of Sept 2015 I began to see a podiatrist for therapy
twice per week. He places the 2nd & 3rd toes in traction for 10 min,
followed by 10-15 min of electrical stimulation, and then tapes the
foot to support & relieve pain. The tape is kept on for a couple days
each time. I've been for this treatment 6 times over 4 weeks and have
experienced some improvement, but he tapes my foot differently every
time and the more recent times it hasn't been as helpful or has even
increased my pain.
Dr Blake's comment: It is more the traction and electrical stim that is helping the symptoms. 

His theory is that my issues stem from my feet being structurally
unsound and that if he figures out how to tape my foot to relieve pain
then I can get orthotics that will essentially do what the tape does
and then I'll be fine.
Dr Blake's comment: I have never been able to minick the support tape does to an insert. They are too different in approaches. However, if you were getting relief from just tape, you can be assured that this has a partial mechanical treatment. 

Side note about my feet: they are very, very flat. I had severe
bunions (& bunionettes) from childhood, which were surgically removed
16 years ago at age 21. Both my 1st & 5th metatarsals were broken in
both feet. The bunionectomies were Austin and the podiatrist says they
effectively shortened my 1st metatarsal, making the 2nd one too long
and setting me up for this bursitis issue. It's also worth noting that
on my other foot (the right foot) the bunion has been slowly starting
to come back over the last 3 years, and my big toe is drifting towards
the other toes. It bothers me because I have tightness in the arch and
between my 1st & 2nd toes, but it's not painful.
Dr Blake's comment: Flat feet in general place too much pressure on the 2nd metatarsal. If you add shortening bunion procedures, you have the perfect storm of getting a problem with the second toe or metatarsal. The secret to your rehabilitation is to design off weight bearing pads to float the 2nd met head, at least to give it less pressure. Have you tried simply marking the sore area with lipstick, transfering that spot to your shoe insert, cutting out that spot and perhaps even another layer. Then, adding a Hapad support just behind it (close to the arch).

So what do you think? Orthotics? Cortisone shot? Anything else I can
do/consider? I'm very frustrated because I haven't been able to walk
properly in over a year and am experiencing all kinds of other
hip/back issues now as a result. I'm only 37 and really want to be
active again!
Dr Blake's comment: I would work mainly on the mechanics as mentioned above. I would also get some Budin splints for some shoes. I would ice pack twice daily for 20 minutes. I would get the PT. Then, send some comments to this post. Hope this helps. Rich

Thank you for any insights or recommendations you can share!

Sunday, September 27, 2015

Chronic Ingrown Toenail: Email Correspondance Post Chemical Nail Root Procedure

One of my patients recently came in for a chronically ingrown toenail. He wanted a permanent fix, so I suggested he schedule for a chemical matrixectomy (where 2 applications of 89% phenol is used to kill the root (aka matrix) cells. 5 days before this email the procedure was performed, and I had emailed the patient to see how he was progressing. 

Patient's Response:

Thanks for the follow-up email, Dr. Blake.  I was just going to email you today!

My toe is doing great.  Outside of a little on the first day/night, I have had zero pain.  I also have had zero oozing, and virtually no bleeding.  In fact, the only blood I see is on the tip of the Q-Tip when I insert it at the base of the nail halfway thru the soakings.  And actually that little has even stopped, as I ran out of the Q-Tips you supplied, and now I am using regular store bought Q-Tips.  It seems to me that I could even stop the soakings, as I don’t see them adding anything?
Dr Blake's comment: I tell the patients to soak twice daily for one hour for 2 days, then twice daily for 30 minutes until they feel like the soreness is diminishing and healing going well, then once a day for 30 minutes for a minimum of 4 weeks (and it can be up to 6 weeks). The acid, which has been used to destroy the nail forming cells, produces dead tissue which the body needs to flush out. Keeping the wound open for the first couple weeks with Qtips or face cloth, prevents the hole from sealing over, and allows the bad stuff to come out. 

In fact, my ONLY concern is if the wound has “closed up” or “scabbed up” (mentioned sometimes happens), and so the needed discharge is not happening.  Does that seem possible/probable given the info above plus the two pictures?
Dr Blake's comment: You photo below looks like the wound is really open well. Good job with the Qtip!!

Let me know if I should continue with the soakings, the Q-Tip “gentle jabbing” (with slight pain), and/or the antibiotic with band-aid – and if so, for how much longer?

Thank you again!

Typically after all this soaking and covering, the wound needs to be less macerated with 50% air exposure. As soon as you are home for good, soak for the 30 minutes, then dry off and leave open to the air all night until the next morning. Oxygen (air) is a great healer.

Dr Blake's comment: 

     You are definitely looking good. Continue once a day 30 minute soaking to continue to pull  out. You do not need the q tip, but each day after you bath, take a face cloth or piece of gauze and gently scrub the wound placing pressure on the nail border and then wiping outwards away from the nail for 30 seconds. Makes sense?? Send me more pictures in 2 weeks. During the day, topical antibiotic and bandaid. During the evening 12 hours, expose to air. Great healing!!! Rich

Saturday, September 26, 2015

Ankle Snapping: Email Correspondence

Dear Dr. Blake,

How fabulous you are taking questions again! Just my wonderful luck and timing! Thank you!
Dr Blake's comment: I am hopeful to be more consistent now. I have had a wild year with my dad passing and my mom living with my wife and I part time. It has been great to have this time with my mom. I thank everyone for their patience, and I apologize to those I could never answer back. 

Peroneal subluxation. I’ve been scouring your blog looking for info on this. At this point I am self diagnosing (I know, I know) but with my myriad ankle issues I’ve read a lot of information over the years about different ankle esque conditions. I am now 43 years old, still very active. My left foot had the lovely sesamoid fracture which occurred at age 39 I believe. It appears to be fine now but a good year of healing and more time of tenderness ensued. Then I’ve dealt with a 20 + year ankle fracture that occurred during a hard sprain (I thought) while snowboarding. My outer ankle (again left foot) continues on with the multiple fragments hanging out in my subtalor joint. I’ve chosen to forgo surgery since I really have a few occasions a year of periodic swelling and pain.

So today I am writing on behalf of my right foot. Until now I’ve really had no issues with it but am realizing now it’s been taking up serious slack for my left foot. Here’s what’s happening.

I significantly ramped up my yoga routine over the last 8 months and I’ve done a lot of hiking over the summer. A lot of several hour jaunts up steep, very fast elevation gains. Since the trails are fairly smooth and clear with just some uneven areas I just wear Keen brand waterproof lace up low top shoes. Not a ton of support but it’s a nice low shoe that doesn’t bother my left ankle issues and seems to serve well in many trail conditions. Overall comfortable and semi supportive I guess. Have practiced yoga for 20 + years and the yoga I do is fairly strong, vinyasa flow. Lots of odd angles and pressure on the outer ankles doing pyramids, side angles, balancing poses on one foot, warrior I’s etc. etc. Yoga as much as I love it can be oh so hard on ankles and notice more and more pressures/sensitivities while doing it (left ankle is speaking of some Achilles issues at the moment..will save that for another day).

So about mid summer I began to notice this ‘snapping’ happening on the exterior of my right outer ankle, going up my leg a few inches. When I place my fingers over the area and rotate my foot clockwise I feel a band or bands shifting side to side (more over the back portion of the ankle bone). The snapping is especially noticeable climbing steps or hills or pushing off to the left in a side step motion with pressure to outside of right foot. Along with the snapping I found myself waking in the morning and rotating that ankle as I felt like it needed a stretch and multiple cracks sound off from the ankle area as I rotate it clockwise. Lots of cracking. It feels really good but now I’m trying not to do that.

Here’s the thing. There is NO pain in my right foot. Maybe after a long hike I feel a touch of soreness near outer part of ankle but there is no swelling, no pain during any movement. Definitely no pain or tenderness over the snapping areas. But the snapping seems is getting worse and it’s becoming very unpleasant. I haven’t been to a doctor yet because as I’ve mentioned I live in a remote area where each doctor visit begins with the most basic diagnosis, then a long wait ensues for a specialist in an area not usually related to the specific area you are requiring assistance for.

I would love any advice on bracing, exercises, taping, and/or suggestions I could offer to my physical therapist who may know little about the condition. If you feel like this could be masquerading as something else or would like me to get an x ray or consult with a physician before a reply I can do that. Hopefully I’ve done a good job self diagnosing :)

Thanks in a advance for any words you may have for me and thanks for the many you’ve already provided me!

Dr Blake's response:
     This syndrome of snapping ankles is does come from the peroneal tendons moving over themselves. There can be only muscular tightness involved, or a combination of tightness and inflammation. The treatment is exploratory. Most start and work on the inflammation with icing twice daily, and begin some form of peroneal muscle massage (say with a rolling pin or massage stick). You need to stay away from tendon massage since that is hard to avoid irritating. ART or soft tissue mobilization of the peroneal muscles (not tendons) can be very helpful. A few cases I have seen are joint related with some joint mobilization needed (to get it unstuck!! in the wrong position). I can image it can develop from weakness, but I have never seen that, so peroneal tendon strengthening seems to not be helpful. I see this over and over on the side that was not injured, as a secondary limping residue. It seems that if we want to take pressure off our left side, we love to go all the way over to the lateral (outside) of the right. A change in foot pronation (more!!) could cause this. Have you noticed any change in your right side mechanics? Hope this helps you. Rich

Here my wife Patty and I are walking into Azofra in Northern Spain Sept 2015

Patient Response:

Good afternoon Dr. Blake,

Awesome about your journey! The pics are wonderful! I had seen a bit about it on your blog but wasn’t too clear on how far you went.  That is quite a ways!!!! Wow! :) I’ve heard that trek is amazing and so inspiring and also that Spain is very very lovely. On a side note my condolences to you for the loss of your dad. Hope you all are making it through.

Thanks for you quick reply to my questions. Your post is great! It gives me hope that it’s not too serious and perhaps a simple fix! I have been told by several massage therapists that my lower legs are horrifically tight! There are also some adhesions here and there. I have just begun exploring foam rolling and use of a tennis ball for self massage and I will investigate this issue with that. I think you are right on. Right side mechanics? Wasn’t sure about that question. I don’t think I’ve had any issues if you were asking direct. In looking at my shoe soles each seem evenly worn on newer and old pairs. Only the tiniest bit of extra inner foot wear.

Wanted to pass on to you that I was able to get into my physical therapist who agreed yes the peroneals are for sure snapping on the right leg as I described. Then she told me braces or sleeves wouldn’t be very helpful and then gave me some oldish advice about strengthening. Oldish in that what I read was thats what they USED to advice patients. The new info is parallel with what you are saying that strengthening does little to assist the issue. I will get down to the business of experimenting and see what I can do for it and will update you.

Before I go I wanted to mention my left foot. The achilles pain I mentioned. Last week when emailing you the snapping in my right foot was far more annoying than the pain in my left but now it’s becoming critical and increasingly debilitating! It’s not constant but caused mostly by the weird pigeon toed bent back foot angle used in yoga warrior pose and the same type of foot position in surfing (left is my back foot). Today with every pop up and ride aaaagh the pain!!! Medium stabbing and burning. It’s been bothering me a bit more each time I go out but today was bad. The pain is very central to right behind the outer ankle bone running up an inch or two. But it’s actually really hard to locate exactly where the pain is originating from. Only about a 3 inch diameter area. My PT said it was not achilles. Had me going up on my toes and other moves and nothing hurt it moving or palpating except three inches above the ankle bone I get an electric shock sensation when I press on it. I know there’s a million things it could be. Old fracture, arthritis, bursitis, more peroneal business but does anything stand out to you? 

No hurry on this! In fact I’m sure I have hit my quota of questions. Like two years ago lol.

Have a beautiful day!

Dr Blake's response:

     The left is probably in neuro spasm. PTs typically can use electical stim to break the spasm. Docs will use trigger point injections with local anesthetic. You can try to use deep ice massage with some painful acupressure. Rich