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Saturday, February 25, 2017

Turf Toe Stable or Unstable: Surgery or No Surgery

I just reviewed an MRI and x-rays of a patient with chronic sesamoid injury and there definitely was plantar plate involvement. This is a great article documenting an unstable plantar plate with a 2mm forward position of the non injured sesamoids. The x-rays should be taken in a position where the big toe is bent upwards, called a stress x-ray. 

Arrow under the big toe joint shows a disrupted plantar ligament (plantar plate) with intense inflammation.

Sesamoid Fracture: Email Advice

Hey Dr. Blake,
Thank you for all the hard work you put into your blog. I injured my sesamoid bone three months ago and your blog is the only thing I've come across with any good information. With that said, I have some questions if you have the time and can help me out.

I am a runner, but take very good care of my feet. I have never had any pain or problems anywhere but my right knee (once, after a half marathon last May). In November, I was on a walking break during an easy run and felt a "crunch" in the ball of my right foot. It was followed by immediate pain and I knew I must've broke something. Went in to have it x-rayed that afternoon, nothing looked off. The doctor said this is normal with fractures and to return in 4 weeks if the pain was still present (didn't mention anything about a boot at this time, just told me to try and keep weight off of it). The tricky thing about the timing of this, though, was that this happened the Thursday before I was set to perform in a musical for the weekend. I worked for 3 months rehearsing and wasn't about to quit right before opening night. So, I danced on it for three days (icing it when I could), and started some serious time off right after the weekend was over. My doctor wasn't thrilled that I chose this, but said I should be fine just for a weekend. 4 weeks later, the pain was still there. I went back and they re-did the x ray, this time there was a fracture visible in the sesamoid bone towards the inside of my foot (I believe you call this the medial sesamoid). He put me in a walking boot and scheduled a follow-up for 6 weeks later. He asked me to limit weight bearing activities, but told me I could swim, stationary bike, or do other things that didn't require my body weight. This appointment was mid-December.

I got along okay for 6 weeks, but I really miss running. I swim 3 days a week and do Pilates once or twice a week, too. When I went in for my 6-week follow up last Monday, the x ray didn't show any improvement at all. I'm feeling very discouraged. He mentioned that I'm a candidate for surgery now that it's almost been 3 months since the initial injury, but I'm wary of that option. My questions for you are:

1.) To me, this seems like a very acute injury rather than a chronic stress fracture. My doctor keeps using the words "stress fracture," but should I be treating it differently if it was a sudden, trauma-induced injury?
Dr. Blake' comment: Both are treated the same at this point. Stress fractures you never see the fracture line, and acute fractures yes. A stress fracture never goes  "crunch". So, you have a potentially healing fracture of the tibial or medial sesamoid. The nature of the injury is suspicious of some underlying bone health issue (like Vitamin D Deficiency) so that needs to be checked out. Did you change to a less padded or stiffer shoe just before that could have increase the stress?
2.) What can I be doing to help this darn stubborn little guy heal? I read some of your advice in the sesamoid post "advice when not healing well" and I bought some hapad metatarsal pads and dancers pads for my shoes, but I'm wondering if I need further immobilization?
Dr. Blake's comment: Yes, it is typically get the bone health evaluated and treated if needed. Get the biomechanics secure with off loading in all things, even the removable boot. Spend 3 months in the boot, and if you have attained the 0-2 pain level, begin another 2 to 6 weeks weaning out of the boot with no increase in pain. This usually means experimentation even begins now with orthotic supports, dancer's padding, spica taping, shoe change (possibly Hoka One One). I love of course Exogen bone stim, so see if you can use that for 9 months. It is way too early to consider surgery.

3.) Have you seen runners be able to return to the sport after healing their injury? I'm not finding anything encouraging online and I'm supposed to run my first marathon this November. My training doesn't start until June, but I'm starting to think it's really unrealistic and it's getting me down.
Dr. Blake's comment: Yes, runners get back to running for sure. You should not have any deadlines on your calendar, because that we potentially have you rush through the rehab and take too many risks. Set goals to get better not participate in events right now. Goal #1: Get out of the removable boot in 5-6 weeks into an equally painless environment.
4.) Is it a bad sign to not see any healing in an x ray after 6 weeks? I've been so careful and the only time I haven't been in the boot is when I'm in the pool or the stationary bike at the gym, at home relaxing, or using my Birkenstocks to take my dog for a walk (I don't feel pain when wearing those shoes).
Dr. Blake's comment: X-rays can be 2 months behind showing the actual healing of the bone, so are poor indicators of bone healing at times (and this is one of them). I love MRIs to follow. You need a baseline, and 6 months from now, if you need another one, that comparison baseline can come in handy. Good luck and keep me in the loop. Rich
Again, thank you so much for doing what you do. And if you make it this far, thanks for reading!

Friday, February 24, 2017

YouTube Videos: Summary of 128 for easy access

Dr. Blake’s YouTube Videos      Achilles Tendon Evaluation for Flexibility      Achilles and Plantar Fascia Stretches      Achilles/Calf Stretching for Tough Cases         Achilles/Calf Strengthening     Achilles Tendon Taping Version      Achilles Tendinitis Taping         Achilles Tendon Weak Area        Ankle Sprain: Initial Treatment      Ankle Sprain: Compression Quickly   Ankle Strengthening Range of Motion         Ankle Strengthening with Bands    Arch Strengthening        Arch Taping: KT tape       Arch Taping: Low Dye Classic     Arch Taping: Low Dye Modifications       (Arch Taping: Support the Foot)       (Balancing)      Balancing: Single Leg      Bike Seat Height Changes for Rehab       Big Toe Pain: Spica Taping   Big Toe Pain Treatments    Big Toe Pain: Variation of Spica Taping       Bio-mechanics: Mechanical Causes of Foot and Ankle Pain      Bow Legs: Gait      Bunions: 4 Stages       Bunion Pain: Or is It?         (Bunions: Strengthening)     Bunion Taping        (Bunions: Toe Separators)        Calf Tightness in Achilles Injuries      Crutches: How to Wean Off         Crutches: Progression to 1 Crutch     Cushioning Concepts        (Dancer’s Pads)       Falling Problems Helpful Tips      Foot and Ankle Strength: General Program       Foot Strengthening with Marbles         Foot Strength by Playing the Piano       (Functional Hallux Limitus)       Gait Evaluation Basics       Gait Evaluation Basics 2         Gait Evaluation Basics 3     Gait Evaluation Supination      Hallux Limitus Guidelines of Treatment      Hallux Limitus/Rigidus: Self Mobilization        Hammertoes General Treatment     Hamstring: Upper and Lower Stretches       Hamstring Stretches: For Tough Cases           Hannaford Orthotic Manufacture     Heel Pain Evaluation       Heel Pain Treatment PT        (Hiking Boot Lacing for Stability)    Hip X-rays post Replacement        Ilio-Tibial Band Stretches        Knee Pain: How to Ice        Knee Pain: Foot Wedges Can Help      Knee Strengthening: Short Arc Quad Sets    Knee Strengthening: Home Based       Knee Various Positions Gait     Knee: Weak External Hip Rotators in Gait        Metatarsal Doming Exercise         Metatarsal Soreness    Morton’s Neuroma Evaluation      Muscle Stimulation for Weakness    Nerve Pain: Low Back Cause?       Neural Flossing       Orthotic Check by Heel Change      Orthotic for Supination: Multiple Rx Variables       Orthotic Designs for Supination (custom mold variations)      Orthotic Evaluation for Supination in Gait       Orthotic Evaluation for Supination in Gait after Denton Removal    Orthotic Design Supinators  Orthotics for Forefoot Varus          Orthotic for Supination: Denton Modification  Orthotic: Inverted Technique 60    (Orthotic Mold Corrections for Pronation)      Orthotic Negative Casting to get proper Impressions      Orthotic Rear Foot Posts         Osgood Schlatter’s Knee: Anatomy and Treatment    Phases of Rehabilitation       Plantar Fasciitis: 3 Important Home Treatments      Plantar Fasciitis 5 common treatments          Plantar Fasciitis: 2 Vital Orthotic Components      (Plantar Fascial Stretching)    Plantar Fascial Stretching     Plantar Fascial AM stretching         Plantar Fascial Night Splints       Plantar Fascial Wall Stretch      Posterior Tibial Tendon Anatomy      (Posterior Tibial Strengthening)      Posterior Tibial Strengthening     Posterior Tibial Taping Version       (Posterior Tibial Taping)      PTTD: Gait Evaluation        PTTD: Gait with Inverted Orthosis         PTTD: Muscle Testing       Pronation Walking     Quadriceps Stretches        Quadriceps Stretch: For Tough Cases     Rehab: KISS Principle      (RICE: Initial Injury Treatment)          (Running: Walk/Run Program)      Scar Tissue Breakdown     Second Metatarsal Taping       (Sesamoid Evaluation: Part 2)          (Sesamoid Evaluation: Part 3)    (Sesamoid Fracture Treatment)         Shin Splints: 4 Types     Shoe Flexion and Torsion Tests      Shoe Inserts: Interpreting the Signs            Shoe Power Lacing for Stability           Short Leg Evaluation Standing          Short Leg Heel Lifts   Short Leg Full Length Lifts          Short Leg: Making Sure Lifts Stable         Short Leg: Limb Dominance in Gait        Stretching with Contract/Relax       (Stretches: 5 Most Common)           Stretching: 7 General Principles       Supination: What it Looks Like         Supination: Evaluation in Stance         Supination Running           Swelling Reduction with Contrast     Bathing        Tailor’s Bunions          Toe Injuries Buddy Taping         Toenail Fungus        Walking Aid: Roll A Bout

Monday, February 20, 2017

Incision Health??

Hello Dr. Blake,

I am 18 days post op from a medial sesamoidectomy. My podiatrist removed stitches on day 14. I've been advised to slowly ease in to walking part-time in a well supported shoe. With the remaining 80% of the time in a walking boot. 

I am concerned that my incision may not be normal. Looking at other medial sesamoidectomy pictures on the web, they seem to look "cleaner." Below are pictures of my incision at day 18. At times, I'm experiencing sharp pains when I touch parts of the incision. Is my incision normal? Or should I be concerned with the way it appears and feels? 

Dr Blake's response: 

I am not a surgeon, but the incision meets all the normal criteria: no oozing, no gaps, no infection I can appreciate. Rich Good Luck!

Post Op from a Patient's Perspective

Hi Dr. Blake,

Today I am at exactly 6 weeks post-op for accessory navicular excision and partial post tibial tendon reattachment. My surgery was January 9th. My surgeon has cleared me to start driving, and he said I am allowed to walk without crutches or the walking boot if I want to, starting today. 

I am not ready to walk without boot/crutches yet, but I can drive short distances. I have been pretty careful/conservative with my healing, so despite being allowed to put weight on my foot in the boot the past several weeks, I have not done so frequently because it would sometimes hurt and cause swelling. I tend to worry, so I erred on the side of caution while carefully moving/stretching/building back some muscle non-weight-bearing.

I know some surgeons prohibit weight-bearing entirely the first 6 weeks. My surgeon takes the approach that it is better for me psychologically to be more mobile (which I appreciate) and he knows if I am in pain, I will stop. He has assured me that the tendon is very structurally sound and I can't do damage. It's just a matter of pain management. He only had to partially reattach the post-tibial tendon so it is probably more solid than an entire reattachment.

My Achilles' tendon is very stiff and my foot is weak. I have noticeable atrophy up to the lower thigh. I could have been using an exercise bike, but since I haven't had time to procure one yet, I've been doing light motion/pushing exercises on my roll about scooter. I'll be scheduling physical therapy today for the next few weeks.

I rarely need to ice because elevating my foot reduces the heat/swelling. I've been given some heavy duty compression stockings. I don't like them, but I should probably try to wear them when I start walking more.

I am currently able to limp with the boot only, or walk smoothly with one crutch on the opposite side of the boot. Yesterday I noticed when I did a lot of walking with one crutch I had pain/tenderness later. A good night's rest seems to reset me, and I always feel better in the mornings.

The incision looks great and is healing nicely. I decided on my own to use silicone strips to protect it and help it heal better.

I've never seen my leg like this. It's all bone and floppy fat! Even if someone didn't have surgery, I doubt they would be able to walk if they didn't use their leg for 6 weeks. 

One thing I would like to comment on is the issue of post-surgical depression, which had been a struggle. I usually beat the winter blues by going shopping and staying as active as possible in the winter. Spending the majority of the worst part of the winter on the couch is challenging. If someone has never had surgery they might not be prepared for the emotional and mental challenges of being weak, vulnerable, bored, etc. 

Plus, as I'm sure you're aware, other parts of your body become overworked after a surgery while trying to compensate. My "good" foot is aggravated, and every week I've pulled a different muscle somewhere in my body by mistake! I can't wait to get back into full body workouts! You see, the past 3 years I was more sedentary than I used to be. So I wasn't in the best shape pre-op. I would recommend to anyone undergoing foot surgery to do a lot of strengthening prior to the procedure so it's not such a big impact.

I'll keep you posted. Thanks for your support.

Sunday, February 19, 2017

Our Neglected Feet: Guest Author Gemma Gerb

Out Of Sight, Out Of Mind - The World’s Problem With Foot Care
We treat our faces with semi-obsessive care and attention. We cover our hands in expensive creams that they probably don’t even need. We brush and floss our teeth, we exercise our biceps - we even pamper our hair (and our hair doesn’t actually do anything other than keep us a little tiny bit warmer, and make us look good). But we put our poor feet through an awful lot of casual abuse. We force them into appalling shoes, we mash them up with our gaits, we lock them up in humid boots - and then we act surprised when they start hurting, look strange, or develop skin conditions.
The way we treat our feet simply isn’t fair. Our feet do a hell of a lot for us. If you’ve ever suffered from foot problems, it will have been driven forcefully home to you just how vital your feet are for everyday life. Living with compromised feet is not impossible - but it’s tough. And, with feet, assuming that you can just pop a painkiller and carry on is generally wrong. When feet go wrong, they take time and patience to heal. Blithely walking around as normal with a hefty dose of opioids inside you (as Americans tend to do) is only going to heap damage upon damage. There’s a reason why evolution put so many nerve endings in your toes and soles - it needs you to seriously know about it when you’re in danger of damaging your feet! That’s why stubbing your toe or treading on lego hurts so much.
Our attitude towards feet is strange. We either think they look ‘weird’, or fetishize them, or pretty much ignore them. I’m of the opinion that our peculiar attitude towards feet stems from our habit of hiding them away in shoes, the fact that they’re in contact with the ground, and the fact that they’re far away from our faces (they also smell - but that, in fairness, has a lot to do with the shoe thing). Our peculiar attitude towards feet is probably related to our peculiar attitude towards ‘dirt’ in general. We’re increasingly moving towards an unnatural, hyper-sanitized world in which feet don’t quite seem to fit. And, as the associations of feet become implicitly ‘forbidden’, foot fetishism is on the rise
But enough cod-psychology. Here’s what we SHOULD be doing to care for our feet.
  • Wearing good shoes. Shoes are, hands down, the number one cause of foot damage. High heels, flip flops, poorly-fitting shoes, non-ventilated shoes, worn out shoes...all of these will damage your feet in different ways. If your shoes are too big (or are flip flops), you’ll strain your arches ‘gripping’ them. If you’re a habitual heels wearer, you run the risk of shortening your tendons and damaging the bones of your foot. If your shoes have poor ventilation, you’re creating the perfect environment for fungus and bacteria to thrive - causing problems like athletes foot, verrucas, and pitted keratolysis. Ideally, your shoes should be well fitted, without any pinching, and without your toes butting the ends. They should have a decent amount of support for your arch, but not throw your gait off like high heels do, and they should be reasonably well ventilated.
  • Washing and drying your feet. It’s amazing how many people scrub the rest of their bodies assiduously, but don’t bother so much with their feet. Perhaps it’s because washing your feet involves bending down in the shower? Whatever the reason, your feet need washing just as much - if not more so - than the rest of you. And dry them well, to limit the risk of bacteria proliferating in the damp between your toes!
  • Trimming your toenails properly. Cut your toenails straight across, and carefully. Cutting at an angle can cause ingrowing toenails.
  • Moisturising and/or filing. If your feet have hard skin, you can moisturise them, or file the hard skin away. Do be careful, however, about how deep you file - overdo it and the skin will grow back harder than it was before!
  • Changing your socks frequently. Wrapping our feet in socks and then enclosing them within shoes gives fungus and bacteria a fantastic environment to thrive - which causes a nasty smell, among other things! Change your socks frequently to stop this from happening.

Saturday, February 18, 2017

Inverted Technique for Flat Foot Children

Hello Dr.
my daughter has severe overpronation and has been using a sole with your inverted technique for 2 and a half years and she has improved a lot.

her feet is bigger now and need a new sole.
I read somewhere in your blog 3 years ago you have a very good friend in fort Lauderdale fl.

I would like to take my daughter to see someone that know very well your technique, could you please provide his clinic phone number, address and web page, is any? please.

he probably can do a good assessment of my daughter, because the dr in Miami just took her cast and that's it.

in case you know another Dr.  in Miami that know very well your technique please let me know also.

thank you very much for your work and dedication, its really  making a very good difference in my daughter.


Dr Blake's response:

Pronation noted in the back of the heel of the right foot. Ruler denoting vertical, and the heel bisection line shows marked eversion which flattens the arch.

This same right heel in the Inverted Technique attempting to center the heel.

Mari, above is the members in Florida of the AAPSM. I looked at the list and 5 names popped up. They are not in any order:
Matthew Werd
James Losito
Russell Rowan
Brian Fullem
Joseph Agostinelli

You would have to call their offices and inquire. 
You can also get the names of who uses the Inverted Technique alot by calling the 4 Labs I know use it alot:
Root Functional Orthotic Laboratory

Richey and Company

Allied OSI Lab

ProLab USA

The labs would have the doctors names in your area. Please let me know what you found out and thank you for your kind words. I am very happy to hear that the technique is helping your daughter. Rich

Sunday, February 12, 2017

Thinking About Bunion Surgery: What is the next Step?

Hi Dr. Blake,

I am a 65 year old very active woman.  I have been a runner for over 40 years, and in more recent years have added cycling, hiking, and yoga.  I did a 600 mile walk in Europe last summer, and a 500 mile walk in Europe 2 years ago.

I have a bunion on my right foot near my big toe and also have arthritis in the big toe.  My bunion has now progressed to pain such that I can't walk more than a mile without a lot of pain.  I have come to the realization that it is probably time for surgery.

I live in the San Francisco Bay Area and am not sure how to find a podiatrist for the surgery - one with lots of experience, well regarded, metal vs plastic implant?, etc.  I was a Kaiser patient until December when I turned 65 and now have insurance that I can use more universally.  Where is the best place to go for a bunion surgery in the San Francisco Bay Area?  Can you recommend a skilled bunion podiatrist?  Probably sounds funny making such a big deal about a bunion surgery.  But I have tried to put it off as long as possible and want to go to the best.

Thank you so much for your help.  I would not have been able to run for 40+ years without the skill and care of podiatrists.

Best Regards, 

Dr Blake's Response:

Thank you so very much for your email. I would definitely get the opinion of 3 surgeons. Please start with my partner Dr Remy Ardizzone, very skilled and use to dealing with athletes. I have no trouble if you end up going somewhere else, but it is a great starting point. To me, the problems sounds like you need arthritis surgery, and the bump of the bunion also removed. If they only do the bunion, and leave a lot of arthritis, you will be very unhappy. But, with your x-rays in hand, get these opinions and see what makes sense. Find out the type of surgery, the post op course, and what you can expect to do afterwards (can you ever run again?) I hope this helps. Rich

Thursday, February 2, 2017

Possible 1st Plantar Plate Tear

Hi Dr. Blake,
First of all, thank you so much for all of your hard work on your blog and for taking the time to answer these types of emails.

My story is a frustrating one so I'll try to start from the beginning and provide as much detail as possible.
I'm a tap dancer who rehearses weekly for about 2 hours twice a week. I've been tap dancing since I was 2 years old and it is truly my passion. I've never been injured as a dancer.

This past November I attended a tap workshop in which I was dancing pretty much non stop for 6 hours straight for 2 consecutive days. By the last class of the second day I had some pain in the ball of my foot but chalked that up to normal for the amount of pounding my feet had taken, and didn't think much of it. The next day something in my left foot didn't feel right. I wouldn't say it hurt but it felt somewhat unstable. I still didn't think too much of it until the next day it down right hurt when I walked on it a certain way. I could still walk but I was limping a bit. There was also some swelling. I called and made an appointment with a sports medicine physician in my area who deals a lot with foot injuries. I also shifted to wearing only birkenstocks and sneakers at this point.

In my initial appointment, the doctor did x rays which showed no fracture and had me go up on my toes which at this point had become impossible for me. I instantly felt intense pain with this action and a grinding or buckling sensation in the big toe joint. He prodded around the bottom of my joint and ended up diagnosing me with sesamoiditis and tendinitis of the FHL. He put me in a walking boot for 4 weeks and gave me oral steroids to reduce inflammation and told me to start physical therapy when the swelling went down. I followed these instructions and did start to have improvement. My foot felt 90% better by Thanksgiving and I was feeling optimistic. At this point he had told me I could start weaning out of the boot.

I think I became overzealous and decided to spend the first weekend of December bringing my winter clothes downstairs from storage. I spent the whole day going up and down stairs in my Birks and not the boot. By the end of the day I knew something was wrong as my foot had swollen again so I put myself back in the boot and wore it throughout the holidays  and scheduled a follow up with my doctor at the first of January.

At this point he recommended I wear the boot but try to wean out of it as I'd been in it for almost 4 weeks and go back for more physical therapy. I did this and the swelling did go down but I still could not walk normally. I persisted with physical therapy for 3 weeks and was able to go up on my toes again but still had issues with the toe off phase of normal walking. In PT I was able to do 3 sets of 10 reps of heel raises on my injured foot at a time, but when I'd try to walk normally I'd feel a twinge of pain in the ball of my foot between my big toe and second toe.
Dr Blake's comment: Definitely some good overall improvement. 

At home I was doing stretches for my calf muscles and hamstrings. I decided to try some stretches from ballet and did a pliƩ in second position. Upon so doing I felt something pop between my big and second toe and later pain, and then it was swollen again. I scheduled another appointment with my doctor who continued to say this was sesamoiditis, wanted me to buy a pair of custom orthotics that would run me $260 because my insurance wouldn't cover them and wanted me to buy steel plates for my shoes. He refused to do an MRI and gave me no further instructions and told me not to use the boot anymore.

In my frustation I decided to seek a second opinion - this time, from a very highly regarded orthopedic surgeon specializing in the foot and ankle. He promptly ordered an MRI as I heard that should have been done a long time ago for proper diagnosis. He told me to continue wearing the boot until further notice. His PA called me with the results today and told me that the MRI showed significant damage to the plantar plate and at this time he was thinking surgery was going to be the best option.

 I have the MRIs on a disc and could send them to you for review. My question is, in your opinion, am I past the point of conservative treatment being helpful? Is surgery really my only option. As a dancer it has pained me to be out for this long and I am aching to be dancing, or even doing moderate physical activity of any type. Any insights or recommendations would be so appreciated.
Dr Blake's comment: Yes, send the MRI to Dr Rich Blake 900 Hyde Street San Francisco California, 94109. Plantar plate tears of the 1st or 2nd joints are uncommon, and can take a long time to heal, if they do. Some patients prefer the conservative route and do well, while some go straight to surgery to a faster rehabilitation (but no surgery is without potential complications). Let me confirm the diagnosis. You should be back in the removable boot for 3 months. I think your initial injury was healed or almost healed, and the plie caused possibly a new injury. Or you changed a partial and healing tear, to a complete tear. Anyways, back into the boot. Let's see if the MRI makes everything clear or muddy, and go from there. Rich