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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