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Tuesday, May 31, 2016

We Shouldn't Have To Be Reminded to Exercise: This Article Will

6 Great Stretches for all Activities

I hope you enjoy my new video on great stretches used for activities. The emphasis is on understanding the techniques of these 6 stretches. Hope they help you. This is part of my Ask The Podiatrist Segment. Please write questions to Dr Rich Blake 900 Hyde Street San Francisco California, 94109. 

Saturday, May 28, 2016

A, B, Cs of Diabetes

A simple, but important, reminder for diabetic patients, and those trying to avoid diabetes.

Achilles Tendons Survive Hill Workouts, but there is a Catch!!

This is a great article stating that well trained achilles tendon survive the stresses of running hills (like in my beloved San Francisco). However, achilles and other body parts for that matter, do not like sudden changes in workouts (like adding hills, speed, or distance). So, make each transition gradually and you will do fine!!

Thursday, May 26, 2016

Ankle Sprain Treatment

Please review my video on the initial treatment of ankle sprains. 

Wednesday, May 25, 2016

Foot Stability with Extrinsic Rearfoot Posts: Sexy Title!!

If any of you have orthotic devices, I invite you to comment on them. What they have done for you, what problems you have had? I repeatedly, since I am getting older, have patients express distress that I may retire someday and they will not be able to get good orthotics. I am honored, but it points to how important they are to so many people. I have been given quite a gift in life to be able to help these patients. For that, I am forever grateful to my profession and my mentors. 
     This short video goes over a small, but very powerful, part of the orthotic device called the rearfoot post. I owe Dr Christopher Smith, founder of SuperFeet, and one of my kind mentors, for introducing me to birkocork. Prior to birkocork, the posts I made were very hard. Birkocork posts are so much kinder on the knee and hip joints due to their shock absorption.

Tuesday, May 24, 2016

Sun Screen Needed for Feet!!

Just a reminder to use sunscreen on those feet also this spring, summer, fall, and winter!!

Hiking Boot Lacing for Extra Stability

If you are going hiking this summer, this lacing technique, even with some modification for lower top boots, can be very beneficial at preventing your heel and foot from moving around causing injury producing motions. I must thank our friends at REI for this tip. 

Leg Length Discrepancy Treatment

Dear Dr. Blake,
I recently completed physical therapy for a leg-length discrepancy that was affecting an entire side of my body (the side with the shorter leg). The chiropractor prescribed me a 7mm heel lift, but I wanted to know how I could get a 7mm full foot lift that would be good for running. I recently found your post when someone asked a similar question to mine on this link:
Dr Blake's comment: You can use two 4 mm full length flat spenco insoles. That will get you very close. Unless the chiropractor measured exactly by xray, that may be enough. Remember all soft insole give on impact, so 8 mm lifts will only give you 6.5-7.5 mm based on the stresses you are placing on it.

Is the only way for me to get a 7mm full foot lift is by purchasing several 1/8th inch sheets from I'm just afraid to do this because I'm trying to get the lift to be exactly 7mm and if I get two 1/8th inch sheets it's going to be 6.35mm. And would you glue the layers together?
Dr Blake's comment: Typically you go with one layer for minimum of 2 weeks, than the second layer for another 2 weeks. If that is working, you can glue together. 

Also, my second concern is not having enough room at the front of the shoe. I recently got the Clearly Adjustable full foot lift and my toes didn't have any room and I can't wear it. You mention you can cut out the toe, but if I cut out the toe then how is it taking care of the discrepancy? 
Dr Blake's comment: You can ask a shoe repair store to thin out the thickness from the sulcus of the toes to the end of the toes on the lift. You can also use sandpaper. The green side should be facing up, and the black side is easy to thin. If you need more room, you can cut out the toe area completely and then bivel the last 1 inch in length. 
On top of the Clearly Adjustable lift not fitting, it took me a long time to adjust each layer to make sure it fit inside my shoe and the result came out a bit choppy from my scissor job, so I'm afraid to try this again with other lifts.
Would love to hear your thoughts.
Thank you so much for helping patients with leg-length discrepancies and for your wonderful blog! I was very happy to find it.
Clare (name changed due to witness protection).
(if you post this on your website can you use another name for me? Thanks!)

Monday, May 23, 2016

Lower Extremity Nerve Symptoms: Looking for more than one Source

This was a comment to my You Tube video which I see often dealing with neurological problems in the lower extremities. There can be 2 or 3 sources of this neural tension that in themselves are minor, but together cause major disabilities. The treatment stems from finding all the possible triggers like poor posture sitting, overpronation of feet, poor core strength with low back issues, piriformis syndrome, etc, etc. I have had patients where the 2nd source of nerve irritation was the neck area, and the foot symptoms would not resolve unless the neck was stabilized somehow.

Hi Doctor Blake, I have a buzzy sensation in the ball of my foot when I walk. It began 10 months ago when I was running long distance. I had a variety of symptoms and was unsure where the pain was originating. It resulted in me developing a strong limp because I was in so much pain. I have had electric shock type pains travelling up my left leg, numbness in the ball of my left foot, pins and needles in my calf, tightness in my hamstring and glute. I have also had varying degrees of back discomfort but not enough for the doctor to think it is sciatica. I can't pinpoint a painful point in my foot and foot specialists haven't been able to either, although it does feel buzzy after it has been manipulated. I have had a steroid/anti inflammatory injection that didn't do much for me. The best thing has been some orthotics that raise my arch taking the pressure of the ball of my foot. I get the buzzy feeling by tapping the tarsal tunnel by my ankle as you demonstrated. What does this mean? Thanks,

Dr Blake's comment:

Thank you for your comment on the above video. You definitely are having neural tension and the source can be from 2 or 3 sources (and they all can be mild in nature, but have an additive effect). Please see a physiatrist or neurologist to look for back issues, piriformis, glut, ham, calf, tarsal tunnel or intermetatarsal neuritis signs. Someone should be able to figure out the syndrome, but it can be a lengthy process, and I am sorry. See my other video on the back relationship to foot symptoms. Rich

3D Printing to help Feet Problems

Even though I am fairly old school, mainly because I am old, I am excited about this new generation with their computer savy ideas. 3D Printing is cool and will gradually change the world I am still plodding through in podiatry. My hats off to this wonderful new generation. My advice: Get advice from those who came before who may help with real world scenarios. Rich

Saturday, May 21, 2016

Top Foot Health Websites: I made #10 out of 25!!

Hello, I am honored to have made #10 of the top 25 Foot Health Websites. I am glad to be apart of helping foot problems and this gives me more motivation to keep going. Rich

Hi Richard,

Just a quick email to let you know that I featured you in a recent article named:
Top 25 Most Credible Foot Health Websites To Follow in 2016.

Here’s a link to the article:

I’ve also made a special badge for you here:

Feel free to download and use it anywhere you wish!

Once again, I hope your inclusion in the list drives some new readers to your blog and I look forward to staying connected!


Plantar Fasciitis Post Cortisone Shot Advice

Love your info! I received a celestone 5mg. injection into the spot that hurts me the most(from plantar fasciitis) in the center of my left heel on Tues.May 17th (Dr Blake is reading this on 5/21). I have had pain since Sept. 2015 (over8mos.)! I am an avid speed walker, zumba dancer, and tennis player at the ripe old age of 76 years old! Guess I wore my thin narrow feet out walking 5 miles a day on the beach along the waters edge for the past 35 years (plus all my other activities)! I had an MRI done in Dec. 2015 that showed "mild Plantar Fa sciitis". I then went to PT for several weeks and do many stretching exercises AM and PM every day icing  for 15 to 20 minutes after each session.
                               I had no  pain after shot for about 3 hrs (Dr Blake's comment: This tells you that the shot was in the right place). Then bad pain till late AM next day. No pain Wed. PM until Fri. Pm. Then slight tinge lasting into this afternoon(Sat.= 4th day. I am icing it as you said! My Dr. never told me to ice it! I am doing this 3 times a day for 15 to 20 minutes after reading your info.
Dr Blake's comment: This bad pain is unfortunate, but can happen and typically lasts for 4 days, so you were lucky. Celestone is a long acting cortisone that can take up to 2 weeks to completely start working. 
Can I start the PT stretching now 2 times a day (icing after)??? Dr Blake's comment: I would do no weight bearing stretching for 2 weeks. You can do active range of motion stretch by pulling your toes towards your nose non weight bearing. You can massage your calf. You can do the frozen sports bottle roll for 5 minutes from the heel into the arch with progressively more pressure over that period.
When shall I try walking and tennis??? Dr Blake's comment: You can walk, but no impact activities for 2 weeks like running, tennis, basketball. 
When shall I contact my Doc again???He said shot should last 2 to 4 mos.? I'm to get appt. after that time if no problem. I am seeing a Sports Medicine Ortho Doc. who has helped me with ankle tendinitis and sole problems with PT in the past!! I really trust him but am getting frustrated over my PF. Dr Blake's comment: The goal of cortisone therapy is to get the pain down to level 2, and then ice and physical therapy can take it from there. Typically you rest for 2 weeks, then spend a week or two testing it, and if you are not consistently between pain levels 0-2, get a booster shot. I do not like to give more than 3, and again, never get the shot where the plantar fascia attaches into the heel bone, just under the heel bone in the relatively fatty area. 
What else can I try before another shot or any drastic treatment? ( extracorporeal pulse activation treatment or ultra sound therapy)??? Dr Blake's comment: There are so many treatments that should be used before injections with plantar fasciitis: orthotic devices, taping, icing, sleeping splints, physical therapy, acupuncture, calf stretches, deep calf massage, topical creams, various shoes, no barefoot walking, boots, etc. So, without knowing anything else you have tried or are using, it is hard to advise you. Hope this helps. Rich
                                               Thanks so much for your time,
The patient's response:

Thank you so much for responding so quickly! Just some clarification. 1.  Does it sound like my shot was in the heel bone? I believe it was where my worst pain was and where the facials come together in the heel? Dr Blake's comment: Typically the shot is under the heel bone in the fatty area that can form a bursae. This is the safest spot to inject. See my video below.

 Is 2-0 pain very little pain on 0-10 scale?Dr Blake's comment: Yes, you are still smiling. 

 3.When should I go back to my full 11 stretch Pt program 2 times a day? Dr Blake's comment: You can do intense plantar fascial stretches starting at 2 weeks. 

 4.Can I use a towel and sit up on floor to do the toes to nose stretch you said? Dr Blake's comment: As long as it is gentle. 3 times daily for 30 seconds only---1 rep.
How many sets and how many times shall I do these? And how many times a day? I believe I should do this for 9 more days?
                                              Wish you were in Phila. area! I would certainly be one of your patients!!!
                                                           Thanks again,

Patient's comments:
Dr Blake,

Thank you SO much!  I feel a lot more confident about the future after reading your response.

I've been using your taping method on and off for months.  I've been doing a lot of resistance band exercises but after watching your video, I think I was letting the tendon on the front of the ankle do all the work.  I'm also doing a lot of arch exercises, picking up marbles, bands, doming my arch, etc.

How often should I use the tape?  I was a little nervous that I may have been weakening the PTT by wearing it too regularly.  Will the exercises offset that?
Dr Blake's comment: As long as you are doing the exercises, the taping is fine. Every 4th or 5th day go without the tape and see how you feel. Do it intentionally on days you will be alittle less active. 

Would you be able to recommend a podiatrist in New York City who has experience with PTTD?  As you can see, I haven't had the best luck here.
Dr Blake's comment: I would travel to Long Island to see my buddy Dr Karen Langone. She is wonderful

Again, thank you so much!  

How To Begin To Run after an Injury: Walk Run Program Video

Please enjoy my latest YouTube Video on beginning to run (especially after injury). Rich

Friday, May 20, 2016

Posterior Tibial Tendon Injury and Long Term Concerns

Hi Dr Blake,

I've been reading your blog archives since I first started having
problems with my foot.  It's kind of a long story, so I apologize in
advance for the length.

I am/was a runner.  I ran anything from 5K through ultras.  I had been
running in the same pair of orthotics for 4 years at that point and
never had a problem.

Then last May (2015) I developed PF in my right foot.  I rested, iced, rolled
and it wouldn't go away.  I saw a Sports Med Doc who eventually gave
me a US guided steroid shot into the PF.  He had me run on it within
three days.  I was fine until two weeks later when the shot wore off
and then I was worse than before.
Dr Blake's comment: Patients get cortisone shots for plantar fasciitis all the time when a plantar heel bursae forms. So, the shot is into the bursae, not the plantar fascia. It is always risky to inject right into the plantar fascia with cortisone, for fear of causing a rupture. The odds of a rupture are small, but it can happen. If the pain intensifies following a cortisone shot in the bottom of the heel, assume that the plantar fascia tore, and start plantar fascia tear protocol of 3 months in a removable cast. 

The pain was still bearable, I could walk but not run.  In September,
one month after the shot, I was hiking and felt a pop in my arch just
in front of the heel but more towards the outside of the foot.  The PF
got a lot worse after that.
Dr Blake's comment: This is when it completely tore.

I saw a podiatrist right after that.  The area was red and puffy and
he noted that my ankle rolled in a little more on that side.  I have
very high arches and roll in a little on both sides so I didn't make
note of that.

He had me fit for corrective orthotics.  When they came back, they
inflamed my heel really badly.  I started aggressively rolling and
stretching my arch (I think this is part of where I went wrong and
tore or worsened the tears).  I kept having the orthotics adjusted
because they really hurt my right foot.  They adjusted the left to
match, even though I was fine on that side.
Dr Blake's comment: So you are in the Immobilization Phase. This is the time you should be in a removable boot with heel cushion, or modified arch support to transfer weight into your arch and cushion and protect your heel. 

About this time, this is late November now, I was at the gym and
couldn't do a heel rise.  My foot was in almost constant pain, my
podiatrist was very dismissive and told me I was fine.  He didn't
really seem concerned with my pain or inability to do a heel rise.  He
told me that I shouldn't be doing them anyway with the PF (??) but
sent me for an ultrasound "for my peace of mind".
Dr Blake's comment: The inability to do a heel raise indicates the arch has been compromised. As you begin to lift your heel, all the weight goes from the heel to the supporting structures of the arch, and eventually to the ball of the foot. But when you can not lift your heel off the ground, some structure(s) has been injured that helps lift up the arch (Plantar Fascia, spring ligament, posterior or anterior tibial tendons, etc). 

It showed that I had a full thickness partial tear of the PF and split
tear of the PTT.  He put me in a boot and wanted to see me the
following week.  Immediately the boot hurt, it had no arch support so
he put in lifts.
Dr Blake's comment: It is good to have an arch support inside the boot in situations like this. 

By the next day, my foot started to swell and the
pain was excruciating. 
Dr Blake's comment: There are 3 sources of pain: mechanical (due to the injury), the inflammatory reaction to the injury, and the gradual onset of nerve hypersensitivity for your body's protection (the worse of all the pain sources). You were now really triggering nerve pain affecting the sympathetic nervous system with some swelling and possible skin discoloration. Ideally, this gets everyone's attention by now. 

I started using crutches the following day.
By the time I saw him the next week, my foot was painfully swollen and
it was discovered that I developed a blood clot in my calf.  He took
me out of the boot and had me NWB.  This was mid December.  After that
he took one phone call from me telling me to stay NWB and that he
wouldn't see me until I was cleared by a vascular surgeon.  I was
cleared, but that podiatrist didn't take or return my calls after
Dr Blake's comment: I apologize for my profession. It was clearly over his head, but you had a bad reaction, and doctors are human and can behave badly. 

In the beginning of January, I started seeing a new podiatrist.  She
ordered an MRI that confirmed the PF tear and showed a small
insertional tear of the PTT.  She thought I needed surgery but her
colleague came in and said that it was small and he thought most of my
problem was from atrophy.  He wanted me to go from the crutches to my
sneaker.  In a matter of five minutes I had gone from needing surgery
to needing nothing, not even a boot.

I was confused and still in pain so I decided to see an orthopedist
foot and ankle specialist.  He had me go from crutches to a boot,
which I thought was reasonable.  He said that the PTT tear was small
and most of the problem was from the large PF tear.  My arch still
hurt in the boot so he had me wear the orthotics I had gotten in
Nov/Dec in the boot.
Dr Blake's comment: Thank you, finally some reason applied to this. 

Around this time, I started getting tingling and pain in my left PTT.
We thought it was compensation. Mid February I came out of the boot.
I was doing physical therapy twice a week and things seemed to be
improving.  The PF pain was gone.  I was able to do weak but pain free
single heel rises.
Dr Blake's comment: I am so happy when the pain got out of control, with the swelling, that you do not develop a condition called "Complex Regional Pain Syndrome". The Golden Rule that applies here is to get the pain level between 0-2 as quickly as possible. That just did not happen. Pain syndromes from the Posterior Tibial Tendon tend to always be on both sides, with different starting dates, so after you identify the posterior tibial tendon as a source of pain, immediately start doing some preventative things for the opposite side (orthotics, strengthening, or simply just icing). 
I kept having medial ankle pain whenever we would do any balance
exercises.  I took a day trip walking around a city and afterwards I
had swelling all long the left PTT.  I was very concerned and went
back to the orthopedist.  He put me in an aircast PTT brace and told
me that he'd send me for an MRI if it didn't improve.  I asked him why
this was happening and he said he didn't really know.  I have very
high arches and that should protect the PTT.
Dr Blake's comment: High Arch feet have worse problems with posterior tibial tendons if the arch starts to fall. High Arch Feet are more unstable in general than pronated flat feet, which can have more alignment issues. High Arch Feet need more muscle/tendon strength around the ankles to keep upright. High Arch Feet never get good arch support from shoes, OTC arch supports, and even most custom foot orthotic devices, so relie on tendon and ligament strength. When these are compromised, even by simply favoring one foot for awhile, pain begins.  

Sorry, I know this is long, I'm almost at present day.

The symptoms calmed down and I stopped using the brace after about a
week.  I kept trying to figure out why the left was hurting me.  I
decided to try my old orthotics again, the ones from now five years
ago, and my left PTT calmed down immediately.  The right one
aggravated the heal and irritated my ankle.
Dr Blake's comment: Good detective work!! Something is off. 

I thought the problem was that they were old and needed some tweaking.
I dug around and found the name of the podiatrist who had made the old
orthotics.  He took x-rays and discovered that I have an accessory
navicular, which, he says, is very uncommon in high arched feet.  He
has scheduled me for shockwave treatment on my PTTs.  He wants to have
the old orthotics refurbished and has me wearing them with a gel heal
Dr Blake's comment: I have no experience with shockwave, but it is to break down scar tissue, and there is good scar tissue presumably helping heel the Posterior Tibial issues. 

The shockwave won't fix the right foot where the arch falls a little
but he thinks that it will help heal the damage.  The plan is to try
to stop it from falling further with my old orthotics.  I've tried
wearing just the old orthotics but on the right foot, the one that
tore, they cause my arch and ankle to ache badly, and the outside of
my foot to hurt.  Yesterday I was limping, my ankle swelled and
something by my lateral ankle sounded like a knuckle cracking when I
walked.  Today I'm wearing the orthotics that hurt the left foot
because they are better, but not perfect, on the right.
Dr Blake's comment: Definitely, you can temporarily wear 2 different generation orthotics on the right and left, or a custom and OTC, on each foot, to handle the pain aspect. Without more complex information, we have to listen to your body and let pain be your guide. 
My questions are:

Can they make me one orthotic to deal with the PTTD on the right side
but not make the same adjustment on the left?  I think that's what
caused the problem on the left side.
Dr Blake's comment: Yes they can. You have very different needs for each foot, so the orthotics made should reflect that with different support. If you were in my office now, before I made anything else, I would try to understand why one orthotic feels good, and one causes problems. It is in knowing that info that you can redesign a new pair to help. 
Can orthotics really halt the progression of my arch falling?
Dr Blake's comment: Never on there own. Orthotic devices are used to stabilize the foot, along with taping, bracing, and good shoes. Then, foot strengthening exercises like the ones in the video below, can triple the strength on the tissue. What you do not know is if there is a degenerative process that will continue in the ligaments or tendons. You have to set a one year goal to perfect your orthotics, your ability to tape as needed, and triple the strength of your ankles and feet.

Will I be able to run again if I have proper orthotics?  Will anything
get me back to running?
Dr Blake's comment: Without knowing everything, my expectation would be that you could run again. Once you can walk 30 minutes for 2 weeks without pain, you can start a Walk/Run program with stability shoes, power lacing, great orthotics, and some version of posterior tibial taping like in the video below. I love having you begin to run as soon as possible, when walking is fine, because your feedback is crucial to modifying your orthotics, changing shoes, perfecting taping, etc.

Is having the accessory navicular removed a reasonable option?  From
what I've read, they anchor the PTT down where it should have been
instead of doing a tendon transfer.  If that's true, wouldn't it be
better to have that done before the tendon stretches out even further?
Dr Blake's comment: I understand completely what you are saying, but right now it is preventative surgery, and that does not sit well with me. I would have a better feel  for that based on the ease or difficulty getting back to running, the level of pain is have to constantly deal with, a repeat MRI and even CT scan looking at the tissue. I have seen plenty of accessory navicular bones that cause no problem whatsoever. I hope this has been somewhat helpful. Rich

I'm really starting to lose hope that I'll ever be able to even go
about my day without one PTT or the other bothering me, let alone run
or hike or any of the other things I love.

Thank you so much for taking the time to read this.  I appreciate any
advice you may have to offer.


Wednesday, May 18, 2016

When to Use Foot Orthotic Devices

Hi Dr Blake,

I just wanted to get your thoughts on the question that I have which is some patients will ask me "Do I have to wear orthotics / or a heel lift for the rest of my life?''

I generally respond with

- it depends on the severity of the condition

- as the stress on the injured tissue is reduced which allows the tissue to heal and adapt to its optimal function over a period of time,
I can gradually reduce the correction of the orthotics and incorporate corrective exercises to see if the patient is able to adapt without orthotics.

If symptoms reappear when the orthotics is removed after the patient is asymptomatic, then I will explain that the patient will need to continue wearing orthotics.

Looking forward to your response.


Dr Blake's response: 

     Most definitely. I explain that orthotics, like glasses, are necessary evils to be used as needed. For some injuries like sesamoid fractures, it can be easy two years of mandatory use, and other injuries like plantar fasciitis, only two months longer than the symptoms. That is the injury protection part. Now, when we are evaluating patients, some patients get the same problem over and over, so long term use of orthotic devices for activities that produce those symptoms are important. But, they may only wear them to run twice weekly, or if they have a big backpacking trip coming soon. 

     And then there are the patients who have very severe biomechanical problems that should always wear their orthotics if the orthotic devices can correct that problem. These are patients with severe pronation, PTTD, lateral instability with chronic sprains, etc.

     A subcategory of this are the preventative patients. Patients that wear orthotics to slow down the course of their bunions, forefoot neuritis, heel pain, achilles symptoms, knee degeneration, frequent ankle sprains, etc. They probably could get by without orthotic devices alot, but chose to use them AMAP. 

     And you bring up a great point about exercises. If you are using orthotic devices to reduce the effects of pronation or supination, you should place that patient on exercises done 3 times weekly to do the same thing. As they get stronger, than they can go longer without orthotic devices, and perhaps not have to use them at all.  Hope this helps. Rich

Monday, May 16, 2016

Recent Sesamoid Fracture with Fear of Osteonecrosis

Dear Dr. Blake,

I'm sure I speak for everyone when I say, "THANK YOU for your informative website and sharing your expertise!!"  I have seen 2 orthopedists and 1 podiatrist and they have only helped me a mere fraction of what I've learned from your website.

My MRI shows "Markedly abnormal tibial sesamoid, suggestive of fragmentation and osteonecrosis."  Based on MRI, the podiatrist predicts 90% surgery for me, but he says that I can try doing conservative tx (8 weeks immobilized, NWB).

On 4/20/2016, my foot injury occured after many months of competitive tennis (no orthotics, pronated foot, high arch)   I had severe pain and could not put any weight on my foot and was in a wheelchair for several days.
Today (3 weeks post-injury), my pain level is 0-2 when walking in flat shoes or tennis shoes!   My 1st Met Joint + Big Toe is swollen; swelling seems to have increased after 1-week of NWB.

I hope you can please help with these questions (which I believe will help many other sesamoid sufferers):

1. Here is the million dollar question:
   For sesamoid fracture recovery, do you advise "NO weight bearing (NWB)" or "LIMITED weight-bearing"?
  (After 1-week of NWB, my GTJ is more swollen!  I see where it is mentioned NWB may increase swelling and also about how NWB can cause mineralization of sesamoid.)
Please clarify:  What is best for sesamoid fracture:  NWB or limited weight bearing and if so, how much?

2.  Will Exogen Bone Stimulator improve healing of a "fragmented" sesamoid?  
3.  The doctors said the MRI quality was poor (like low definition!).  Would a repeat MRI be helpful at this point to obtain better views of sesamoid in order to properly diagnose if it's fractured or fragmented and if there truly is osteonecrosis?   

4.  Will Contrast Bath help with my osteonecrosis?

5.  Do you advise wearing the orthotic boot when sesamoid patient is SLEEPING AT NIGHT TIME or RESTING ON COUCH... or is it okay to sleep without orthotic boot?   Is it helpful to Spica Tape(Plantar-Flexion) of Big Toe,... ALL of the time or only when sleeping? 

6. For a fragmented sesamoid, is the conservative treatment (3 months rest) the same as for a fractured sesamoid?

7.  May I please, please send the MRI to you for your expert review?

Thank you again for sharing your time and expertise!!!  
Kind regards,

Dr Blake's response:

Linda, sorry for your predicament. As long as you can accomplish 0-2 pain level, partial weight bearing is preferred for bone mineralization. NWB always causes more swelling and pain, making decision making harder for progress. Exogen helps strength of bone, but no one is sure about the fragmentation. I have patients doing well with fragmentation and others waiting for surgery. It is one strike against you, however, did you say this was less than a month old. Fragmentation from bone death increases surgery, fragmentation from the original surgery may not. You need a CT to really look at the fragmentation. Yes, get the best resolution MRI you can, call around. Also, may be they can do a CT scan at the same time. Contrasts bathing done twice daily is the best thing you can do at home to really eliminate the deep swelling which cuts off the circulation and leads to bone death. You should not need anything at night, unless you are a sleep walker. Right now, you are probably a fractured in multiple pieces than a fragmented patients. Once you have the CD of the new MRI and/or CT scan, you can mail to Dr Rich Blake 900 Hyde Street San Francisco, CA, 94109. I am happy to help. Rich

Hello Dr. Blake!!!

Thank you sooooo much for your reply and concern!!!

Yes, my fragmentation and osteonecrosis is from injury (it is not from surgery).
Yes, the injury occurred on April 20; it is less than one month old.   Does that increase my recovery chances,... and does it change the treatment plan?  
I play competitive tennis (pronated foot with high arch) which resulted in pain in my 1st Met;  this got worse six months ago.   Doctor suspected stress fracture of 1st Met so I was put into an AirCast Cam Walker on April 15, the day before I went on a cruise ship.

On April 16-20, I wore the AirCast Boot on the cruise ship where I was walking about 2-miles per day because it was a big ship with lots of trips to the food buffet!

***Stupid me,... when walking in the AirCast, I modified my gait in an attempt to keep weight off of my 1st Met...  so my gait was very supinated AND I flexed my Big Toe upwards for 2 miles/day on the cruiseship!   I have since read that supination and big toe dorsi-flexion can expose the sesamoid and moves the protective fat pad away from it's normal location.   I believe my modified-gait resulted in exposure of my Tibial Sesamoid to the hard insole of the Aircast Cam and this resulted in my crushing the sesamoid!!!  

It was cruise day#4 when suddenly after a lot of walking in Aircast, my R foot was suddenly in so much pain (felt like broken bone)  that I could not bear any weight on it and ended up on crutches!    The date was April 20 and my R foot had swelling, severe pain in 1st Met especially planter side, with intense pain upon dorsi-flexion!  
OMG, is it possible that I crushed my own Tibial Sesamoid in the AirCast Cam by walking 2-3 miles with an exaggerated-supinated gait and with keeping my big toe dorsi-flexed upwards?!   Do other patients complain about sesamoid pain in the AirCast Cam?
After my MRI, the doctor put me back in to the AirCast (despite my suspicion that it caused my injury).   The AirCast hurt my sesamoid so after a few days, I took it off and my foot was more swollen.   I now wear a DARCO Ortho Wedge instead of the AirCast.  Is the Darco Wedge okay to use for 4-8 weeks of immobilization and limited weight bearing?  
If the tibial sesamoid dies, then is there an option to leave the dead sesamoid in my foot or is sesamoidectomy required?

Thank you again for your invaluable advice and I will follow all of your advice.   I will also try to pursue another MRI and/or CT scan and I will mail it for your expert review.   Thank you so much again.  

With sincere gratitude,
~ "Squashed Sesamoid"  

Dr Blake's response:
Increase chances greatly, it is not in a chronic state.

Cam Walkers hold the weight down for long periods on the heel and forefoot. Many times you have to modify Cam Walkers to alleviate pressure either in the heel or ball of the foot. So it is possible the Cam Walker caused the problem, but it is important that you are wearing it now with some insert that takes pressure off the sesamoid. The Darco Wedge is okay, but causes an altered gait (not good), and no weight on the sesamoid (some increase in swelling retention and bone demineralization). Okay to wear until the Cam Walker with partial weight bearing has some accommodation to protect the sesamoid and reduces the pain consistently to 0-2. 

No studies about leaving dead sesamoids in there. 

Hope this all helps. Rich

Hello Dr. Blake!!!
Thank you again and your expertise and info are very helpful, and much appreciated!!!

I have one question and I hope this will help others to avoid what happened to me!
     At the risk of sounding really dumb,... I think I caused the osteonecrosis (AVN) sesamoid!
While on the cruise, the pain from my sesamoid fracture was intense and I had NO pain killers, not even Tylenol.   To relieve the pain,  I put ice in a surgical glove and then applied it directly to my foot and tied it on to my foot,... and I left the ice on my foot for one HOUR!   After an hour of icing, my GTJ was numb and skin was red/swollen.    To alleviate the intense pain, I repeated this direct icing 4-5x/day, such that my GTJ was over-iced for 4-5 hours/each day for about one week!  

Is it possible that my excessive-icing applied directly to GTJ caused AVN of sesamoid?!?

Dr Blake's comment: I guess it is possible to cut off enough circulation to kill the bone, but again, I am not sure if you have osteonecrosis yet. It is good to point out that icing more than 20 minutes can cause nerve damage, so you more likely have nerve problems now. The nerve hypersensitivity will improve likely with massage and perhaps nerve creams like OTC Neuro-Eze. 
I read that the sesamoid has very limited blood supply and this raised my concern and regret that by OVER-ICING, I inadvertently froze that limited blood supply, resulting in AVN!   I also read that AVN sesamoid is uncommon/rare.  
Thank you for helping with my question about excessive-icing and AVN sesamoid! 
Hopefully others can learn from my mistake.

I am working on getting the MRI repeated and plan to share the new MRI results/CD soon.

There is scant literature about sesamoid and very few doctors who know how to DX and treat it.
You are a RARE exception and you truly are a doctor sent from Heaven to help me and others.

Dr Blake's comment: We are all our own worse critics, so I appreciate the reference to Heaven. I hope to make it there someday (after a millenium or two of purgatory of course). 

Thank you again and with sincere gratitude,

Accessory Navicular: Blog Comment

Dr Blake, My daughter is 9 years old and started having feet pain off and on last summer. Since January it became more consistent and now it is daily. We initially went to a orthopedic doctor and he referred to PT and a podiatrist. In the mean time we bought New Balance shoes and insoles. She btw was determined to have collapsing arches that had apparently aggravated the supporting tendon. During PT we started noticing a place on the inside of her left foot that now protrudes all the time and is very tender. We have also been to our family physician. Everyone just wants her in arch supporting insoles. We have been given anti inflammatory creams as well. Nothing works! We have tried all creams, advil, several different insoles, icing, stretching and physical therapy. We also took her out of karate, and reduced other activities. My daughter is in pain every day. They say her xrays are normal. Below the navicular bone there are 3 little pebble looking shapes. I am wondering if that extra bone is forming??? I am just at a loss of what to do next. Every shoe we have seems to really aggravate the protrusion on the inside of her foot. Any advice would be appreciated.
  1. Dr Blake's response:
  2. Thank you for your comment. Definitely sounds like the beginning of accessory navicular syndrome for sure. Buy some 1/4 inch adhessive felt which you can adjust/thin as needed to build a horseshoe accommodation for shoes. You really need to get her into a removable boot for 3 months to begin the Immobilization Phase ASAP. This should be accompanied with 10 minute ice packs three times a day. Since there is always time a home that she will walk without the boot, she will know if it is getting better. You stay completely in the boot 2 weeks longer than you need to. During the boot time, you have a podiatrist make a custom orthotic device with an accommodation. Hope this helps your daughter heal faster. Rich