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Thursday, March 31, 2016

Calmare Pain Therapy: Email Correspondance

Dear Dr. Rich,

Yes, I finally got through to Dr. Gutierrez and signed up for the treatment, starting Monday, March 21.  My symptoms were perhaps not typical; most people start with a lot of pain and it gradually reduces.  My neuropathy pains have always been intermittent and worse at night;  a major problem has been sensitivity of the soles of my feet.  So for the first treatment my pain level was zero  before treatment, but they did it anyway.  However, that same day I noticed a marked improvement in the sensitivity of the soles.  The second day I wore a pair of thin soled shoes and before the treatment walked around on rough ground including a gravel path, and it felt OK.  This was something I absolutely could not have done before.   Again zero pain at the start of the treatment, but I am sure the treatment was beneficial.  I don't know if Dr.Gutierrez though I was a hypocondriac, since I was supposed to have more pain.  I ended up having only 3 treatments;  I questioned  whether getting all 10 proposed treatments would be beneficial.  The shooting pains I had for the past year or more had been less lately and have not recurred.  Dr. Gutierrez agreed for me to stop after the 3rd session (and not have to pay for all 10) with the understanding that if pain returned I could "start over."

I am happy about the outcome and grateful to you for telling me about it.  The other symptom of neuropathy, which they call "compression" or feeling like the feet are overstuffed sausages, with difficulty  flexing the toes, is apparently not helped by this treatment.  And then there's the arthritis which is still active.  However,  any progress is welcome and I am now able to wear all my shoes, some of which I could not get my feet into a few months ago, and walk much more comfortably.

So, many thanks, and I hope Calmare gets full approval.

Best regards,

Saturday, March 19, 2016

Sesamoid Injury: Email Advice

Hi Dr Blake,

     I have been to the doctors and they said I have a fracture in my sesamoid bone and sesamoiditis (yes I had an x-ray). I woke up on the 7/03/16 with this horrible pain which has subsided but I do still get some pain. I can't put any weight on my foot or move my foot up or down or my big toe. Its very debilitating. Yes I had a x-ray. I think it was caused by starting a new gym class in January which is high intensity cardio. I don't normally do alot of cardio, but thats when I really started to notice that the ball of my foot was uncomfortable but it didn't hurt until I woke up last Monday morning and couldn't walk on it.

 Do you know much about the condition? It is probably one of the top injuries on this blog. See the link to the original posting below. 

 and or recovery times? This is very variable, up to several years, but 3 monthes in an environment maintaining 0-2 pain seems crucial to obtain quickly. Try to get my patients to understand Good vs Bad Pain and the Magical 80% Rule.

And anything extra I should be doing? I have been doing the RICE method and using crutches. 

Would u know how long it will usually take for me to be able to put weight on my foot so I can hobble around without crutches?. This is based on maintaining 0-2 pain levels. You need to weight bear also for bone mineralization and healing/strength. So, figuring out how to weight bear with the minimal amount of irritation is crucial, and then to gradually increase the stress to the tissue. 

Or if doing exercises to increase blood flow will help? Motion of moving the joint, boot in general, and ankle is very important to circulation. No movement equals increased swelling and pain. No weight bearing equals increased swelling and pain. 

If so what kind of exercises?.  I have been asking around about this condition and not alot of people know much information on it, including the doctors. I just have my foot bandaged at the moment and using crutches to get around which is very difficult.  Typically the first exercises are active range of motion while you do your evening contrast bathing. You pretend your big toe is a paintbrush. Also, as soon as you can start metatarsal doming and Single leg balancing the better. With the balancing, you place the sesamoid area in the middle of 4 one inch high books with a center hole created to place the sesamoid.
Thank-you for your time Hope this helps you get started towards healing. Rich

Kind Regards

Shin Splints: A Possible Resource

I received this email advertisement. I briefly reviewed it only, so can not recommend it in part or whole. I can say that I am impressed by the some of the thoughts, and hated not to pass the information along. Sorry, but you will have to use your own judgement on this. Dr Rich Blake

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Be sure to keep me posted on how you are doing...

Have a great day.


Monday, March 14, 2016

Post Sesamoid Removal and Neuroma Care: Email Advice

Thank you for inviting me to email you about my foot trouble.  

     In the middle of February 2015, I was in a car accident in which someone pulled out from a side street across my line of traffic.  I slammed on the brake and tried to swerve but ended up hitting him in the rear driver's side. My left knee got jammed into the dash and by that evening my right foot had started swelling up and got quite painful. 

     I went to walk in clinic to get checked out and they xrayed my foot. (Dr Blake's comment: x rays do not show small fractures ever or it can take up to 4 weeks).  She said she did not think there was a break.  A few days later I followed up with my primary who went by the urgent care's report and said it was sprain so ice and rest it and take a lot of advil.  I did, it was getting no better.  I went back to my primary a week later because both my neck and foot were not getting better so she sent me to PT.  My neck got better, my foot had no improvement.  It was hurting so bad it was waking me up several times a night

     After several weeks my PT said he thought it must be broken so  I went back to my primary who finally sent me to a podiatrist.  The podiatrist sent me for an MRI which showed the tibial sesamoid was indeed broken.  The podiatrist said that Urgent Care missed the break because they did not take the xray at the right angle. Now the pain I was experiencing was a sharp pain in the big toe joint area.  Driving was excruciating.  I also had pain between the 2nd and 3rd toes.  It felt as if there was a baseball under that joint, which changed to feeling like there was cotton stuck under there.  Sometimes it felt like it was burning. (Dr Blake's comment: This is nerve hypersensitivity kicking in. It is pain generating more pain by making the nerves hypersensitive inorder to protect you, tell you to get off it). 

    My podiatrist did not really address that concern but regarding the sesamoid he said that my options were to be completely non weight bearing for 2 months but that may not even work, or get the surgery (keeping in mind  by this point it has been about 2 months since the accident).  So on May 5, 2015 I had the tibial sesamoid removed.  After the surgery the doctor told me that not only was it broken but the cartilage between that bone and the joint above was blown out so he had to clean that up a bit. 
Dr Blake's comment: This was good news so you know the surgery was 100% necessary to avoid further injury to the metatarsal. 

    I went back to PT but stopped since it did not seem to be helping.  Last October I went back to the podiatrist because the big toe joint was still really hurting and the neuroma was still really bothering me.  He scanned my feet to make orthotics and gave me 2 cortisone shots at the big toe joint.  At first he was saying the pain was due to a bunion, but after the shot and after the difficult time he had administering the shot due to scar tissue he said the pain could be from the scar tissue.  He still did not address the neuroma.  The cortisone helped some for the pain.  I think it was late December before he gave me the orthotics.
Dr Blake's comment: I love to get orthotics to patients right after surgery, if they do not have them already, since I want them walking with sesamoid area protection. 

     In January, I went back because I just could not take the neuroma and at first he just wanted to pass it off as being because of a bunion but then he actually looked at my xrays and said that no that did not look to be the case so he gave me a cortisone shot between the 2nd and 3rd toe.  It helped take away some of the burning pain I was getting.
Dr Blake's comment: This doctor is just slow at doing good things!!!

     I wear the orthotics consistently in well fitting athletic shoes, but they don't seem to make much a difference. Actually the orthotics are so hard (and I did put a thin cushion on them) that when I get home I want to take my shoes off, but I don't because the doctor said not to go barefoot. My job keeps me on my feet alot on concrete floors.  I do have some antifatigue mats around and use them whenever possible.  But I find that if I have to stand or walk on those floors for even a half hour I can feel that neuroma and it feels like my foot is blowing up like a balloon. 
Dr Blake's comment: It is common to need up to 3 shots to calm a neuroma down. See if you can get the second one soon. 

     The big toe is becoming again painful (a sharp pain on the underside and side), but not all the time.
Dr Blake's comment: The surgery for a damaged sesamoid and undersurface metatarsal bruising can take up to 2 years to feel great. Typically a PT will be the most help getting the range of motion better, reduce the scar tissue, and get the muscles strong. I am assuming you are doing met doming exercises and simple self mobilization. Does spica taping help you?

     I went for a second opinion who said he had very little time, just said he recommended a couple more cortisone shots at that neuroma. 
Dr Blake's comment: What a comment!!! I apologize for the sacred profession of medicine. 

 I would like to get back to a normal life but if I try to walk too much, or run I pay dearly.  And I am not sure what to do.  Any suggestions would be greatly appreciated.  I can send you xrays if that helps.  Thank you so much for your time!
Dr Blake's comment: So, I would have the doc do at least one more neuroma shot with cortisone. Read on my blog about neuomas to see if there are other suggestions, like metatarsal pads. Get referred to a PT known in your area for feet and see what they say about the big toe joint and the neuromas. Keep me in the loop. Get a new MRI 2 weeks after you next shot. I would be happy to see the images. Just email me them by taking photos of each frame. What shoes or qualities in shoes have you found helped the most. 

Friday, March 11, 2016

Possible Sesamoid AVN: Email Advice

Good morning Dr. Blake

I found your blog by searching help for my condition, I was just diagnosed with an avascular necrosis of the sesamoid bone. 

I have an increasing pain since last august, at the beginning that was nothing, just like small cramp when I was walking but it gets worse since November. I did X-Ray and MRI and my doc in France concluded a " contusion " of the sesamoid bone and I had some insoles to wear in my shoes, but it doesn't do any real difference and the pain continue to increase. 

Finally, I saw a doc here in the US and he told me that was a AVN after taking new X-ray and MRI where we can see more cyst in my bone. As I understood, that the worst case we can have for this bone, and I don't even remember any event in my life around last summer as a bad jump or a fall ! I don't smoke, I don't drink any alcohol except a glass of wine every two or three weeks.... 

My doc wants me to wear a walking boot for 6 weeks to try to ease the pain, and he will give me my options then... But he never talks about healing the bone, only release the pain ! 

Is there anything we can do to heal the bone ? Dis it happens to someone ? I'm only 24 years old, I never had any bad health problems before, I don't run, I'm normally active but doing low impact workouts for years... I'm getting very pessimistic, I will enter in one of my most important year for my career as I will graduate soon, and I'm afraid that this condition would ruin all my hopes ... 
Dr Blake's comment: 6-9 months of Exogen bone stimulator, along with some weight bearing with orthotics and dancer's pads can turn this around. I believe avascular necrosis can only be diagnosed on CT scan, so consider getting one. If the bone has fragmented, definitely consider surgical removal. 

Does the surgery help ?  My doc told me that if we remove the bone the other bone can get the same... Will I walk normally again someday ? :( 
Dr Blake's comment: Since you did not deserve this, is there any problem with bone density or Vit D deficiency?If you are a vegetarian or vegan, you may want to temporiarily change or at least get a dietician to consult.I have never seen the other bone have a problem, but sure it could. This is one of the reasons you try to save the injured one now, even if it seems alot of time. And it is never at a good time to injure this bone. 

And my other foot begins to be painful too, but the X-ray shows nothing abnormal ... 

I'm trying to walk less as possible, I'm wearing a " step " bracelet and I set the vibration at 5000 steps, and try let it vibe as late as possible in the day ! But i'm working in a lab and you always have to go get stuff in other buildings or just walk in you own building because your experiment requires to go to different rooms.

I also stopped to workout, I was doing occasional weight lifting (no squat or lunges) and some " horizontal " bike, a thing I can do without using the ball of the foot, but I don't have the feeling it helps my bone. Should I stop everything ? I stopped for 2 weeks now. 
Dr Blake's comment: We need circulation, leg strength, cardio, and weight bearing. This is a good time to test things out to see what does and does not bother you. Simply putting the pedal of a bike on the arch can off weight the area enough to help. 

Sorry for the tone of my email, I'm completely down by the news...
Dr Blake's comment: Send me a photo of the 3 xray views when you can to see what they are calling AVN. And ask about a CT scan.
If you have any advice to give me, I would be so grateful ! 

Thursday, March 10, 2016

Sesamoid Injury with Possible Surgery:Email Advice

Hi Dr. Blake,

I just discovered your blog and wish I had found it when I first looked for information on sesamoiditis.  

Almost two years ago I slipped on wet pavement and fell.  My foot only hurt a little immediately after but by the next morning it was painful to walk.  However, I'm a  teacher it's so difficult to take a day off (especially last minute since it takes several hours to create good sub plans).  So I decided to see how it felt in a few days.  I wore tennis shoes most of the time and it started feeling better.  However, a few weeks later when it got worse, I ended up with an appointment at an urgent care clinic.  That doctor had x-rays taken and said it wasn't broken and gave me a "post-op" shoe which he told me to wear for two weeks.  After two weeks, it felt better but not healed.  I had planned to continue wearing the shoe but the sole cracked in half.  Since it was over the two weeks, I decided it should be fine.  I realize now I should have followed up with my regular doctor immediately, but I didn't until the pain was bad again.  She said to try the post-op shoe again since that worked before.  And the same thing happened (including the shoe breaking after a couple weeks).  At that point I made an appointment to see her and she contacted the podiatry department for my health plan who said that I needed custom orthotics for sesamoiditis.  They referred me to a doctor out of my health plan because none of the doctors within my health plan make them.  However, that doctor was on vacation for a month.  At that point I had been reading about sesamoiditis as a chronic injury.  So I asked to see a podiatrist within my health plan to confirm the diagnosis and get some suggestions for what to do in the next month.  That doctor just suggested over the counter shoe inserts and a sturdy shoe (which I was already wearing most of the time).  He also looked at my initial x-rays and said that there may be a fracture  but there was no way to get a better picture of that area to determine because if where it was, but that the treatment would be the same and I needed to get the custom orthotics when the other doctor was available.  (When I eventually met with the orthotics doctor, he said an MRI would tell and was surprised I was told that there was no way to tell if it was broken or not but also said that the treatment was the same so I didn't worry about it.  He also said that he thought I would be in more pain if it was broken--but I wasn't sure he knew how much pain I was in because every time he asked me to walk barefoot he expressed surprise that I was walking entirely on the side of that foot and not putting any pressure on the ball of my foot.)
So finally a couple months later (6months after the injury) I had the orthotics but no treatment plan was ever discussed other than "wear the orthotics."   And I wasn't sure who I was supposed to be asking since the one doctor was out of my health plan but the other one hadn't seemed very helpful.   So after a couple months when I was feeling better I figured even a broken bone was only 6-8weeks and started going barefoot in the house.  Of course the pain got worse and eventually I contacted the podiatrist within my health plan since follow-up visits with him would be covered by my insurance.  
He ordered a bunch of x-rays that he said showed that it was not broken.  He blamed me for stopping treatment early even though I had never been given a time frame for treatment and still had to ask him multiple times in that visit to get a straight answer on when he felt I could stop wearing the customer orthotics for everything except sleeping and showering.  (He finally said two weeks without pain and I could try without them.)  
He also gave me some stretching exercises to do and said that I was probably putting a lot of pressure on the ball of my foot when I walked and the stretches should help change the way I walked.  At that point he said surgery was a possibility but I should try stretching it and staying off of it for longer and that the stretching would help me have a better outcome if I did need surgery.  The problem was that several of the stretches required that I put my weight entirely on my right foot.  So the stretches were making it worse.  Thinking that he was the doctor so wouldn't have told me to do those if they weren't necessary, I kept trying to do them even though they hurt and some I could just never make myself do every day.  Finally, I went in to see him again and he said I should only be doing the ones that didn't hurt.  I was also about to go on a long-planned extended family vacation to an amusement park.  So I asked about precautions for the trip.  He gave me a boot that he suggested using.  My friend had also suggested asking about cortisone shots so he also gave me one of those (although I researched later and saw a lot of negatives on those and wish that I hadn't).  I ended up renting an electric scooter after a few hours using the boot because it hurt my legs and hips. 
I saw the podiatrist a few months later.  At that point I wasn't having pain during the day although it was often achy at night when I took my shoe off to go to bed.  He suggested icing it and also suggested I could try short walks in the house barefoot.  School was about to start again so I said that I would wait for a month to see how being on my feet more affected me.  Unfortunately, I made a poor choice to take my kids swimming just as school started.  I told myself I would be very careful and get out if I felt any pain.  But I didn't feel the pain until the next day.  I was embarrassed to admit to the podiatrist that I over-did it like that after insisting I was going to be extra cautious.  So I just went back to being very careful, icing it, etc and tried to heal it again.  I tried using the boot at school for a couple days but it felt worse when I did that so I went back to my regular shoes & orthotics.  It was slowly getting better.  But a few months after that we cleaned out our guest room so I was carrying stuff down the stairs to the garage and the next day it was very sore again.  It got a little better but was still a little sore at the end of the day.  Then last week I was walking and I stepped down and had a sudden sharp pain in the ball of my foot.  Since then it has been very painful even first thing in the morning.  
I've made an appointment to see the podiatrist again but I really think he's going to recommend surgery (which is another reason I haven't gone back to see him in several months).

I feel like I just told you my whole life story, but I know you've mentioned looking at the big picture on your blog.  You've also mentioned that you respond to comments that have a more general audience.  So I"ll sum and ask my question in a way that may be easier to respond to:

I am nearly 40 and have been dealing with sesamoiditis for almost two years.  It gets better but the pain returns if I try even a moderate level of activity (even when wearing custom orthotics).  I'm not very active.  I'm not a competitive/professional runner or dancer who needs to get back into shape.  I'm just a mom who wants to walk to the park and play with her kids again.  At this point, would I be better off just having surgery rather than continuing what seems like a losing battle to get my foot to heal?  
If you think there are measures I should still try to avoid surgery, then I have one other question.  My doctor has ordered x-rays but I see you recommend an MRI consistently.  Since my injury was almost 2yrs ago, would it be worth it to push for an MRI now or should I just go with what my doctor uses/expects.
Dr Blake's response: I am so sorry for your situation. You would have every right to have surgery due to the length of time you have been suffering. Surgery is every successful and you just want to make sure your surgeon has done these and knows the subtleties of the surgery and post op course. How much PT? What happens if the joint freezes up? How long in a removable boot afterwards? Etc, Etc. 
     That being said, surgery is done for a non-healing fracture, not sesamoiditis. This is why I would recommend an MRI to make sure everyone really knows why you hurt. I have seen situations where the original fracture had completely healed, but the metatarsal head developed arthritis, or a bursitis had developed, or excessive scarring. So, without an MRI to tell you that the only source of your pain is a non healing fracture, I could not at present recommend it. Also, non healing fractures can heal with 9 months of Exogen bone stimulation, rigid sole shoes, orthotics that do off weight the sesamoid, dancer's pads and spica taping, icing and contrast bathing, and making sure your bone density and Vitamin D levels are healthy. 
     So, step 1 MRI. Based on the MRI results, step 2 can be another smarter approach at conservative management if seems reasonable or surgical removal of the damaged bone. Keep me in the loop and I sure hope this helps you. Rich

Thanks for any help you can offer!

Thursday, March 3, 2016

Fat Pad Atrophy Article

Someday it will be easy to get an injection to restore the fat pad when you need it. 

Wednesday, March 2, 2016

Hallux Valgus/Bunion: Email Advice

Thank you so much for taking the time to provide this advice! I am a 30 yo with hereditary hallux valgus. I rarely ever had bunion pain - even through 16 years as a ballet dancer and 4 years on pointe! About 6 months ago I took up two new hobbies: a Japanese martial art called katori and ballroom dancing and my MTP joints have started aching. These conservative options are exactly what I was looking for in hopes that I can slow the bunion progression. I'm especially grateful for your recommendation of a night splint. I spent hours reviewing these but could never decide which is best and which are bogus.

I have a few questions, if you’re still monitoring this thread and have the time to answer:
1. What is your opinion on menthol-containing products like Tiger Balm and Biofreeze? Would they be a good idea in conjunction with the massage? Definitely!!
2. I found one video you posted on bunion taping (incidentally, I have learned a lot on Lisa Howell’s site). Would that work with Rocktape? Definitely!! If not, might you recommend a method for bunion taping with Rocktape? There are so many options for taping that I have no idea where to start. 

3. I also found the video you posted demonstrating metatarsal doming exercises, and I’m eager to start those. Are there any other exercises you recommend for strengthening the small muscles of the feet? (Besides the balancing one in another of your blog posts on bunion care – I can balance on each foot with my eyes closed, but I make sure to do that regularly!)

I would really appreciate any advice. I’ve read through much of your blog and you seem like exactly the type of podiatrist I would like to find! I will, of course, go see a local podiatrist, but it will be a few months before I can see one on my HMO plan and I want to start as soon as possible to relieve pain and, most importantly, slow the progression of the deformity.
Dr Blake's comment: Thanks for your kind words. I hope this helps some. Rich