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Saturday, December 30, 2017

Sesamoid inuries: Followup Email

Subject: RE: 13-year-old daughter (gymnast and ballet dancer) with a sesamoid injury (stress response versus stress fracture)

Hi Dr Blake –
Hope you are well and had an enjoyable Thanksgiving holiday. 

Just wanted to give you some follow up on my daughter and get your thoughts on her progress if you have time as you were so helpful several months ago.  A disc with her most recent images was sent on Dec 6 J

If you recall – she is a 13 yo gymnast and ballet dancer who developed bilateral medial sesamoid stress reactions versus stress fracture (R>L) in bipartite sesamoids in mid-July 2017.

Just to review: She stopped gymnastics due to around July 20, was in bilateral walking boots for 1 week starting 7/31 then bilateral casts (2 weeks on the left, 4 weeks on the right) for the month of August 2017.   She wore HOKA shoes and did PT for a month (Sept 2017) then tried to increase activity in Oct 2017 and developed recurrent sesamoid pain within 3-4 days which is when I contacted you initially. 

Since I contacted you in early October, she has been in HOKA sneakers full time initially with an insole with semi-rigid support under her metatarsal (this gave her the most relief) and now has a custom orthotic with a similar design.  She has been using an Exogen bone stimulator on both feet for 20 min daily and doing contrast baths several times a week and taking calcium and Vit d.   She has been doing PT (foot and ankle ROM and strengthening including theraband work, balancing exercises, hip strengthening) once a week with a PT and 3-4 times a week on her own.  At gymnastics, she rides the stationary bike, does her PT and other strength/conditioning exercises, bars over a foam pit and avoids any activities with any releve, impact or jumping (or even any kind of push off from her feet).  At dance, she wears her Hokas and does a barre work and center work without going up on releve or doing any jumps/turns.  During this time she has been able to remain fairly active (albeit with significant limitations – she is not able to perform or compete) and has mostly been in a 0-3 pain range. 

She saw her orthopedist in follow up in early December and had no pain to palpation over her medial sesamoids but had some tenderness between the first and second metatarsal on the right

Her orthopedist suggested repeating an MRI – he said that he expected that the sesamoid bones may not be fully healed but at least we would know if she was heading in the right direction, and he wanted to make sure there was nothing else going on given the location of her tenderness on exam.  I have included a photo of the report from  12/3/17 below and you should have received a disc with images.  Per her orthopedist  - the edema in the sesamoids was decreased but not completely resolved, and edema in the right 1st metatarsal head was resolved.  

Her orthopedist was pleased with the improvement on MRI and thought that she could begin a slow progression back to full activity over the next 6-8 weeks but did not outline a clear plan.  She tried doing some light gymnastics with her HOKAS on  (just cartwheels/walkovers and jumping into the pit (i.e. pushing off her feet but not landing on them)  and had some pain up to 4-5/10 in the evening after these activities, but it resolved by the next day.  Over the past 1-2 weeks, she has started to do some one-foot balancing exercises with her PT without her shoes on wobble board or airex mat and this has gone ok as well. 

However, she seems to have some apathy about increasing her activity further.  She does not seem to want to do anything that involves going on releve or pushing off the ball of her foot.  I think she is very concerned about the pain coming back or causing long-term damage to her foot (something her orthopedist cautioned her about if she tied to train through pain) and is having a hard time telling the difference between true sesamoid pain and other types of pain from disuse.  Her PT says he can reproduce some of the pain she described in her sesamoid by pressing on other areas of her foot which makes him think she has some neuropathic component to the pain or some tightness of the ligaments.  This s a little surprising to me given how much PT she has been doing and how active she has been, so my concern is that it is still some degree of true bone pain given that there is still some edema on MRI.

My questions are as follows:

1)      It has been approximately 4.5 months total (though her initial immobilization phase was relatively short).  Do you think it is too soon to try to re-introduce dance and gymnastics activities? 
Dr Blake's comment: The 12-3-17 MRIs still showed edema in the sesamoids which were better than July, but still present. If she has level 4-5 pain after workouts, she is still doing too much. You can probably keep her where she is at, but you can not increase the ball of the foot bend or impact. I was happy to see the first met edema on the right side was normal again. She is healing!!!
2)      If she does start to re-introduce activity, what is the best general progression?
Dr Blake's comment: So, we have 2 factors that influence the sesamoids now. The bend of the big toe which as she releves, the sesamoid is pushed into the first metatarsal head. And, the direct impact onto the ball of the foot which also will drive the sesamoid into the metatarsal head. The far more dangerous, and thus the last one added is impact. You gradually add speed to the walk on a weekly basis taking her from here until March first (9-week buildup). You gradually add time on the ball of your foot, and time up on releves. Look at each skill she does and break apart these 2 components. Email me some of your thoughts. She probably has nine skills to manipulate. If she is doing the vault, we won't allow impact just now. So, over the next nine weeks, one week at a time, she increases her walk to sprint down the runway. You walk, then fast walk, then slow jog, then medium jog, then fast jog, then if she gets through each one, she sprints. And, that is only one skill in a gymnast. Whew!!
3)      Should she try to introduce activity in her HOKAS first and then progress to bare feet? Or do the HOKAS with the orthotic force her to use her feet too much with pushing off and should she actually try barefoot activities on a  well-padded surface (like the soft, carpeted spring floor at gymnastics)?
Dr Blake's comment: This, of course, is a whole other variable. I hate barefoot for sesamoids for the next 6 months if I can get away with that emotionally. I also do not think training in Hokas is that realistic. You would have to start all over again when you start going to gym slippers. I would use Hokas only if walking in whatever shoe you can like a ballet or gym slipper with dancer's pads and spica taping and cluffy wedges was still painful. So, you would first try to get out of your Hokas before you started a faster walk, then slow jog, etc. 
4)      What kind of Pain is OK as she re-introduced activity?  
Dr Blake's comment: 0-2 when doing the activity, and 3-4 after, that settles down before the next workout back to 0. If you want to progress to more and more activity levels, you have to maintain 0-2 during, after, while sleeping, while doing your homework, brushing your teeth, texting friend, do you get my point? If the athlete feels 0-2 during, but more than 4 after, or the next day, on 2 different days, you must lower your activity by where you were 2 weeks ago. Each level should be maintained for a week. 
5)      Do the ganglion cysts on the MRI mean anything and/or could they be causing pain?
Dr Blake's comment: I do not believe they are causing any pain.
6)      Do you see any role for extracorporeal pulse activation therapy (EXPAT) also called “shock wave” therapy?  I know this type of ultrasound treatment can sometimes make things worse before they get better, but my concern is that the bone stimulator is only treating one very small area (about 1.5 x 1.5 cm) and that some of her pain seems not to be exactly in the area of the injured sesamoid bone (i.e. in the surrounding tendons and soft tissue). There is a local podiatrist who has been using EPAT for years with reportedly good success rates  - several of the gymnasts at her gym have done it for severs or plantar fasciitis with very good results.  Her orthopedist has also purchased a machine for the new University of Colorado Foot and Ankle Center that just opened, so it seems to be gaining some credibility.   I read a case report of EXPAT being successfully used to treat sesamoiditis in a football player   I also saw some case reports and small studies of it being used to promote fracture healing including promoting healing of non-union fractures.  I feel like we are stuck with her not being willing to increase activity due to ?nerve/soft tissue pain and I am not sure how to get past this and it seemed like it might help.  In addition, doing it over the upcoming holiday break would be ideal as she would not have to miss school for appointments and she has time off school/activities so could let her foot rest more during the treatments.   
Dr Blake's comment: I think these things have their place, but the word "chronic" is important. Your daughter does not have chronic sesamoiditis which would warrant this treatment, she has 2 very well healing sesamoids. They are sensitive due to the edema and some nerve hypersensitivity, but if we were not talking about a high level athlete doing things barefoot, explosively, ballistically, we would not be talking about re-injurying the bone to hope it can heal better. The ECSW therapy is to produce fresh acute injuries to reheal tissue. Basically to wake up the healing when sometimes gets chronic. The body tends to stop healing for some reason. I see no reason based on the last MRIs. 

Thanks so much for any thoughts, feel free to post to the blog if you think it will help!

Sarapin Injection for Nerve Pain

Sarapin injection has been recommended by one of my blog patients. I have no experience, but it may be very promising, and could be in your discussions with your docs if you are suffering with nerve pain. 

SARAPIN® is an injectable analgesic indicated for the management of muscular or neuropathic pain that may be treated by local infiltration or nerve block. The distillate of a suspension of powdered Sarracenia purpurea (Pitcher Plant), SARAPIN® has been used safely and effectively for pain management by physicians for over 70 years

The patient stated: 
I had read about it and the doc that I go to happened to have used it before.  He used it after my suggestion.  There was a study done with injectable b12, dexamethasone, sarapin, and lidocaine that showed very good results: 

Tuesday, December 26, 2017

Sesamoid Dilemma: Already Down One!!

Hi Dr Blake

Trying to keep this short, but it isn’t going to end up short.   I’ve been through years of sesamoid pain (fibular, originally).  Now I’m facing the loss of both sesamoids in my left foot.  Catch your attention?  Thought it might… btw, love your blog. 

Fibular removed June 2016, no instruction is given on after-care, and a few months in after being told to walk normally my supposedly healthy (medial, the inner one) fractured.
Dr Blake's comment: One of the reasons I try to get my sesamoid patients to try everything before surgery is that at least they have a system in place after surgery to avoid just this. I am so sorry!! When you break a major bone like this, you also want to make sure your bone health is great. 

Xrays before showed intact medial.  So it definitely broke after the surgery. 

Looking back on the MRI I had done way back before surgery, there were signs of marrow edema in the medial that I was never informed about.  I suspect that hasn’t helped things.  Frankly, if I had known that I probably wouldn’t have had the fibular removed. 
Dr Blake's comment: So, I am dying to know what was done pre-surgery for the first fracture. How was it treated? Was bone health overall accounted for? What about the biomechanics of your foot? Some patients have such a high degree of pronation or a high degree of lowness of the first metatarsal (plantarflexed first ray or metatarsal) that they are just set up for this problem. The more analysis of the situation more surgery, in the process of trying to avoid surgery, the more chance of hopefully avoiding this scenario. 

So here I am, with heavily customized orthotics (from another Dr), which include a metatarsal pad and Morton's extension.  Bouts in a boot haven’t healed things, so I got another MRI done.
Dr Blake's comment: So, Morton's extension tries to limit the big toe motion, but puts pressure on it. A dancer's pad also called a Reverse Morton's, attempts to float the metatarsal head/sesamoid, at least taking significant pressure off. Have you experimented with both to see what is better?

I’d like for you to see it.  The gist is they “can’t rule out AVN” and there is prominent bone marrow edema.  They also mention edema in the base of the proximal phalange which may be degenerative.
Dr Blake's comment: I would be happy to look. The mailing address is Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109

The dr basically tells me it is up to me on how to proceed.  He seems to think to remove it will help the pain, which is substantial.  He seems smart, but hard to talk to a bit.   I have no clue how I got AVN. 
Dr Blake's comment: AVN, or avascular necrosis, means the bone has been so swollen for so long that the bone circulation has been compromised. Only a CT scan can really make that call in my mind. If the bone fragments from avascular necrosis the recommendation is to remove it. If the bone just gets sclerotic (denser, harder), I have seen these reversed with Exogen bone stims for 9 months and daily contrast bathing. Acupuncture can be a great idea also. 

Have you run into anyone having both sesamoids removed?  I understand the weakening after having one removed, as I can feel it, but honestly you really still have the strength to push off.  But I can for example, still stand on my toes (though it hurts like crazy).  Getting down in the catcher position (I used to be a catcher as a boy/young man), that is nearly impossible though.  Pulling weeds in the yard, impossible.  Running, getting in shape… you know where I’m going here.
Dr Blake's comment: I have attached only one other email correspondence I had with someone, but no idea what is going on. Without the sesamoids, even one, you lose strength in push off, and probably like a hip replacement you can run, but should avoid things that stress it too much. Golf okay, sprinting not, etc. These are long-term preventative, and I am not sure if any that studied patients having both sesamoids removed. My patients that have one sesamoid removed should be in orthotics, or at least some form of dancer's pad, forever. And, they are usually so smart about their feet, you don't have to remind them.

I am really curious how much different it would feel to walk without any sesamoids.  I’ve read that it might be like “walking on a pebble” and that sounds awful.  Then again, the pain is pretty dang bad.  I am envisioning that it would be like crawling with no knees maybe…. And that my metatarsal would essentially drop and it would mess up my gait and probably my knee.
Dr Blake's comment: I think you live with orthotics to protect your feet and you will do fine. It can take some work of a good orthotics person, and they typically start before surgery to make you more comfortable, and then 3 months after surgery when you are really walking again. 

To make matters worse, after the 2nd fracture was discovered I was sent for a bone density scan by the first doctor who removed the sesamoid, and subsequently told I have osteoporosis and extremely low Vitamin D.  I’m 34yo MALE.  They put me on Forteo which they said might help the fracture, but it hasn’t.  I also have my Vit D back up now after being on 10k units/day for over a year.
Dr Blake's comment: Wow, so do not be in any rush to remove this bone. Get it protected. Get your bone health better. Can take 4-6 years to see a much healthier picture. But, more important than your sesamoid, reversing osteoporosis at your age will be life changing as you get older like me. You want your body to have great bones in your 70s and 80s. 

Here are the MRI’s… mind giving me your thoughts on how out of luck I am?  I’m super depressed about it.  We just had a baby and I can already barely keep up with her….

These are the full scanned medical records, but I want to share them with you (I don’t mind pics of them on the blog either but please safeguard sensitive info).  I think you have to run the application to view them.  The links are on my one drive account that is why they have all the gibberish in them, but I can tell you they are legit/safe.
Dr Blake's comment: Please send them to me on a CD if you can. Better for me. 

One more question.  What is the word on implants for sesamoids?  Any talk in the medical community about folks trying to do this? Dr Blake's comment: No, sorry

The patient then had a followup to my questions.

Thank you.  Means a lot to me, I hope it helps others more than anything to get people thinking (more than I did) before they jump into surgery.  If I’d found your blog before I had my first surgery, I know I wouldn’t have had it done.  Patience is truly the name of the game. 

By the way, you asked me about the care I had before the surgery.  It was comminuted and non-acute by the time I realized it needed to be looked at.  I was walking through the pain for at least a year before I looked for a doc.   At that point, he told me it was too late to do much but cortisone shots and a stiff leather orthotic.  I went through the most excruciating 1st cortisone shot.  I can’t describe to you the pain, but it was the worst I’ve ever felt in my life.  The rest of the shots didn’t hurt at all, oddly.  After about 6 months in this orthotic, which had no Mortons/reverse Mortons or dancers pad, I couldn’t take it anymore and asked for the surgery, which he was very willing to perform (said he had done many). 

The surgery took some pain away, particularly pain I had laying in bed (the sheets over my upward toes used to ache, and that went away).  He told me to keep walking after a week on crutches in my leather orthotic and eventually, it would get better.

A few weeks later, the other one broke.   He x rayed it, saw it, stared at me dumbfounded, told me to get a bone scan from my primary care doc, and sent me home with a boot.  (that was my last time seeing him).  Primary care ordered a scan, found the osteo, and the rest is history.  Since then, flare-ups in the sesamoid are regular.  Now that you explained that my current orthotic likely puts more pressure on it, that definitely makes sense.  I might call them to see if it can be adjusted.  I do have a bump insert in the middle, that lifts my metatarsal up though.

Just seeing your reply gives me hope that folks like me aren’t forgotten in the universe.  For a small bone, the sesamoid is life impacting.


Fifth Metatarsal Fracture: Email Advice

Hello Dr. Blake,

   Thank you in advance for answering me and I will be happy to donate to
your blog.

 At the beginning of May of this year (2017) I rolled my foot and broke my
5th metatarsal.
It is a slightly displaced avulsion fracture at the base.
I kept it in a soft cast non weight bearing for 4 weeks. After 4 weeks, I
felt I could walk on it while in the cast with out too much pain. After a
week I took it out of the cast and walked carefully. I wonder if this was
too soon, but I thought it was okay because I really had minimal pain.
Dr Blake's comment: This is considered appropriate as you want to stimulate mineralization and the fracture should be knitting well by then. And, you are creating and maintaining the 0-2 pain level. 

When I had a follow up xray 6 weeks after the initial xray, I was actually
surprised that there was no sign of healing and that it was still broken.
Somehow, maybe because of inflammation, I wasn't feeling the break at that
time. Over the course of the summer, I felt weakness in my ligaments and
like I had a 'dumb foot'. I have been trying to strengthen with a tensor
band and balancing. September 27th xray showed no healing in the bone.
Dr Blake's comment: Xrays reflect the amount of calcium in an individual area. Since the fracture area has high metabolism, typically there is alot of water in the area, giving the impression of poor healing. The Golden Rule is that xrays reflect the healing 2 months late, so they are poor indicators of what is happening right now. 

Now, almost 8 months later, I feel the break (tender), and the whole foot
feels sore and achy after walking on it for a half hour to an hour. It
feels great with no pain when I wake up in morning. I just had a CT scan
yesterday to see if there is any sign of healing. Will see surgeon about
results on January 8th. My questions....
Dr Blake's comment: The base of the 5th metatarsal typically bears all of our weight as we lift our heal off the ground. The fracture area can be healed, but sensitive, for 6 months after the injury. Things that help reduce the sensitivity are taping to stabilize the area, inserts with off weight bearing padding to float the broken area, icing and contrasts bathes to daily reduce inflammation, and pain free massage to move the sensitive tissue out of the area and de-sensitize the local skin nerves. I am always afraid, unless you are doing these things, an agressive surgeon will look at the CT scan and do surgery. But, of course, there is no guarantee you will need it, but these are options. Also, if we feel that he bone is slow, get a Exogen bone stimulator for twice daily home use. 
How long before I have to worry about Avascular Necrosis?
Dr Blake's comment: Were there signs of demineralization of the fragment? Since there is such good blood supply, I have never seen it in this area. 

Should I consider putting it back in the boot, or even using crutches
again? Will it make any difference at this point?
Dr Blake's comment: You have to create the 0-2 pain level environment. Some docs and PTs are good designing the padding, experimenting with taping, using PT treatments, perhaps stiff soled hiking boots, hike and bike shoes, etc. Can you send me a photo of the xray, honing down on the fracture? I personnally would not go back in a boot, unless off weight padding or inserts are not helpful. 
I received an Exogen in the mail today. I've heard it's never too late to
use it and can help 'non unions'.
Dr Blake's comment: Great!!!

Should I be concerned about ligaments that are not healing?
Dr Blake's comment: An MRI is needed to check. Definitely with a bad sprain in this area with ligament tears, orthotics and taping for one year in normal. Golden Rule it is normally better to break a bone than sprain a ligament. I know too little to really comment. 

I know surgery is an option if I am still not pain free in a few months
but I have doubts that it will heal from surgery. If such a simple break
doesn't heal naturally doesn't it seem likely that it would also have
difficulty healing from surgery?
Dr Blake's comment: If you do need surgery, it will be depend on what they do. Typically, they rebreak the bone, and put a screw across the fracture. They heal wonderfully unless you have some overall problem with healing: diabetes, smoking, obesity, vascular disease, etc. If you smoke, stop now. There are good studies showing the positive effect that has on surgery healing even if only 3 months have elapsed from stopping. If you have any question on bone health, get a Vit D3 level and bone density. 

 I have done everything I can think of to heal this...supplementation
(calcium, vit D, vitamin C, trace minerals, collagen), acupuncture,
osteopathy, physio.
Dr Blake's comment: Have not heard anything about taping (specifically for the fracture and surrounding ligaments, orthotics of some sort to off weight the bone at heel lift, icing and contrasts for anti-inflammatory, and of course, an MRI to look closer at the soft tissue. 

My main question is...can I be optimistic that I can still fully heal the
bone and ligaments 8 months after the accident?
Dr Blake's comment: I can only say from this far away that it is very rare that surgery is needed, although not impossible. Therefore, with those odds, try to work with my suggestions above, and see if they help. Good luck, and Merry Christmas. Rich

Thank you very much and Merry Christmas!

Sesamoid Pain: Email Advice

Dear Dr Blake,

I found your blog through a search engine and I have read stories on your blog, I feel positive that you may give me a proper advice. I have this pain below my big toe on right feet for almost 2 months since October 22,  developed during my sister in law wedding. I am not a sports person nor do running or dancing. After I return to Singapore, I felt my toe bone hurts very much. I have trouble walking and have to walk while dragging my feet to work. I ignore it for over a month. It is an on and off pain.

After one month of pain, I could not take it, I google about my symptoms and found out it may be likely is Sesamoiditis, which match my condition very well. I read other doctors advises such as stop wearing heels, take as much rest as possible, massage with ice and etc. It helps my condition however with my work nature that requires me to walk a lot, the pain came back. I am still thinking if I should go to see a doctor and do Xray. As I do not have insurance to cover the cost, this is a big dilemma for me. I am afraid it may take a toll on my finance. 

I have switched to a better support shoe and I am also looking for an arch support sole to help my feet to recover faster. Dr Blake, do you think I need to see a doctor? 
Dr Blake's comment: I am sorry for your dilemma. Unfortunately, everyone would tell you the same. Please see a doctor and get the right treatment. Severe sesamoiditis, as you may have, requires months of protection. You must create the 0-2 pain level environment quickly. See if you can find a doctor to put you on a payment plan. You have to treat this as a stress fracture with 3 months minimum of some form of immobilization. You could get adhesive felt from a supplier, and build a dancer's pad to off weight and put yourself in a flat stiff shoe, I use postoperative shoes to start the process. Experiment with spica taping, cluffy wedges, OTC arch supports to protect, immobilize and off weight. Good luck. Rich

Thanks for your assistance in advance.


Sunday, December 24, 2017

Sesamoid Healing Success!! Keep the stories coming in!!

Hi Dr Blake,

Merry Christmas and Happy New Year! I am thinking back on the year I’ve had and the sesamoid fracture from a few months ago. 

I am happy to report that other than some persisting swelling, I am living a very normal life and not thinking much about my foot at all. I took a trip to Southeast Asia last month, where I did lots of walking and climbing around ancient temples with no pain. I also played a game of baseball with my family recently and had a fun time running all the bases at full speed.

Thanks again for your blog and all your advice!

Dr Blake's comment: Here is the original posting from 3 months ago. 

Sunday, December 17, 2017

Ankle Strengthening with Resistance Bands.

This is an email from one of my blog patients who is trying to strengthen his feet due to severe pain. 

  Hello Rich, how are you?  I have been slowly getting better.  I have been using the ankle-foot maximizer ( for foot strengthening every other day and have a question about strengthening.  There are 4 different color bands with this, yellow being easiest, then red, green and blue.  I am so glad I saw your video on not using the anterior tendon when strengthening the post tib!( This is what I've been doing in the evening 3x/week:


BFST heat for 20 minutes
foot circles 20 each direction
foot dorsiflex and plantar flex 20 reps each

Then start with afx bands: (Yellow for a couple weeks then Red)

Plantar flex         Slight knee bend    
Eversion             Slight knee bend
Inversion            Slight knee bend
Eversion             Knee almost 90 degree
Inversion            Knee almost 90 degree
Dorsiflex            Both slight and bent

Plantarflexion Ankle with Knee Slightly bent

When I do the 90-degree ones, after watching your video I decided to keep my foot slightly plantarflexed by putting a 1" lift under my heel as to not use anterior tendon.  I have been starting with 2x10 on all 6 of these movements.  Next time do 1x10,1x15.   Next session do 2x15 until I reach 2x20 on everything and then move to the red band, which I did just the other day.

Does this sound good?  Any recommendations or changes?
Thanks allot Rich, I hope all is well!

Dr Blake's comment: Almost my friend. The Plantarflexion of the ankle should be done first with the knee slightly bent, and then the knee at 90 degrees or so. The first part gets the gastrocnemius and the second part gets the soleus. The Eversion should be done with the knee slightly bent in both and the ankle first pointed (like in Ballet) and then the ankle at a right angle. The first gets the peroneus brevis and the second the peroneus longus. This the same for the inversion: pointed for the posterior tibial and ankle right ankle for the anterior tibial. You can actually add the third inversion exercise with the ankle pointed and the knee at a right angle to fire the soleus more. The dorsiflexion movement is only with the knee slightly bent. I hope this helps. 

Achilles Tendon Rupture: Email Advice

Dr. Blake

I'm 4 weeks nonop, recovering from a full achilles tendon rupture (approx 7mm) that was sudden impact and not degenerative or sport related, no history of weak tendons, very fit and active 45-year-old male, very clean diet, no drugs or alcohol.  Over the past four weeks, aside from the pain and frustration that comes with the injury, I've dealt with what I've perceived as incompetence and/or lack of care from hospital and ortho specialist staff.  I was in a splint from the er for 7 days, in a cast from ortho for 7 days, and currently, have on a walking boot with wedges in it.  I also ordered a Vacoped/ Vacocast that finally arrived.
Dr Blake's comment: This all sounds fine. You want to keep the achilles plantar-flexed, like the pointing of the foot in ballet, for the next 8 weeks. You will then slowly remove the wedges 1/8th inch at a time over the next 3 months as you get stronger. Start strengthening now by contracting the calf and pointing your foot in the boot. These are isometrics to be done three times a day. You hold a count of 6 seconds, relax for 4 seconds, and repeat 10 times per session. See if you can wear a muscle stim while you are in the boot on the calf. As you wean out of the boot, you have a month of vulnerability where re-ruptures occur. Avoid dorsiflexing over 90 degrees, and especially placing your heel in a negative heel position for this next year. As you wean from the cast, you need to make sure the step you are taking does not produce any tension in the calf. I typically work with a PT at this point who is seeing the patient once or twice weekly to manage the re-strengthening while I see the patient once a month to check strength gains and flexibility problems. I have seen both over flexible and too tight, but once recognized, easy to get back on track. 

I'm anxious to begin rehabbing, but currently exercising patience and caution.  I am willing to give 100% to the right protocol.  My problem is that I can't find any consensus on what is "right".  I'm hoping that your expertise can help ease my mind and that you can offer some help on my path to finding an optimal recovery.
Dr Blake's comment: Feel free to ask questions, and I will place everything in this post. 

Thank you in advance, any advice would be greatly appreciated.

Dr Blake's response: Thank you for your email. First of all, here is the link to one of the previous blog posts on the subject. 

And here are the rules of treatment from my book "Secrets to Keep Moving".

The top 10 treatments for achilles ruptures are:

1.  Decide on surgical vs conservative treatment first
2.  Strengthening begins as early as possible with muscle stimulators or isometrics
3.  Strengthening of the achilles post rupture will take 2 years to complete
4.  Post repair (surgically vs casting) it is vitally important to find out if the tendon is too           tight or over flexible
5.  Control swelling as anally as possible with anti-inflammatory measures since it stops         the normal circulation for healing
6.  Strengthening goal (or you are not rehabbed!!) is 50 one-sided toe raises consistently,       however you need to start with the active range of motion exercises, then progressive         resistive strengthening like with therabands
7.  Deep calf massage started after the tendon is together
8.  Avoid any negative heel stretching
9.  Shoes should have heels or contain heel lifts and/or orthotic devices
10.  Orthotic devices are crucial with overpronators or over supinators

Thursday, December 14, 2017

Sesamoid Stress Fracture: Email Advice

Hi Dr. Blake, 

I was wondering if I could get your input on my situation and whether I should pursue additional treatment for the hairline stress fracture in my left tibial sesamoid.

In February of this year, I started feeling an occasional sharp pain when training for sports and went to see a podiatrist in CT who took x-rays and diagnosed me with inflamed sesamoids. I rested/iced/took high strength ibuprofen for a while, but eventually decided to return to playing frisbee because the pain wasn't improving at all and it was my senior year (and we ended up making it to the National Championship game so I wanted to participate). After I graduated, I saw another podiatrist who took more x-rays and also said it was inflammation but thought I should be fine without orthotics or anything. Just continued rest.
Dr Blake's comment: Golden Rule of Foot: Create a 0-2 Pain Level for Healing. Rest however is very destructive overall in allowing deconditioning, swelling, nerve hypersensitivity, etc. I definitely want a more active approach to heal. 

After stopping all running and resting as much as possible for the summer, I still had pain and a lot of swelling. I saw my third podiatrist here in San Francisco and an MRI showed a hairline stress fracture in the tibial sesamoid (even though that spot never particularly hurt when pressed by any of the doctors).
Dr Blake's comment: Could be an over-read of the MRI for just bruising and inflammation. 

I have now been in a walking boot for 6+ weeks, semi-weight bearing with a crutch for the past 4. There is a pad on the bottom with a cutout for the sesamoid. The sharp pain is mostly gone, but I still get bouts of pretty severe swelling where I feel like all the blood is rushing and pooling in my foot. It gets red and hot and tingly. I also have noticed a general tingling when I touch the ball of my foot and big toe. I also developed more pain on the top side of my foot directly above where the sesamoids are and on the underside of my big toe where it meets the foot. Sometimes it feels like it is bruised there.
Dr Blake's comment: Pain, swelling, tingling, etc. that you did feel until after you went into the boot is probably caused by the immobilization and will get better once you leave the boot. Since your injury is so small, and we are not worried that it is a displaced fracture may be needing surgery, try to alternate environments with boot, hoka one one shoes, hike and bike shoes, and normal athletic shoes with orthotics and dancer's padding. 

To make matters more confusing, I am moving in three weeks and starting a new job right away in Hanover, NH. My podiatrist here hasn't really laid out a plan for me, except looking for a referral for me. I am worried that the walking boot may be causing more issues and the lack of PT or rehabilitation could be slowing my recovery. I am wondering what you think about my symptoms and response to treatment so far, and what my plan should be moving forward. I am also very willing to come see you in person since I will be in the area for the next few weeks.
Dr Blake's comment: Several weeks have passed since you emailed this, so you have probably moved. I hope the idea of alternating environments and daily working on the inflammation and nerve hypersensitivity is helpful. Good luck. 

I look forward to hearing from you and truly appreciate the time you take to help others like myself. Thank you very much!