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Saturday, July 30, 2016

Monday, July 25, 2016

Sesamoid Fracture: Email Advice

Hi dr Blake 

I am a physician in early 50s with dx of medial sesamoid fracture since April 2016 after initial misdiagnosis of gout. Been reading your blog on sesamoid injuries and I am impressed with your advice to so many fellow sufferers. 

Here is my story with my main question now at the end

1.  April 15 X-ray showed R medial sesamoid fracture. Likely from hard sprinting and then 3 days later stepping off a curb with sharp pain in ball of foot. DPM saw me on April 15 with x ray and made dx. Tx was low dose cortisone injection and J pad w sesamoid cutout and activity modification. 

2. Only mild improve 2 weeks later so start. cam walker with metatarsal padding.  Then signif slow improvement for about 3 weeks but then signif relapse with swelling of MTP joint and pain similar to initial presentation of April when I drove in stop and go traffic While in cam walker  
Dr Blake's comment: Definitely against the law in California to drive with one of those boots, even on the left foot. 

3.  End of May- now in relapse I get a second low dose cortisone injection and MRI scan. Go to crutches and non weight bearing. MRI shows medial sesamoid fracture with AVN, stress reaction in big toe and maybe some signal in fibular sesamoid.  DPM recommends more time non weight bearing and orthofix EMF stim. If no improvement by end of July. Then consider medial sesamoidectomy. I used EMF stim 3 hrs daily for 2 weeks and it seemed to cause more swelling and pain so I discontinue it at end of June. 
Dr Blake's comment: These bone stimulators do increase circulation, so the 20 minute daily of Exogen is preferable. Non weight bearing I hate, because it always causes more swelling, which causes more pain. The MRI results suggesting AVN really forces the docs hand, since the AVN protocol is non weight bearing. 

4.  I get second opinion from orthopedist foot specialist in notable academic center early July who reviews history and exams and radiology. Says stay with cam walker and non weight bearing for another 8 weeks, start PT to help with reconditioning and strengthening foot muscles, and exogen stim which he feels is more effective than EMF. Wants to avoid surgery because of risk to the fibular sesamoid. While waiting for insurance approval of stim, I get 2 acupuncture treatments with low electrical stim which seems to help.  I just started exogen 20 min treatment for 3 days and now notice possible increase in swelling and pain. Call exogen and they say swelling not common but possible. Tell me to stop 1 to 2 days and restart 5 min a day and build up to 20 again. Thoughts?  Does bone stim cause more swelling again? Maybe this is sign of increasing vascularity and bone healing?  Just ice and do your contrast bath technique?
Dr Blake's comment: Yes, bone stims increase circulation. Stay with the 20 minutes daily since the bone strength is crucial. Twice daily ice pack, and once daily contrast bathes with one minute heat one minute cold reps for 20 minutes for deep bone flush. 

Also crutching around is breaking down my body. Now possible big toe tendonitis in my other foot and R elbow tendinitis. So using I walk 2.0 no hands crutch to give arms a break although I am worried about developing sesamoiditis in my other foot.  More padding now in my other shoe to avoid further strain on my good foot. 
Dr Blake's comment: I love the concept of the iWalk but have no experience. I am happy to review your images. Just take a photo of the T2 images for 3 planes of the sesamoids to start, and several xray views you have. Have they done a plantar axial view. Rich

Thanks so much

Sunday, July 24, 2016

Ankylosing Spondylitis: Video Presentation

I have had several of these patients in my practice over the years with this rare condition. It is tested with a blood test called HLA-B27. It can be associated with chronic heel pain. My current patient Keith, no need to change his name, only comes in for me to cut his toenails since he can not bend over himself. Secretly, he only really comes in to work on his stand up comedy routine, but I benefit for the occasional good one!!


Q: What did the blonde say when she saw the sign for the YMCA?
A: "Look, they spelled Macy's wrong!"

2nd Metatarsal Pain: Email Advice

Hi Dr Blake

I am a 37 yr old female of average size and weight - on the thin side actually- presented with foot pain predominately to the first and second digit as well as the metatarsal-phalangeal region.
Dr Blake's comment: What type of pain are we talking about? How does it affect your function, day to day and athletics?

Tried the walking boot for one month without relief. Second opinion doctor ordered mri which showed 2cm bursitis in that region as well as inflammation of the second toe joint.

 I am an active mother but not a runner or extensive athlete. Possibly ill fitting shoes at times. Had a cortisone injection 4 days ago. Have had some nerve pain in the first and second toe but not terrible post injection, but I am not having total relief from the foot pain. 
Dr Blake's comment: It can take 2-3 weeks, if long acting cortisone was used, to see the overall effect. 

Still it is there as before but slightly reduced. The initial injury pain began 4 months ago. Took oral steroid first and antibiotic - now injection. 
Dr Blake's comment: Do you have the option of physical therapy? Have they tried met pads, Budin splints, accommodative padding, toe crests, etc to check its effect on the pain syndrome? 

Mother recently diagnosed RA however negative bloodwork but positive on clinical presentation. Should I be concerned of an impending RA diagnosis for myself ? Should I be having full relief from the injection and if so why am I not ?
Dr Blake's comment: If you see my post on cortisone shots, it can take 2 to 3 shots to check the effectiveness. It is easy to get several arthritis lab screens done, which I would do in your case. 

Strength Training: Correcting The Weaker Side

This concept of strengthening is truly a big deal. We need to strengthen the weaker side by doing either twice as many repetitions as the strong side, or by breaking down the sets into smaller reps to keep proper technique. This applies to any strengthening program you are doing on both sides, even if you do not know the current reason. Correcting these imbalances will always help you in the future.


Sesamoid Fracture: Email Advice

Hi Dr. Blake, 

Thank you so much for all the information you share on your blog and YouTube channel. I have learned so much over the last week or so while trying to get some relief from my foot pain. I was wondering, is it ever possible to heal a sesamoid fracture without wearing the boot? 

A little over a week ago, I started experiencing intense pain in my foot (I know now that this was from a fibular sesamoid fracture that happened gradually). I couldn't walk on it, could barely stand to touch it, and it woke me up two nights in a row with an aching/throbbing/burning/sharp pain. During the day, the pain was slightly less intense, but my foot was swollen, purplish, and hot. Prior to this, I would sometimes get pain and minor swelling in that area and the side of my foot just below the base of the big toe after running, plyometrics, wearing flip-flops a lot, even some yoga, etc, but rest would take care of it. This cycle went on for about a year. 

After trying to treat the new, more intense pain myself with rest, ice (which made it feel worse), and elevation for a couple of days, I made an appointment with a podiatrist, but the earliest they could see me was several days away (my fault for calling on a Thursday). Since I had to wait so long to see the doctor and none of my shoes were comfortable anymore, I researched a bit on what type might take the pressure off of the painful area and offer good support. I ended up purchasing a pair of Birkenstock Gizehs with a normal, not soft, footbed. My heel sinks low into the shoe, the sole is extremely stiff, and it has support for my high arches like I've never had before. I stopped going barefoot at all and kept those on my feet Friday-Monday. The swelling was almost non-existent and the pain was completely gone by Saturday morning, but I kept my appointment with the podiatrist. He found the fracture in the x-ray, put me in a rocker-bottom boot, and said to come back in six weeks. I've been in the boot for about a day now but I feel like it's slightly increasing the pain (dull throbbing in that area and my big toe joint) and the feeling of inflammation on the side of my toe, and maybe even putting more pressure in that area at times. 
Dr Blake's comment: I am sorry for your dilemma. Even though I prefer the removable walking boots, you can heal a stress fracture to the sesamoid without one. My office handout reflects that as well. You basically have to listen to your body, and create a 0-2 pain level consistently for a 3 month period. The Gizeh is not listed as a stiff sole, but I will take your word from it. Removable boots have to be modified in probably 50% of the situations with dancer's padding, etc, to make comfortable. Plus you need an EvenUp for the other side. Several of the problems not wearing the boot are 1) John Q Public does not know you are injured, and 2) you forget you are in the 3 month period of no pushing off, or it can rebreak.

How is it possible for my foot *not* to hurt if I have a fracture? I took my last Aleve on Friday night. And based on the relief I felt from wearing the Birkenstocks vs the discomfort of the boot, would it be possible to wear those instead of the boot and still heal?
Dr Blake's comment: Sesamoids initially hurt mechanically due to the injury, and then the inflammation comes in causing its own pain. When you were woken up for two nights, you probably had a combination of inflammatory pain and neuropathic pain (the pain produced by the pain itself and your body making the area hypersensitive to protect itself. So, you seem to have addressed the neuropathic pain, and stiff shoes helping with the mechanical pain. Keep icing 10-15 minutes twice per day, and contrast bathing in the evening for the inflammatory pain. 

What is your running shoe recommendation for someone with a very high arch, narrow feet, and a history of a sesamoid fracture? What about cross trainers?
Dr Blake's comment: The high arch feet seem to do better with Brooks Ghost or New Balance 928 with narrow width selections. The 928 has a rocker forefoot. For cross trainers, I like the New Balance 608. I sure hope this all helps. Good luck. Rich

Thank you so much for any advice you can offer.

Sesamoid Fractures:

By Richard L Blake, DPM

The top 10 initial treatments for sesamoid fractures are:

  1. Exogen bone stimulator for 6 to 9 months
  2. Removable boot or a stiff soled shoe like Hike and Bike for 3 months to create a consistent pain free (0-2 pain level) healing environment.
  3. Ice pack twice daily and contrast baths each evening for anti-inflammatory and deep bone flushing. Do the contrast baths twice on non-work days.
  4. During the initial 3 months of immobilization, have orthotic devices developed that off weight the sesamoids.
  5. Learn how to use 1/8th inch adhesive felt from Moore Medical to make dancer’s pads for the boot and for post-boot action.
  6. Learn how to spica tape for post boot action
  7. When you are not wearing the boot, avoid barefoot.
  8. Do cardio, core and foot and ankle strengthening the minute you hurt the bone, and on a daily basis. Keep Strong and Keep Fit!!
  9. Since we are dealing with bone metabolism, make sure your calcium and Vit D intake is good, and get counseling if you think that there might be a bone density issue.
  10. Use strict activity modification principles to keep the pain levels between 0-2 as you go from boot to regular shoes. The weaning out of the boot period can take anywhere from 2 to 6 weeks and no added soreness is allowed.

So, what do we know about sesamoid injuries that may help? Here are my top 20 plus pointers when teaching about sesamoid fractures.

  1. They rarely do not heal.
  2. Even with normal healing, they can take up to 2 years so patience is a virtue here (some fast and some slow, and all patients want the fast ones).
  3. Healing, and feeling better, is based on many factors that are unknown when the patient first presents.
  4. MRIs and CT Scans are common imaging techniques that can really elucidate the problem, and sometimes change the direction of the treatment.
  5. Follow up MRIs, when needed to check healing, are often done between 5-6 months after the first baseline MRI.

6.            The MRI can show initially that you are not dealing at all with a sesamoid fracture, but something else, and prevent treating the wrong diagnosis (self pay MRIs of this area are $500 in the San Francisco Bay Area).
7.            Since we are dealing with bone, we must look at diet, Vit D3 levels, calcium/zinc/magnesium, and bone density.

8.            Treatment of sesamoid injuries flows through 3 phases that are normally overlapping--Immobilization, Restrengthening, and Return to Activity.
9.            When the patient is in the Immobilization phase, the treatment visits should be thinking about (and acting on) the Return to Activity Phase with visits dedicated to shoes, orthotics, strengthening, cardio.
10.         Often times treatment mistakes involve having the patient in the wrong phase (like return to activity when they should be in the Immobilization phase).
11.         One of the crucial aspects of treatment, that can be hard to design, is protected weight bearing inserts and shoes.
12.         As treatment starts,the patient is placed in an environment (be it cast, shoes, orthotics, boot, etc) that maintains 0-2 pain level.
13.         The initial goal is to create this pain free environment for 3 months by whatever means it takes.
14.         Non weight bearing (via crutches or RollaBouts) always increases swelling, so some protected weight bearing is crucial. Every step pushes fluid out of your foot.
15.         The best way for reduction of bone swelling is contrast bathing. Typically, icing twice daily and contrast bathing each evening is needed.
16.         If you are basing treatment on x-rays alone, you may be way off base.
17.         Do not let the joint freeze up (frozen toe syndrome) with routine pain free range of motion or mobilization techniques. Go to YouTube and type drblakeshealingsole Self Mobilization.
18.         Start strengthening the minute you get injured, or at least after you read this, even if it takes some modification for pain. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist. Keep the joint/foot flexible and strong.
19.         Patients with sesamoid injuries are prone for setbacks so do not get discouraged.
20.         If you have a sesamoid fracture, one of the hardest fractures in the foot to heal, get a bone stimulator and begin using. Some insurance companies require 3 months wait to document delayed healing, some not. Self pay for Exogen Bone Stimulator is around $500.

The patient's response:

Thank you so much for all of this wonderful information and for taking the time to type out such a thorough response. I'm especially interested in the mobilization info and eager to watch the videos you mentioned because I was worried about a bit of stiffness in my big toe joint (it's not bad, but I'm glad to know there's something I can do for it). The Gizehs I bought have the classic footbed, so that may have contributed to the stiffness of the shoe. I'm not sure if that makes a difference since this was my first pair, but noticed there were two versions. They're a bit more flexible now than they were when I got them, but they still feel good.  

Thank you again. I really appreciate your advice. You have been such a huge help and I am so grateful!

Sesamoid Fracture: Email Advice

Hi Dr Blake

I discovered your blog/YouTube channel after conducting my own research on my fractured sesamoid bone. I was first diagnosed with this injury 1 month ago when I went to the ER for an X-ray. The ER doctors acted like it was no big deal and told me to follow up with a podiatrist.
Dr Blake's comment: Feet injuries are typically never life threatening, so if that ER doc had just saved someone's life suffering a cardiac arrest, your injury may have seems not that important at that time. 

 I saw a local podiatrist the next week and they put me a in cam walker and told me the fracture would heal it's self in a few weeks. 
Dr Blake's comment: I am sure my sesamoid patients would concur that typically 3 months in the boot is important, followed by 2-6 weeks of weaning out of the boot into shoes with orthotics and dancer's pads to off weight the area. 

They wanted to see me for a follow up after being in the cam walker for 14 days. At this appointment I got the bad news that my fracture had actually gotten worse. The doctor then told me that I was back to square 1, no weight bearing, crutches and to wear my flat walking shoe that the ER had given me. This new treatment plan really confused me and that is when I started to do my own research and discovered you.
Dr Blake's comment: Following these injuries by xray is very difficult. Xrays show the amount of calcium in a given area. When an injury is flooded with healing body fluid bringing in calcium, etc, to the wound site, the relative amount of calcium is less and the fracture looks worse. This would be usually the wrong interpretation of that xray. Yes, the fracture could be worse, but it is not typical unless you fell or had a high impact stumble while in the boot. By 2 months into the injury, the xrays are supposedly 2 months behind demonstrating the actual injury healing. What good are they after the initial diagnosis, unless there is a fall, etc? If I only had xrays to image, I would wait 4-5 months to get repeat xrays. 
I have 2 small children and we are extremely active. I jog, bike and weight train 5x a week so I need to heal this completely. I'm committed to doing whatever I have to and know that it is going to be a long road to recovery.
Dr Blake's comment: You have to listen to your body. As long as you can keep the pain level in the boot from 0-2, typically this is a weight bearing injury. I can not overstep the treating doc, of course, but I find non weight bearing causes more swelling, more pain, more bone demineralization, and slower healing typically. 

I'm currently on day 4 of zero weight bearing. I've been icing and elevating. I have
an appointment to see my podiatrist, but I think that I need to find a new Doctor in the meantime. It seems to me that he doesn't know how to treat this specific injury and is not giving me the correct information on how to heal it. I am going to start the heat/cold baths you recommended tonight. My other questions to you are do you think that I should continue to be non-weight bearing or do you think I am ready for the cam walker with the dancers insert? My doctor seemed to have no knowledge of the insert and seemed to treat it as any old fracture.
Dr Blake's comment: You have to feel comfortable with your treating doctor, and I am sure he means well, and because of the caution going to non weight bearing, you will heal fine. There is no research I have seen on non weight bearing vs weight bearing, but definitely get another opinion. One good place to start is the AAPSM website. Go to their member's list and see if one is near you. These are sports podiatrist who typically are conservative, and are very familiar with this injury. If she/he says the same thing, you can choose to go to whomever. Read all my posts on this subject. 

I'd greatly appreciate any input you could give me. I'm only 28 and as I've mentioned I have children so I'm just very worried about having to suffer from this for years to come. I will be donating to your cause and I look forward to hearing back from you.
Dr Blake's comment: Thank you so very much for that. I wish you well and you can comment on this post or through the email at any time. Rich

Thank you for your help.

Sadie Zeuner

Saturday, July 16, 2016

Sesamoid Injuries: The Meaning of the word Sclerosis

I have been studying sesamoid injuries for years and see sclerosis (dense white) of the bones all the time. I hate when it is just assumed that this is an indication of dead bone. I have not found this one finding to play any role in my determination for overall healing. Here are two references sparked by my patient with a great CT scan documenting healing, but mentioning that sclerosis was seen. I am trying to encourage her that sclerosis is more a sign of normal bone remodeling, whereas bone fragmentation is more a sign of avascular necrosis. I think the use of bone stimulators increase the sclerosis findings, and they are allowing the bone to heal quicker and stronger. Ok, off my platform. Do they still stand on boxes in Hyde Park, London? Rich

Jane (name changed),  here is an article talking about sclerosis as part of the normal healing spectrum. Everything points to you healing fine. Claim it, just do not abuse your foot. Gradually go towards more activity. Rich

​And this slide talks about the sclerotic bone seen that many call avascular necrosis, but it is well vascularized new bone, So, the word sclerosis that does not help, and it more confusing. If you read your report minus the word sclerosis, you should be very happy. Rich

And this article only talks about sclerosis as a normal part of healing. 

And one last reference (read point 22 on page 35). Thanks

2nd MPJ injury: Email Advice

Dear Dr Blake,

I came across your website trying to research my foot problem, however I am not able to view it well (text & images overlap, things are scrambled) I use a Mac and have been trying with Safari and Chrome). I did find you e-mail and hope you don't mind me writing to you directly.
Dr Blake's comment: Not sure what that is about, but I hope it is not a wide spread. It would ruin my blog for sure.

I have not found anyone to help me with some disabling left foot pain in the 2nd metatarsal area and wonder if you have by any chance have any recommendations for specialists in New Mexico.
Dr Blake's comment: Look for Dr Robert Parks in Albuquerque. 

 I am attaching a copy of the MRI I was finally able to get. Summary says “prominent chondromalacia, prominent bone marrow edema and subchondral cystic/erosive change of the 2nd metatarsal head" also "various/adduction of the forefoot osseous structures associated with mild subluxation at the 2nd MTP articulation”. Big toe also showed some much milder issues. There was also thinning of cartliage in both & small amount of joint fluid in both”.

Dr Blake's comment: There was no attachment to this email. The MRI report says that there is extensive damage to the 2nd metatarsal head which typically means at least a joint surgery with cleanout. 

A very quick history of this: about 2 years ago I started having some mild pain in my left foot when going for my daily walks, 2nd metatarsal area. Never had it before. (I’ve only always worn excellent shoes, e.g. birkenstocks, wide toe running or walking shoes, some Keens). In the beginning it was off and on and got worse as I walked. It also got worse in the winter when I had to wear my winter boots or hiking boots.  (I do have severe osteoporosis (-4.5 DEXA) due to hyperparathyroid disease that was not caught in time (I ended up having parathyroid surgery, but my bone density did not improve).
Dr Blake's comment: With that low bone density, you can not heal well when your bones are injured, even in the slightest degree from walking. 

So I went to a podiatrist last year who did X-rays and ultrasound (said x-ray didn't show anything but ultrasound showed a “slight thickening" in the area where I had pain and said maybe a stress fracture) and had his tech put a metatarsal pad on. That immediately made it much worse (told him, just said to keep trying it) and I ended up having to take it off later at home (later, from my own reading, discovered that he hadn't put it in the correct place on my foot). In the following months I could usually still walk in birkenstocks or running shoes, so I thought maybe it would just get better.
Dr Blake's comment: The met pads are to off weight the painful area, so need to be towards the arch just next to the sore area.

Then over a short period of time (about a month), it got significantly worse, very severe pain and I couldn’t walk in anything (except barefoot in the house, though not great on the tile floors). Even started having pain up ankle and in heel of right foot but probably from way I was compensating when walking. My second toe seemed to (suddenly?) be very loose at the joint, which I hadn’t had before. Saw a podiatrist who thought I had capsulitis (though from what I’d read it didn't seem like I had the symptoms of that). She only did a very brief exam (just touching a few points in my left foot) and wasn’t interested in x-rays.
Dr Blake's comment: So, sounds like arthritis in the joint, possibly from osteoporosis and wear and tear, and then plantar plate tear with resultant joint instability. 

So I went for a consult with an orthopedic surgeon. He read the MRI, and in addition to the radiologist’s report he said there was a small cyst in the area and the tendon was "stretched out”.  He mentioned surgery that could be done but said he’d “hate to be the one to put a scalpel in me” (and really didn’t seem to be recommending it). Said I could get a steroid injection under X-ray but also said it could worsen the tendon issue and at best is only quite temporary relief. Said physio wouldn't help at all and a boot would throw off my gait more so didn’t recommend.
Dr Blake's comment: Yes, avoid the cortisone. Consider the New Balance 928 wide with rocker bottom. You need to get a Budin Splint looping it gentely over the 2nd and 3rd toes. Ice 2 or 3 times per day. The splint is like a ankle brace for ankle sprains. You wear for 6 months minimum. 

Needless to say I’m extremely reluctant to have surgery, and I don't even know if I should have a steroid injection (for only temporary relief and perhaps worsening of tendon, and from what I’ve read, risk to plantar plate), but he said that’s all he can offer. I’ve being reading several medical journal articles…with no real answers, except that with the marrow edema, there’s a danger of necrosis (which orthopedic surgeon acknowledged), mention of need to get at underlying cause, and some say immobilization (though orthopedic didn’t say this).  I did read some cases of bone marrow edema treated with IV iloporst which I hadn't read at the time of my appointment, so didn’t ask about that.  I asked about  a couple other things I’d read about  bone stimulators, PRP and he said "they are extremely expensive, and show no scientific evidence”. I’m not sure how the marrow edema and chondromalacia and other things mentioned on the MRI relate to each other, or what to do about any of it.
Dr Blake's comment: I am hopeful Dr Parks can help you. You can also look on the AAPSM website for other members on the sports academy. They tend to be less aggressive for surgery. Surgery may be what you need, and the plate may now be already torn. Try to create your painfree environment (0-2 pain levels) first either with rocker shoes with splint or Anklizer boot (with EvenUp on the other side if needed to level your hips) with splint. Ice to calm down. Comment on this post if you have other thoughts, or progress over the next few months. I will be off line in September. Hope this helps you some. Rich

I’ve not had any treatment really except to try on my own metatarsal pads with no real success, but at this point it’s painful to walk at all. The only activity I’ve done for the last month is walking around the house as necessary. Is there any treatment I could try? Does something like this get better eventually?Do you think a steroid injection would help?
Dr Blake's comment: No steriod please. The joint sounds messed up, so it is hard to predict the outcome. Just take one step at a time, and create that pain free environment. I have seen very bad looking MRIs and x rays that did not hurt, so your pain and function are the best indicators over the next 6 months on whether surgery is needed. 

Thanks for any help or suggestions you can offer,

Friday, July 15, 2016

Sesamoid Injury: Email Advice

Dear Dr. Blake,

     Last July I was dancing in a regional production of Hello Dolly.  I began experiencing pain in the ball of my foot and up my big toe but didn't really think much of it because I was dancing long days in heels and was used to some discomfort. 

     The pain got worse and worse until I could barely walk after the shows.  I took a week off from dance after the run of the show was over and felt completely fine.  I went back to dance and felt good after my first class back but after my second I was experiencing the same pain.  I went to a doctor who gave me an X-ray that showed I have partial sesamoids. 
Dr Blake's comment: Partial sesamoids is a name given to the sesamoids when the condition is considered congenital, not traumatic. 

      She thought I maybe had fractured one of the bones and put me in a boot for a month.  I tried to start dancing again after that month and experienced more pain.
Dr Blake's comment: I tend to see that if a boot is needed, 3 months is the key unfortunately. We all think we will be the exception. 

      I went to a podiatrist who made me orthotics and told me to get an MRI.  He told me dancing wouldn't further damage it, so I began dancing at a lower level of intensity.  I went to see a doctor to give me an MRI, and he said that his advice would be the same regardless and just told me to take five months off from dance.  I went to a different podiatrist who told me to "light up the area" before the MRI to be sure that the sesamoid was causing the problem.  He suggested that the day before the MRI I aggravate the area, so I ran around my block a few times and subsequently felt a lot of pain.  I brought my MRI to a dance doctor in NYC who suggested I get a PRP injection at NYU.  I went to NYU and they gave me an ultrasound which showed I did not need a PRP injection, but they said that my fracture was very bad and very active. 
Dr Blake's comment: So, you have a fracture, and your career depends on it. I love Hello Dolly BTW and my son played Patrick in a local production. I know it does not help you. Fractures need prolonged immobilization with the boot with dancer's padding, bone stimulator for 9 months,  contrasts and icing combinations, spica taping, dancer's padding, orthotics with dancer's padding, dietary counseling with calcium and Vit D intake considerations, etc.

     I was then put on crutches for three weeks.  I saw a podiatrist in NYC who specializes in dancers and he said that I should stay on crutches for another four weeks and gave me a bone stim machine.  I went from the crutches to a boot to new orthotics.  I then started experiencing a very mild amount of pain after walking long distances.  I got another MRI  (after stopping the bone stim for three weeks) which showed no difference.  I have been told to try dancing and seeing if I have pain, and if I do to consider surgery.  
Dr Blake's comment: Professional athletes do have surgery more often than us mere mortals, due to the loss of income. But, sesamoid removal is a potentially career changing surgery. For the patients who can afford to wait, a careful 3 month immobilization period with bone stimulation, followed by a 3-6 month restrengthening and return to moderate dance phase, and finally full activity. I would be happy to look at your MRIs for an opinion. My address to mail is Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

     I have also been told that I shouldn't ever consider taking out the bone.  I really feel like I am at a complete loss with very little direction as to what to do next.
Dr Blake's comment: Now that is baloney, or salami, or swiss cheese. Patients do well post sesamoid removal. And, unfortunately, when your care is not great, you have a higher chance of needing surgery. You only have a 10% chance that the surgery, when all is said and done will effect your career. Even, though 10% is high, it is considered wonderful in surgical odds. When I have a patient who needs sesamoid surgery, I wish I could have avoided it, but I never feel like it will ruin their life. It is a highly successful surgery. 

     I am not sure if some pain is normal when getting back to dance or how to gauge whether it has healed.  I have one doctor telling me it has to be healed because I experience very little walking pain and have really exhausted my options.  My other doctor seems to think it hasn't and wants to follow the MRI.  I am 20 and feel like I am watching my dance career slip away.  I need to get back to dancing as soon as possible but am so scared to further delay the healing process.
Dr Blake's comment: I like the first doc. Yes, continue the bone stim for 9 full months, continue to keep your walking and dancing levels at a 0-2 pain level, learn to spica tape, learn to maximize your own dancer's padding in all shoes. Avoid barefoot, as you increase activity keep the pain at 2 or lower. Look at your Vit D levels, your calcium intake, your bone health and diet. Get bone density test if there are questions. Send me MRIs if you need some advice. I hope this helps. I hope you dance in San Francisco and I can watch you. My wife and I would love it. Good luck . Rich

Thank you,

Saturday, July 9, 2016

Sesamoid Injury: Email Advice

Dr. Blake,
Thank you for taking the time to read through this email. I just started reading through your blog and have read all the sesamoid related posts over the last couple days trying to soak up as much information as possible. I have learned that I need to ice twice daily now and start contrast baths at night, but there are some things I'm worried about.

To preface I dance classical ballet as a hobby so my typical cross training is pilates and cardio. Last summer (June '15) while on vacation I wanted to lose some stubborn weight so I upped the cardio (plank jacks, burpees, jumping jacks, etc). I wasn't paying attention to the fact that most people wear shoes while doing these exercises and I prefer to be barefoot anyways so I didn't bother with shoes.

Jumping Jacks without shoes on a hard surface is a recipe for disaster

 I started to notice a stubborn pain in my left foot under the ball and a severe decrease in ROM. I paused all exercise that involved being on my feet and stuck to mat pilates only to heal. It seemed to get better though it was still very stiff. So I began a very typical dancer's routine for stretching and strengthening my feet with therabands and returned to more static plank exercises to see what I could handle.

Everything seemed fine until early September when I was doing plank jacks (still barefoot) and felt a very sharp pain in the ball of my foot.

This time it never healed. I had to pause dancing and the cardio exercises I liked and resume mat pilates. But the pain kept getting worse. In mid October I was so frustrated with how stiff it was that I pulled on my toe until something popped and resettled. The pain greatly reduced very quickly after that, but I really didn't give it much time to heal. At the end of October I went to a career fair and walked all day in heels until I was in tears. I had to stop exercising again for a few weeks and I started icing around the base of my toe after massaging it. Nothing was improving the range of motion but the pain was now down to a three most of the time (which was amazing to me).

In January I decided whatever was still wrong was chronic and started to dance again. It wasn't too hard to dance on my foot, but as a ballet dancer I have a high pain tolerance and really my pain was chronically around a 3 or 4. I started wearing sesamoid pads in my shoes and stayed in some ancient running shoes all the time except at dance as any other kind of shoe caused more pain.
Dr Blake's comment: Most dancers need to learn the difference between good and bad pain.

At the end of last semester I went to the doctor (finally) and got x-rays. The doctor referred me to the podiatrist to see if he could determine the source of the stiffness and pain. He determined sesamoiditis was most likely with a possible fracture. (When he went prodding around the area was "too" tender and he was concerned about the stiffness in the joint and he was also concerned about the general compressibility and flexibility of the foot) He wants me to start conservative with orthodics alone in my shoes (he actually placed dancer's pads in my shoes for me, but instructed me to experiment until I was pain free. It turns out I had them in wrong so they weren't helping). He wanted me to come back after walking around on the pads after two weeks, but my schedule has not allowed that and won't until mid August unfortunately.
Dr Blake's comment: You really need to spend some time in a removable boot with dancer's padding to float the sesamoid. This is Phase I of rehabilitation which you may need to be in a short or long time to the indefinite amount of healing of your injury. That would be guess work for everyone. 
Example of accommodative padding of 1/4 inch being used to off weight an area of pain. For this patient, the hole of course would be under the sesamoid.

 This next appointment was to be the one where we would plan an MRI and if the pain were still too much I would need a cast. I want to avoid a cast if possible but I've had no luck getting pain free walking. At a minimum my foot is very sore at the end of the day. I also have all sorts of strange feeling referred pain. For instance, when I try to test my range of motion I feel a sharp pain on top of my foot where my big toe joint meets the toe. For some reason this type of pain leaves me with the impulse to "break through" the block but instead I back off. Still my ROM is not improving and I'm worried I waited too long to get treatment and now the foot is ruined. I keep up with mat pilates but it hurts too much to do anything on my feet. I walk plenty for work anyways (~10,000 steps most days, I honestly wish I could rest it more).
Dr Blake's comment: There is 3 types of pain: mechanical from the injury, inflammatory from the body's attempt at healing, and neuropathic as the nerves become hypersensitive in trying to protect a chronically painful area. This neuropathic pain can end up being what takes so long to heal. Make sure all 3 of these pain sources are addressed in your upcoming treatment. I just learned about a new device called Quell that may help you. I am only beginning to study it. The website is 

I really like this doctor, he fractured his own sesamoid and healed it without surgery and he assured me that everything looks like I could heal too and dance again. He told me to be patient but it's hard. I hate feeling like I'm "sitting around doing nothing". I don't want to see him in mid August and end up stuck in a cast but I fear I'm not healing and maybe getting worse. What more can I do?
Thank you again.
Dr Blake's comment: Please review my latest video on sesamoid fractures and then add your comments to this post. Hope all this helps.