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Friday, September 30, 2016

Sesamoids and Shoes

(if this is not the correct way to submit blog questions, please let me know!) 

Hi Dr. Blake,

I’m a 47 year old male, fairly active (and aspiring to be more so). In April/May of this year, I developed pain in the sesamoid area in both feet, which started out much worse in the left foot and a mere annoyance in the right, but over time the right has been catching up with the left.  A few Pod visits led to a diagnoses of Sesamoiditis. MRI w/ contrast showed no fracture. I believe I developed this due to (very stupidly) trying to do heavy squat exercises in the gym in bare feet, which I’ve obviously stopped doing forever.

A few things I’m doing to try in order to facilitate healing which is a combination of advice from local podiatrists here in NYC as well as your blog and a few others: ice (work in a very busy corporate office and can’t do nearly as much as I should), contrast bath 4-5 times a week in evening, KT taping as per your advice and the videos you’ve put on youtube, trying different OTC orthotics and cutting pressure relief holes in the sesamoid area which seems to be very helpful but can also be tricky depending on the shoe, wearing gel dancer’s pads, MAJOR activity modification which is depressing beyond belief and consists mostly of just 30 minutes a day of light stationary when I used to do a ton of walking/city hiking/weights. I’ve got some shoulder issues so a lot of upper body weights are difficult at time. Swimming isn’t practical for me in the city. I’ve been hesitant to go down the road of expensive custom orthotics (though I do need some arch support) because so many people I know have found them unhelpful , and also because I have been stuck on and struggling on one gear for a while: SHOES. I have tried so many different shoes over the last few months, keeping the shoe companies, Amazon, and Zappos very busy with my purchases and returns, I have spend way too long in all the major shoe stores in Manhattan, with lots of returns. I will say that it is EXTREMELY difficult to find a good quality shoe that meets the desired criteria: very stiff/rigid sole, some degree of rocker bottom, deep and wide toe box (I also have some minor great toe bunion action going on in the left foot which makes it more fun), low drop from heel to forefoot. It’s actually really amazing how difficult it is to find all this in men’s shoes, and equally amazing how very little most podiatrists seem to know about specific shoe recommendations.
Dr Blake's comment: Try also a roll of 1/8th inch adhesive felt from moore medical company to make your individualized dancer's pads and arch re-enforcement strips. You want as much dancer's pad as you can take without falling into the hole initially, and you can also back it down later. Sometimes you can take more dancer's padding if you equally balance with good arch support. Many of my patients on top of the OTC arch support add a thinned out small longitudinal medial arch pad from Hapad. They will play with the balance. Also, the more protection you can get into the shoe insert, and less  you will need from the shoe except forefoot cushion, overall stable, and a good roomy toebox. You can place a Otto Bock carbon graphite plate under the orthotic if you need stiffness.

The biggest challenge is the stiffness. It’s virtually impossible to find, and when I do, it’s in a $900 Brooks Brothers dress shoe made for men with narrow bird feet. I’ve tried Dansko clogs (forget the non-clogs when it comes to stiffness) and I’m surprised these are so heavily recommended because even with that strap in the back, they still forces my toes to grip and work to stay in the shoe which I thought was counter-productive to what we need for this injury. I’ve tried all the major “medical” shoe companies like Drew, Apex, etc. but even though they have a lot of deep/wide options, all those shoes have very flexible soles. I’ve tried (and spent way too much money on) the carbon fiber inserts. I don’t know how anyone really gets these to work. You need a totally flat footbed(hard to find, believe me I’ve tried) otherwise you bounce up and down where the plate doesn’t meet the footbed, and getting them to fit in a shoe with assorted inserts and padding is like stuffing your foot in a vice. 
Dr Blake's comment: First of all, make sure the carbon plate is flat, firm, and goes the length of the shoe, and the width of the shoe.

The stiffness is to be used when you are trying to completely immobilize the area. At your disposal are carbon plates, stiff soled shoes, shoe repairs stores adding forefoot stiffness, spica taping, removable boots, and orthotics designed with forefoot stiffness. Ask if you need the stiffness, and when, because you eventually want to go in the top direction. 

So here is what I have so far:
MBTs: I finally caved and got a pair even though I hate the way they look, and they are very difficult to find in wide. I do think these help. I finally understand the concept of keeping the forefoot stiff along with the rocker motion. I used these to walk around the city a lot but they are also very unstable and make for dangerous treks up and down subway stations. I also can’t wear them in the rain which is a problem.
Dr Blake's comment: In this category are the very popular Hokas. They may do the trick. Hokas run narrow overall, but you can find one style wide. Check them out if you like the MBTs.

New Balance 928: I am not sure why I see these are recommended so often for these kinds of foot issues. I like the shoe itself, the footbed and inside feel good, but they simply aren’t that stiff. I’ve held many, many pairs in my hand and I can always bend the forefoot upwards. New Balance tells me they are designed to bend. They are not designed to be stiff. But they keep popping up on all the blogs as the Go To for foot problems in need of stiff soles. It’s a mystery to me, because they aren’t. But since I like the way the overall shoe feels despite the bend, I brought my pair to a Pedorthist and spent too much money having a steel plate and rocker bottom installed. I haven’t had a chance to wear them since I just picked them up, but I have hope they will help with walking around the city and such.
Dr Blake's comment: I agree, the 928 has a rocker, but is not stiff. I am glad you have a Pedorthist. He/she can slide a 1/16th poly plate 1 inch by 1 inch into the mid sole right under the big toe joint to make that stable. We have done it for years in the arch of shoes that needed arch stiffness. My dad as a teenager would have that done for arch support. 

So I am getting desperate for two kinds of shoes: a good pair MEN’S DRESS SHOES, that can be worn in an office with a suit,  as well as a some type of HIKING/RAIN/WINTER BOOT that will work well on the sidewalks of NYC. I used to live in that amazing town you call home, San Francisco, and miss it greatly but now I am in the sometimes wintry wet environs of New York City. Winter is coming and this is a major concern.  MBT makes some Men’s Dress Shoes, but they are extremely narrow, not well suited for extra padding and orthotics and they look really strange in an office setting. They also make boots I think, but I wouldn’t dream of that extreme rocker in the snow and ice, up and down subway station stairs, and again the issue of no Wides. I know Hoka makes some Hiking Boots but again those don’t come in Wide sizes yet.
Dr Blake's comment: A boot that is wide in the toe box for us foot people to put things in is the Lems Boulder Boot. Definitely give me your feedback. The pedorthist could add a front stiffener. I have told patients to try the Hoka Hiking, the New Balance 1069, and the Zamberlan boots to see what fits. All, with the Lems, have different qualities.

For the Dress Shoe, something like an Alden might work, in spite of the major cost. They will be stiff but they won’t come in Rocker Bottoms and it is my understanding that the stiffness isn’t very helpful if you aren’t also rocking. I’ve looked at some Clarks, and Ecco’s, all have flexible soles and even the rigid ones are not rigid by Sesamoiditis standards. I think with the Dress Shoe, I may be forced to find something wide and deep and good quality, and have that modified with a still sole and rocker by a Pedorthist. I could go back to one of the diabetic Apex, Drew, etc. and have the sole done, but I'm hesitant to spend that much money on modifications to a shoe that might not last very long.
Dr Blake's comment: Personally, I have not placed too many rockers into shoes. I take what the shoe has and go with it. There are so many factors: stiffness, rocker, cushion, heel height, toe box room, along with all the things you can put into the shoe. So, for my patients, I try to get at least 3 of these features, especially toe box room, and then I play. 

As far as the Hiking Shoe, I would be surprised ifhere weren’t a good quality hiking shoe that would be good for the city, can be worn in snowy conditions, and is very stiff and rocker bottomed, comes in wide with a roomy deep toe box. Don’t these exist?
Dr Blake's comment: I hope Hoka will come out with one. Can you tell me in an email if you are getting better? Sesamoiditis needs to be treated by these mechanical factors, and some anti-inflammatory measures, and then should get better and better. As it gets better, the restrictions of rocker, and stiffness, etc, are removed slowly. Where are you in this realm? Should you go into a removable boot at least 4 hours a day to rest the sesamoid?

So my entire novel here is a longwinded way of including some background in my pleading with you to see if you might guide me towards some specific HIKING SHOES and some specific DRESS SHOES that are good for people trying to get their foot in a healing position for Sesamoiditis. Might you or your Colleagues there in the office have a few recommendations for shoes? It’s truly overwhelming trying to find these on one’s own and the ironic thing is, especially in a place like NY, I spend a lot of time on our feet running around trying to find them. I am convinced I would have healed better and sooner if I had gotten into proper footwear earlier.
Dr Blake's comment: I will ask the podiatrists about the general shoes and sesamoiditis. For now, consider my thoughts on temporary removable boots, and better dancer's padding. See Joseph D'Amico at the New York College of Podiatric Medicine. Also, call the owners of Richey and Company in Virginia, give them my name, and see what they recommend. Any feedback on the above, positive or negative, is great. We are all just trying to help. Good luck.
P.S.  There are a million podiatrists here in NYC, and from what I’ve been able to tell, not many really seem to understand Sesamoiditis or the shoe situation. I wish we had a YOU here.

I greatly appreciate any suggestions you can make, and thank you very much for your blog and your commitment to helping patients heal.

Thank you kind sir!


  1. Hi Dr. Blake,
    What do you suggest for shoes when taking a shower, or going to the bathroom at night? I'm in two boots and as an over 50 male I have quite a few trips to the bathroom during the night.

    Also would be helpful to know what the best shoes would be for riding a stationary bike while I'm still in the boot.

    One final question - If one does stretching and the sesamoids seem to be sore to the touch after that should one continue stretching? It does not hurt during the stretch. PT says that tendon needs to be stretched to relieve the pressure.

    I have had sesamoiditis since May starting on one foot and now on both. I have really struggled to find anyone in Birmingham Alabama to help me and its progressively gotten worse. I sure wish you lived in Alabama!

  2. Hi Dr. Blake, I am commenting in an already existing thread because I can't figure out how to create a new post. I am suffering from what I think is extensor tendonitis, but I am not sure. I've been having pain at the top of my foot for a couple weeks, and now starting to feel it in the other foot as well. I am leaving for Iceland next week, and I am trying to figure out how bad would it be to do a little walking/hiking with this condition. I am desperately trying to schedule an appointment to see you this week (new patient) but you seem booked for the rest of the week. Would appreciate your opinion, generally, about whether or not walking could make my tendonitis much worse long term..

    Thank you so much!

    1. Hey Helen, I hope you trip is going well. I hope the BRISS treatment for tendinitis is helpful that we discussed at your visit. Sorry I am late with this comment. Have to get better. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.