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Saturday, October 31, 2015

Happy Halloween San Francisco Style!!

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.

Thursday, October 22, 2015

Mustard Seed Plaster with Tumeric for Acute Injuries

A patient recently told me of an old, much forgotten, treatment for inflammatory and neuropathic pain. This treatment is called Mustard Plaster. I love remedies like these. She said you take mustard seed oil and mix with tumeric powder into a dry paste. You must use latex gloves since it will stain everything and hard to get out. She uses it after an Acute injury for anti-inflammatory while sleeping. You put on the paste and then several socks to hold on the paste. Something to consider.

Low Impact Running for Hip or Knee Arthritis

Dr Blake, what can you tell me about this style and the shoes that help-- Newton, Altra, etc. I discovered advanced arthritis in my right hip and trying to prolong its life. Having a gait analysis next week.

Dr Blake's comment: This is a nice video below discussing low impact running to help slow down the stress on your hips. The basic biomechanical changes do not revolve around running slower however, unless you are going down a hill, which is sort of counter intuitive. The basic changes are to get away from heel strike (which may or may not require a zero drop shoe like Newtons or Altras). I can easily run midfoot to forefoot strike which my normal Asics. You need to actually focus on improving your stride rate to 85-90 strides per minute. A stride is the distance from right foot land to right foot land, or 170-180 steps per minute (right heel strike to left heel strike). As you increase your stride rate, you will have a natural pull back of the landing foot that gets you more on the center of your foot). This increased stride rate allows us to avoid over striding, which produces a jarring damaging force on our knees and hips. You can also see the videos on Chi Running on my blog which emphasize the proper mechanics of midfoot landing/strike.  Hope these principles help. Rich

Dr Blake's comment:
     So, to summarize:

  1. Avoid down hills with a passion, and run slowly down them if encountered
  2. Work on Chi Running Techniques to get more midfoot or forefoot land, avoiding heel strike
  3. Find a Zero Drop or Neutral Shoe (both well cushioned but stable) that allows you to land on the midfoot or forefoot easier.
  4. Gradually try to increase your stride rate with proper landing foot pull back to avoid heel strike. 

Wednesday, October 21, 2015

Foot Fracture: Email Advice

Dear Dr Blake:

     I had pain in the ball of my foot for awhile. finally went to the dr and he said i have
two broken bones there. Since it started to heal he said just see how it is in a few weeks and if still not good come in for the boot cast.
Dr Blake's comment: So far the advice is good. The use or no use of the boot is based on creating a pain free environment. This is crucial to keep the pain in that 0-2 ranges where normal healing can occur. 

After he pressed on it its been more painful now then ever. i feel like i am walking funny to compensate and now my knee is really bothering.
Dr Blake's comment: I have done this also to sweet, kind, innocent patients that come to me for help. Most of the time it is just I do not know how sensitive it is when I am exploring. Your walking funny is called limping. Limping causes knee, hip, back pain, even to the other leg, so I would go into the boot if it stops you from limping. If you can not keep the 2 sides level with the boot, get an EvenUp (wonderful savior of spines!!)

What do you think is best to do…what about a shot will that help
Dr Blake's comment: No cortisone around a fracture since it can negatively effect bone healing. Get the boot, ice 2-3 times a day, and give it some rest. 

Its painful and feels like a heart beat of pain
Dr Blake's comment: That is the inflammation out of control. Hope this information helps. Rich
> ps im curious will ball of the foot pain cause back pain to ?

Sunday, October 18, 2015

Accessory Navicular: Email Advice

Hi Dr. Blake

I have a son with accessory navicular and somewhat flat feet.  He is a 6 ft 8th grade, power forward and has been playing for many years.  Last year he had a hairline fracture of his fifth metatarsal and this past spring he rolled his ankle again and was in instant pain and we discovered it was related to an injury to his accessory navicular.  That foots accessory navicular five months later is slightly larger on the foot that was injured and was recently kicked in a game inflaming it slightly.  He dropped running cross country as he plays both aau and school basketball.  He uses voltaren diclofenac gel topically when it was acute.  He originally five months ago was in a boot for 5 weeks.
Dr Blake's comment: Due to the vulnerability of that bone to have flareups, make sure he is using taping when he plays, and ices daily for 20 minutes each evening every day religiously. 

He was told by a sports orthopedist to use Superfeet inserts which he played in today and they were fine.  He wears Adidas high tops which are good for people with flat feet.
Dr Blake's comment: Sounds great---good stability shoes, taping, arch support!!

Questions: are there other things that can be done for accessory navicular issues/syndrome?
Dr Blake's comment: Based on the extent of reflare, you can increase or decrease the mechanical support and anti-inflammatory measures. I always love accessory navicular patients to do posterior tibial strengthening as long as it is non painful. Sure, you can go to custom orthotic orthotics if the Superfeet are not enough support. You would have to see if he is walking and running whether he is still pronating. You can improve the taping by going to a good Posterior Tibial J Strap. You can get a Stromgren Ankle Brace and only use the inside strap (I have my patients actually cut off the outside strap that would pronate them. 

   Are Superfeet inserts what is best for this?   I say your wish list I. Ur blog and in always after him to not walk barefoot around the house and wear slippers.  He has been playing competitive basketball since 4th grade and this discovery/injury of this accessory navicular was just discovered in June of this year.

Any suggestions would be much appreciated.  He is a very good player, will be the captain of this 8th grade team, and would like to potentially play in college.   I would like to do everything I can for him to realize that.
Dr Blake's comment: Please comment on this post where he is now in regards to his injury. As long he is not limping, he can play. I hope this helps somewhat. Rich 

Thank you in advance for ur help Dr. Blake!

Saturday, October 17, 2015

More Images from Our Pilgrimage in Spain on the Camino de Santiago

Straightening Your Back: Exercises for the Curves

Dear Dr Blake:
Great to see you yesterday.
Congratulations to you ~ new grandfather!
I love your grandson's name and it was really fun to see the pictures. Thank you for sharing those with us. 

Thank you for seeing my daughter and helping her with her pain. I would be very interested in any kind of exercises that you do find on the web if you end up searching for any. I know when she has time she'll also look as well. I never even imaged the pain in her thigh could have stemmed from the scoliosis!

See you soon, 

Dr Blake's comment: 
     Here are some of the videos that represent what I know. It would be wonderful to show this to a PT who can review here curves and decide exactly on the top 4 exercises. Typically there are 2 concaves areas in an S shaped curve that need to be stretched out, and 2 convex areas that need shortening by strengthening. I believe you can get faster results if you can do less general stretching and strengthening (although there is a role for that), and more specific stretching and strengthening due to your understanding of the individual curves. These videos do help you guys start understanding the process. I would love to watch you two do the partnered stretch in the third video, I think it could go viral if you make your own!! Hope it helps. Rich

Fascia: A Part of some Pain Syndromes we should not Ignore

This short note was sent to me by one of my blog patients. It is an area that affected my plantar fasciitis patients and my achilles/calf patients. I realize I have a lot of learning to do to understand this complex structure that covers every muscle in your entire body. 

Found this wonderful article on fascia after doing a home practice video with the instructor Jenni Rawlings. Wonderful and interesting.

Sesamoid Fracture: Email Advice

i have tibial sesamoid fractured too from running backward at high intensity, had small bump in my new shoes and broke my sesamoid and felt the pain immediately, i got MRI and seen at least 8 specialist... 

after 1year they told me i had fractured my sesamoid, i stilll have pain i went see a orthopedic surgeon and he told me he could remove a part of my non-displaced sesamoid fracture (a very small liquid is between the 2 part shown on MRI a month ago). so his idea is to remove the smaller part(about 45% of the sesamoid..) do you think its a good solution?
Dr Blake's comment: I have only seen one case of this which was unsuccessful, so my limited knowledge won't help. Alot depends on how healthy the joint looks when they go in there, so you have to trust the surgeon to possibly remove it all if appropriate. But, technically it makes sense. 

 he think the pain is coming from that sesamoid not healing completely. But i hesitate so much on getting the surgery im so scared the problem become worse.. 
Dr Blake's comment: The surgery to remove the whole sesamoid is very common, and 85% successful (meaning 85% of the patients say they wound have done it over again). So, since it is a successful surgery, most do not hesitate to do after 6-9 months of conservative care. The downside with this is you have to wear toe spacers between the first and second toes forever, and some form of dancer's padding/orthotic device, to protect the other sesamoid. And you have to get the abductor hallucis very strong. 

and another weird thing, when i walk in the sand its magical for my sesamoid pain, i cant explain why walking in grass and in sand help me and anything involving anyking of shoes or sandals or anything give me pain. I learned to live barefoot because thats truly helping me. when i stand on my sesamoid i dont have pain, but when i touch it i can get about 8/10 in pain also bent it cause pain. 
Dr Blake's comment: The hypersensitivity to the touch of finger or shoe is nerve pain that settles into some chronic problems. You need to work with NeuroEze, prescribed nerve creams, neural flossing, massage for desensitization, etc. 

But if i keep my feet flat i have no problem. One important thing in my case is i learned 1year after the acute injury that i had fracture because they didnt seen it on x-ray. then 1 year later i bought a MRI and they finally seen small crack in the sesamoid that is non-deplaced fracture. Another thing is that my feet now cracking all the time when i walk and it never been like that before the injury.
Dr Blake's comment: The crackling is from fluid retention, either inactivity, chronic swelling, or both. It will disappear as your foot gets normal. The MRI makes me believe that the nerve hypersensitivity may be your biggest problem. Check out some pain management specialists who deal with peripheral pain syndromes, before any thought on surgery. My patient that had the unsuccessful partial sesamoidectomy finally got better with soft Hannaford orthotic devices with dancer's pads and a pain management approach. 

Its impacting a lot my life and tried everything i could, at this point i have 3 solution that i found could work:
1- Live on the beach 24/7 in a hut where i would NEVER walk on hard surface(dont have that $$$ to do that) Dr Blake: Sorry!!
2- Have sesamoid removed partial or completely
3- I never been in the boot, they told me its too late after a year, is it true? do you think if i put my feet in a boot pointing my toes downward for a while could fix my problem?? im thinking about trying this
Dr Blake's comment: When you take a pain management approach, you have to spend 3-6 months in a pain free environment (the boot may help in that regards), use topical and sometimes oral nerve meds, learn biofeedback and other desensitization techniques, and ice three times daily. I hope this helps. Thanks for your kind words. Rich
please come me back dr.blake you ARE the ressource on the sesamoid over the internet!!!!

Sesamoid Injury: Followup on Long Conservative Care

This kind young man, injured his sesamoid 3 years ago, had some ups and downs, has avoided surgery, and wanted my readers to know what he had discovered. Thank you. 

Hi Richard,

I hope you are well. I haven't been in contact for quite a while. Been trying to solve my pain and I think I got some results...fingers crossed...

Here's what really helped me I think:
  • orthopedic soles made to measure by podiatrist.
  • flat shoes (this model:, with thin and loose socks to minimize pressure (no thick socks like tubes etc.).
  • no walking/running for several months. I basically used a car or a bicycle to go to office (with pedals under the back of my foot/heels level so no pressure on ball). This enabled me to stay pain free for several months in a row and I think it helped a lot. I think cycling is great as it enables you to do cardio workout without triggering pain.
I can now run 40 mins with my soles in good running shoes (Asics). Not 100% fixed but a big improvement compared to a few years ago....I hope this will help other patients, this injury truly is a massive pain (both physically and morally).

Thanks much again for all your work and assistance and don't hesitate if you want more details.
Best regards, 

Peroneal Tendinitis: Email Correspondance

 I have been suffering from peroneal tendonitis for four years now and I'm hoping you can shed some insight on how I can kick this thing for good! Originally, my podiatrist recommended motion control shoes to control the torque in my ankle: that was a complete failure. I rolled both my good and bad ankle twice in a matter of hours.
Dr Blake's comment: Wow, that was bad luck. Peroneal tendonitis stands be more from over supination (aka under pronation) than over pronation, so I am not sure why the motion control. Neutral, and some stability shoes, are great for this problem. My favorites are the Saucony Triumph and Brooks Ghost right now. 

After this my local running store recommended a support shoe instead. These shoes are usually fine for a few weeks, but as soon as they start to break in the underpronation gets worse and worse. It's a weird combination of feelings: like the arch support is so heavy that my feet aren't touching the ground on the inside, but also that the heel has worn out so quickly that I feels like it isn't touching the ground either. 
Dr Blake's comment: Look at the posts on lateral shoe wedging (which may be crucial), and common modifications of supination control. You can even power lace for supination protection.

I recently switched to a neutral shoe after the owner at another local running store was horrified that I was literally walking on the edges of my feet (and I have the ugly calluses along the entire edge to prove it). The neutral shoe has helped greatly. I feel significantly less later calf pain, but I can feel the tendonitis creep back in. It almost feels as though my feet slide from one side of the shoe to the other while I'm underpronating, and no amount of lacing can keep them in place. When I strike the ground evenly I have no pain, but when the edge of my foot hits the ground I can feel it right up the tendon.
Dr Blake's comment: This is why are supinators fall in love with shoe wedging and inserts that correct. Over supination is the most unstable and dangerous biomechanical problem I treat on a regular basis. You can even purchase some Red Sole Inserts from REI and other stores, and use masking tape and/or duct tape along the lateral under surface border, to straighten your foot until you get some professional help. When dealing with injuries, finding the mechanics that are causing or aggravating the problem, is vital. Or the problem is a repeating issue. 

I've also tried a lateral heel wedge to no avail, and a full over the counter lateral insole. Are there any other options or am I doomed to pain? I can't understand how one ankle sprain 4 years ago has led to such significant change in my mechanics, I always just grabbed any old shoe and had no problems before. 
Dr Blake's comment: Ankle sprains, where there is loss of ligament stability, can cause subtle and not so subtle instabilities that the body has to deal with. Besides the info above, start doing your Single Leg Balancing nightly (for it will take 1-2 years to get super strong in the protection of your ankle and probably now is a good enough time to start).

Foot Pain and A Higher Source

    I am having foot pain only. It may be from higher up. I feel it in my buttock too and some faint pain sometimes in my leg. I have a clean back MRI, though. Is it possible the L5 nerve impingement causing foot pain can be found in the hip/glute muscles instead
  1. Dr Blake's comment: 

  2. For sure, you should read about piriformis syndrome, but the sciatic nerve can also get hanged up in the hamstrings or behind the knee. Rich