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Wednesday, June 28, 2017

Progress in a Sesamoid and Nerve Hypersensitivity Challenging Injury

Dr Blake

Wanted to pass on some good news for a change! I'm doing much better and have walked 7 miles this week!  That's the most since last summer!  A couple of things have seemed to help me.  Started using the Exogen which you recommended about 2 months ago.  I had some AVN per the orthopedic doctor and I believe that has helped.   Riding a regular and stationary bike has also helped. Also have used a spikey ball 2 times a day and that seems to help the blood flow to the area.  Another thing that I believe has really helped me is a foam wedge used for stretching. The bike, spikey ball and the stetching give immediate relief to me that seems to last a few hours. The biggest help has been my PT who has guided me through this!  She made a doctors appointment at the orthopedic and even went with me to go see him!  It's been a long journey and still have a long way to go but starting to see the light!   Thanks so much for your help and encouragement!

Healthy Nail Salon Program!!

If your city does not have one, get it!!

Big Toe Injury from Fall: Email Advice

Hi Dr. Blake,
I realize you must get absolutely tons of emails from desperate foot patients humbly looking for advice--and, yes, I'm one of them as well.

First off, I am very grateful that you take so much time out of your day to work on your blog and also respond to perfect strangers. I'm glad I found it, since there is SO much helpful advice and perspective! (and I'm long overdue for making a donation, since I think I've read just about every single post at least twice). Since you are so generous in offering general opinions online, I'm hoping you may be able to advise on my situation (sesamoid-related, surprise surprise! I think you may be one of the best DPMs in the country for this issue). I'm on an HMO in DC, so it'd be challenging to see you for a proper visit, but I would be more than willing to pay a fee for you to give second-opinion correspondence from long-distance.
Long-Winded Nickel Tour:
I had a fall-injury in early March which impacted mostly the ball of my foot, and hurt my medial sesamoid (MRI report indicated "stress reaction"). I went in a boot right away, since the pain was awful. I also almost immediately developed CRPS symptoms (no swelling, but horrible pain and purplish discoloration). I have a history of the OTHER foot having a plantar injury with CRPS from 8 years ago, so I knew the signs and how to deal with it (get a pain management doctor, get on gabapentin immediately, keep the foot moving as much as possible, etc.) Fortunately, with a lot of daily work, the CRPS symptoms have slowly abated a lot in the past 4 months.
However, I think my bigger problem is the sesamoid (my podiatrist calls it a "deep bruise") that does NOT seem to be healing. I've had a total of 3 MRIs  in 4 months; here are the impression notes:

 MRI in March:
"Moderate edema within the medial hallux sesamoid with adjacent plantar subcutaneous soft tissue edema. Findings may be seen with a stress reaction or sesamoiditis. No acute fracture identified. Mild hallux metatarsophalangeal joint effusion with mild osseous marrow edema and subchondral cyst formation at the hallux metatarsal head. Findings most consistent with stress reaction or early osteoarthritis."
Dr Blake's comment: This is normal for a stress fracture (no fracture line seen) although the impact of the sesamoid may have irritated and damaged the metatarsal also (where they come together, seen in impact activities). Sources of pain at this point are nerve hypersensitivity from CRPS, inflammatory bone and soft tissue, sesamoid, and first metatarsal.     
MRI in May:
"Interval improving marrow edema along the medial hallux sesamoid and the head of first metatarsal. Subchondral cystic changes along the head of the first metatarsal along the plantar aspect of the dorsal aspect with resolving mild marrow edema"
Dr Blake's comment: Good improvement in 2 months. I tend to wait 6 months, so this is fun to read. 
MRI in June:
"Minimal interval improvement in marrow edema within the medial hallux sesamoid. Stable degenerative changes in the first metatarsal head at the crista" (not sure if "minimal" means "the radiologist can't really see a difference…")
Dr Blake's comment: The first change was probably just the decrease in overall swelling and inflammation. I would never expect any reliable change in a month. Do not get another MRI until October or December even. 
I went and looked at the images myself--to my (admittedly untrained) eye, the marrow edema doesn't look like it's changed at all in 4 months' time!
Dr Blake's comment: Probably right, but a very indirect reflection on healing. The bone is getting stronger, but the remoldeling phase causes the bone to have more water than it should. It could be healing just fine. Also, have you been icing twice daily and doing contrast bathes each evening to help control the deep swelling. Also, as you bear more normal weight the swelling gets pushed out more normally. The bone mineralization process needs this period anyway. With no fracture line, you do not have to be overly concerned about the bone healing. You have to flush, insure you have good bone health, create your 0-2 pain level yet increase your activity (this is why we need to experiment with orthotics, dancer's padding, Cluffy wedges, rocker shoes, spica taping, etch.
I'm on my second DPM (first was a nightmare who didn't seem to even believe in CRPS), and I'm limited in choice by my HMO unfortunately--the second DPM has 30+ years experience, but doesn't see many sesamoid injuries, nor does any other doctor in the HMO--I think it's maybe because they serve general population and therefore not as many athletic types.  He said he doesn't read MRIs, so can't take a second look at the "progress" of the bone. He originally wanted to cast the foot for a period in the beginning, but I objected because of the CRPS symptoms (immobility=very bad). DPM has now advised to wean out of the boot with J-pad orthotics and Hokas/Altras, but I can't maintain 0-2 pain level (per your advice) in the sesamoid area for more than several steps--and I've experimented with dozens of shoes/orthotics/dancer pads/adhesive felt/jerry-rigged orthotics combinations, to try and offload the bone without upsetting the rest of the foot. No dice there.  I’m having a custom one made, but I'm not expecting miracles or even a better solution than what I've already constructed.
Dr Blake's comment: Sometimes you have to really work with the inflammation and nerve hypersensitivity alot, before the mechanical support gives you 0-2 pain level. Typically a good arch support, a metatarsal support and 1/4 inch dancer's padding, cluffy wedge, and spica taping will give you level 2. What level does it give you? If more than 2, try to work with anti-inflammatories, contrasts, ice, gentle massage and range of motion to bring the pain down. If you touch your skin, and the skin is sensitive, then there is a lot of nerve hypersensitivity. Work with bio feedback like mirroring to get the toe working. Any thing that increases normal touch or motion will tell the nerves all is fine, so stop hurting. People have to neural floss or use Neuro-Eze to relax the nerves. Some need an oral med, like Elavil or Lyrica, to at least calm the nerves while you sleep. 
I've read every single one of your (very helpful and informative!) posts about sesamoids (along with lots of other reading/research), and am doing everything I know of to help it: Vit D and other supplements, daily warm soaks, daily stretching/intrinsic strengthening of the foot (per a physical therapist), daily stationary bike and floor exercises (trying not to atrophy too much elsewhere),  trying all the different shoe/orthotic combinations, acupuncture, more antinflammatory foods.   Have recently added icing and 2x daily contrast baths--I tried in the first 2 months, but ice/cold often makes CRPS much worse, and my foot was definitely not happy with it then, when I had to ice the sesamoid in the first few weeks! Now that CRPS has calmed down a lot, though, I'm tolerating cold therapy, so I'm religious about the contrast baths (along with everything else. I am on the extreme-compliance end of the patient spectrum).
Dr Blake's comment: Since the fall cases impact to hurt the soft tissue, sesamoid and 1st metatarsal, it was a significant injury. You could have an element of turf toe (ligamentous involvement) in there. Be kind to yourself and do not rush, because it is probably not just a sesamoid injury. I would consider getting a CT scan to work at the 3 dimensions of the bone, a nerve evaluation for possible nerve entrapment, and of course an Exogen bone stimulator for the next 9 months. 
 It wasn't covered by my insurance since I don't seem to have a fracture, but I got an Exogen anyway, and doing that once a day--just in case it might help. I’m very worried that the marrow edema hasn't really improved in 4 months, and that it might start to get necrotic.
I've also read the horror stories about people not being able to walk normally for years because of sesamoid issues (or the bone eventually going AVN after fighting for months to save it, and then necessitating surgical excision). I'm desperately trying not to become a member of that camp! I will do ANYthing to help this get better. From my other-foot injury 8 years ago (which got complicated and had me on crutches for a whole year, with several awful years of leg-atrophy rehab following), I already have an INCREDIBLY deep appreciation of walking and mobility in general, so you can imagine how this latest injury is taking a huge toll on my psyche and soul. I'm extremely depressed/grieving and afraid that I'm looking at many more months of immobility and problems. Before March, I was very active walking-wise, ~7 miles/day, and need to walk a lot for my job (and sanity). I'm fully aware of the domino-effect of injuries--and I'm also having some mild symptoms of sesamoiditis in my other foot now, presumably due to compensation.
Dr Blake's comment: First of all, you are doing what you can as a super patient (if all my patients were this good!!) Somehow you have to stay positive to keep the blood flow going. Anxiety is a vaso-constrictor to the sesamoids, and a vaso-dilalator to the quads to make you run again from danger. This is why CRPS patients in general need meditation, gentle healing music, and psychiatric help. I am so happy the CRPS is better, but some nerve hypersensitivity, the type that lingers and lingers, may be still there. Typically a skilled neuro-physical therapist can help with this (what pain to honor, what pain to push through). I can not recommend over 2, but I have had patients okay pushing themselves with 5-6 pain max. That sensitivity is not the place for this blog. 
I'm so grateful for all the helpful information on your blog. Is there anything additional you might advise me to do here? I have these specific questions, if you are at all able to answer them:
  • I now have good flexibility in my foot and joints (it doesn't hurt to flex, only to weightbear) and don't see the benefit of spica taping at this point in the injury. Should I be taping?
                            Dr Blake's comment: You can spica tape to hold your big toe down, and your sesamoid completely off the ground. We call it the ballerina walk. Give it a try to see if it helps. 
  • I've read that biophosponates *might* be helpful for stress injuries (I believe the studies are limited, though--can you speak to this as a possibility?
                           Dr Blake's comment: First get a Vitamin D level and bone density and report back. 
  • Does weightbearing on the sesamoid cause more internal bone inflammation and edema? i.e., Should I just get back in the boot full-time (sigh)? The edema doesn't seem to be going anywhere and I'm terrified that the weightbearing I'm doing may be hindering healing.
                           Dr Blake's comment: Without knowing you any better, and believing that maintaining 0-2 is safe for healing, spend the next 2-3 months in the boot and on crutches. We want some weight bearing for bone mineralization, swelling reduction, bio feedback, etc. Tell me what it takes to create the 0-2 consistently and we can go from there. That will be your July 1st benchmark, and you re-evaluate where you are August 1st. 
  • Is it possible that the internal edema hasn't really healed in 4 months because the already-tenuous blood supply to the sesamoid has been compromised or injured by the internal bruise? And if so, is the bone likely to eventually die?
                           Dr Blake's comment: Sure, anything is possible, but not likely. The CT scan now, and in 3 months, will help assess the possibility of avascular necrosis. That is a much better test in the next 6 months than another MRI. You have done way to much to get necrosis (Exogen, contrasts, some weight bearing). I worry more about turf toe which could require surgery. Have them look at the ligaments really well to see if there is any sign of sprain. 
  • Could the Exogen possibly prevent necrosis? Would you recommend upping the frequency? (I'm on once/day)
                            Dr Blake's comment: Sure, most recommend 2 times daily. It is one of the biggest factors to fight against dying bone because its purpose is to wake up those bone forming cells. And studies show that Exogen helps healing in pretty bad bone!!
  • If you cannot do a long-distance consult, is there anyone you'd recommend in the DC/Baltimore area? I'm stuck with my HMO right now, but may change it at the end of the year, or even pay out of pocket for someone who has a lot of experience with sesamoids.
                           Dr Blake's comment: I love Dr Stephen Pribut. He is wonderful. Pay for a consult and after you get the CT scan, and let me know what he says. We should start there. Good luck. 
Please let me know if you'd be able to consult coast-to-coast.
Very warmly and appreciatively,

Plantar Fasciitis: Fun Video with helpful tips

Being a podiatrist, and having videos myself on stretching, strengthening, anti-inflammatory, I still really enjoyed this video. Thumbs up. I do not like the negative stretching where you lower your heels off the stair, but this is my only criticism. No matter what, you have to create that 0-2 pain level consistently. 2 of my youtube viewers independently recommended I review this.

Running and Not Developing Arthritis: From the blog of Dr Lance Silverman

Dr Lance Silverman runs a beautiful foot and ankle blog which everyone should subscribe to. Here is a great article on the healthy benefits on our joints by running!!

Tuesday, June 27, 2017

Running and Arthritis Concerns: Good Sense Article

Sesamoid Fracture: When One is Already Missing

Dr. Blake,

I'm a very fit and aggressive 65-year-old hiker and backpacker who left the Bay Area eleven years ago for a remote small town in New Mexico.

I have high arches and I pronate, and my left fibular sesamoid was diagnosed with a displaced stress fracture 27 years ago, and was excised dorsally. I was given no further recommendations or precautions at the time.

Pain in that area began recurring 15 years later. Since then, I've seen three different podiatrists, none of whom ordered radiology and none of whom diagnosed a sesamoid problem. No one has ever analyzed my gait. They all simply prescribed new orthotics, and now I have four sets of expensive prescription orthotics, only one of which provides reasonably good arch support.

The latest pain began three months ago. Our (only) local podiatrist likewise just recommended yet another set of orthotics, but it took over a month to get them, so I continued hiking with stiffer boots, adding a metatarsal pad to my best existing pair of orthotics, on my own initiative.

Within three weeks, the pain became acute and I had to stop hiking. I rested it for a couple weeks, but it got no better and began aching at night in bed. Then I iced it three times a day for another two weeks. The ache went away, and the pain (on loading) decreased, but only to a point, so I returned to the podiatrist and requested an x-ray. After reviewing it, he said the tibial sesamoid appears deformed and may be fractured. He said if it is, he will need to remove it and fuse the joint, likely resulting in permanent disability. He ordered a CT scan and left on a three-week vacation before the results arrived.
Dr Blake's comment: No, you first try save it with all the things in this blog, or out in the universe. 

As in the past, he didn't suggest any further precautions or limitations, but on my own initiative, I conscientiously keep the load off that joint. What little walking I need to do around the house, I use my best orthotics/met pad, take short steps, and walk on the outside and heel of the foot to keep pressure off the joint, and I also keep the foot flat to avoid extension of the big toe. For anything more strenuous, like driving my truck with clutch, I wear my heavy hunting boots with orthotics/met pad to distribute the load over the arch and outside of foot, continuing to avoid big toe movement. This way, I've been able to avoid all but intermittent light pressure on the sesamoid.
Dr Blake's comment: You are a better rehabilitation specialist than anyone you have seen. 

In the meantime, I've researched the condition online and find that time is of the essence in treating a fractured sesamoid without surgery. I'm already three months into this condition and I've read that four to six months is the window for preventing nonunion and potential avascular necrosis.
Dr Blake's comment: Sure, you want to catch them early, and you are doing good things. Try to create the 0-2 pain level environment for healing. I have seen them heal or not heal after 3 years undiagnosed, so there are so many factors like biomechanics, bone health, work, etc. 

My next appointment, to receive and discuss results of the CT scan, is July 6. I am EXTREMELY frustrated with how long this problem has been recurring, and how bad it's gotten, without adequate attention, diagnosis, and treatment. I'm concerned that my local doctor may only give me the option of debilitating surgery, and I've learned from previous experience that our local physical therapists have limited experience and limited availability, usually with a month-long waiting list.
Dr Blake's comment: See what he says. Bring in a copy of my blog post attached on treatment thoughts. 

I'm open to traveling anywhere, for example back to the Bay Area, for more aggressive treatment to keep the use of my foot. I've read about treatments like hyaluronic acid injections, platelet-rich plasma injections, rejoining a fracture with wire or screws, arthroscopic debridement, shock wave therapy, bone stimulator, biomechanical analysis, gait analysis, spica taping - none of which seem to be available here. Here, I haven't even been given a walking boot to keep the load off the sesamoid.
Dr Blake's comment: I do not do the PRP or surgery, but can establish in 2 weeks a good program. I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few. 

Do you think I should be patient and wait for a local diagnosis on July 6, or should I be looking into outside options ASAP?
Dr Blake's comment: You can mail the CT Scan to Dr Rich Blake 900 Hyde Street, San Francisco, Ca, 94109. Definitely have a long discussion after reading my post above with the podiatrist. 

And regarding outside options, it seems that sesamoid conditions are often difficult to treat. Should I really be looking for a medical team with deep experience in sesamoids, or do you think any general podiatry practice would be sufficient?
Dr Blake's comment: You just need a good rehab person, who can take the information, protect your foot, give it time to heal. You need an MRI 6 months after the first to check its progress, and another 6 months later. Anyone can do this, but they have to want to do it. Good luck my friend. 
Thanks for your consideration!

Dr. Blake,

This is the patient you replied to on your blog on June 27 - the 65-year-old hiker in a small town in New Mexico whose fibular sesamoid was removed a long time ago and is now having problems with the remaining bone.

I've put in a request for my CT scan to be sent to your office. They say it will go out this week. My local podiatrist says that all he can tell from the CT scan is that my remaining tibial sesamoid is arthritically deformed and enlarged, and the only treatment he can offer is surgical removal. He agrees that I might have better options in a big city, and I'm skeptical about arthritis and the need for surgery, since this problem became acute rather suddenly after years without symptoms.

Therefore, I'd like to initiate the intensive two-week round of appointments with you and your team that you mentioned in your response: "I would want to make the appointments if you can come in on a Monday and leave the 12 days later. I would have you see our surgeon, me several times, our physical therapist, and bone stim guy, to name a few."

How should we proceed? Would you like to wait until the CT scan arrives so you can review it first and decide on a plan?

Dr Blake's comment: Yes, let me see the CT Scan. I will put some of the best images on this post. Our surgeon is gone from July 24th to August 14th. I am here except several days in Sept. When we you thinking of coming, after 8/14 is best. Rich

Monday, June 26, 2017

Big Toe Joint Problems: Email Advice

I wanted to reach out to you as I've been using your blog so much for my injuries and I was hoping for your opinion. About 6 months ago I started to notice pain in my arch and it almost felt like more of my arch was touching the shoe than I was used to. This pain then turned into pain in my heel and ultimately, plantar fasciitis.

I ended up getting a cortisone injection in my heel which did help with the inflammation. Unfortunately, I had to walk on the ball of my foot for 2 weeks after the shot because I had a really bad cortisone flare up and the pain was excruciating. Once the pain and swelling subsided, I felt so much better. Unfortunately 2 days later I woke up with awful pain in the ball of my foot, above the sesamoid bones, almost like it was between my 1st and 2nd metatarsal. I never had much pain when the actual sesamoid bones were pressed.

I went to my podiatrist again and he diagnosed me with sesamoiditis. The pain was worse than the PF and was felt every time I took a step. I tried dancer pads but those only made my PF start to hurt more. I went back to my podiatrist again and he ended up giving me another cortisone injection, this time for the ball of my foot. The pain was worse for the first week or so as I had a viable bruise but after 9 days the bruise and pain went away.

At this point I thought I was finally done with all the pain. Now I'm experiencing a lot of pressure and stiffness in my big toe. If I stand barefoot, there's a lot of pressure at the MTP joint. I still have range of motion in my toe and it doesn't hurt to use my hand to flex the big toe up but if I make my foot dorsiflex, I feel a lot of pressure in the joint. I can actually stand barefoot for once but the pressure is just so uncomfortable. I went back to the podiatrist again and he thinks it's just the sesamoiditis causing this pain. My concern is it's arthritis developing in the 1sr MTP joint.

I'm going back to the podiatrist again tomorrow as I would at least like an xray (he never did one but I had one prior to seeing him, maybe 1 month prior and it didn't show anything) just to make sure it's not arthritis. I'm still unsure if I had sesamoiditis in the first place.

I wanted to get your thoughts if this truly does sound like sesamoiditis and can sesamoiditis cause this much stiffness and pressure in my joint now? Or does it sound like I might have something else going on in my foot? Can sesamoiditis eventually cause arthritis?
Sorry for such a long email. I've been so anxious to heal since I've been so inactive for 3 months now trying to rest my foot and we've got a 12 day trip to Germany in 2 and half weeks.
Dr Blake's comment: It sounds like when you walked on your toes abnormally (never a good idea, but definitely what we all would have done in the circumstance) you sprained the big toe joint. The feelings of a sprained joint is stiffness, pressure, some loss of motion if real bad). See my postings on how to do contrast baths to reduce the pressure, and spica taping for long walks. I would also ice the joint with a pack for 15 minutes twice daily. 

Thanks for any advice possible.

And the patient also wrote:

Dear Dr. Blake,

Recently I started to have nerve sensitivity in my left foot right where my bunion is. I never paid attention to my bunions before because they aren't that big and never bothered me. I was trying a new pair of sneakers that creased every time I walked, and rubbed my bunion. This caused a nerve sensation to develop that I feel every day now. I've been using YogaToes everyday to help stretch out my toes but would you recommend anything else to help calm down the nerve sensitivity? It's not really a pain, it's more of just an irritation but definitely gets worse when I wear shoes now. Any advice would be greatly appreciated!
Dr Blake's comment: Order some Neuro-Eze gel to massage in 3 times a day for 2 minutes. Until you get that use any type of massage oil to do the desensitizing massage. 


Star Excursion Balance Test: Ankle and Lower Extremity Rehabilitation

Our physical therapists do this testing of stability all the time, but have the patients use it at home to rehab. It is easy to make with tape in your basement, and it shows deficiencies and progress. If you are doing any type of lower extremity rehabilitation, but ask your therapist if this is right for you.

Psoriatic Arthritis: Nice Overview

Downhill Running Techniques

Sunday, June 25, 2017

Metatarsal Fractures: Email Advice

I broke my feet (age 54 female with a great diet raw and grass fed only) and walked on them for four months orginaly at Christmas building fence using my feet in a way I should not have.  (lever)

 Upon x-ray last week after resting weight free for three weeks it showed the breaks and white line on my fifth where it was said to have started healing.    Broken: 5th and 4th metatarsals on left and 4th on my right foot.  My  Chiropractor  took the xrays and put me on a vibation machine for a bit but it was a killer.  I think I re-injured them with that or at least it felt like it.   Then I got the great idea to swim just the next day.  Not moving them but a bit. Then the next morning did a stretch a couple of times touching my toes and it felt like my tendons were going to pop out of my feet. 

My feet were in cam boots but that squished them too much. The pain is right at the tendon attachment on both feet. Right where the  Peroneus Brevis tendon inserts into the 5th matatarsal bone on the outside of the foot.  So i ordered the flat shoe you wear next and that is far more agreeable.  I have no insurance and live in a small town with no podiatrist I trust. I was just wondering since I walked on them so long after they were broken could i have also damaged this tendon on both feet?
Dr Blake's comment: Possible yes, probably no. Usually only with a severe fall. When the tendon is injured, it hurts back to the ankle, and sometimes, up the leg. Usually no localized. 

 I probably only had stress fractures as I only had pain on the right the lesser break but I did not know until it got to the point I could not walk then I gave in and figured they must be broken...Then the x-ray after three weeks with them up.  I have been doing the hot and cold baths and have a used Exogen on they way.  How long should i stay non weight bearing.  
Dr Blake's comment: You want to create the 0-2 pain level, but gradually weight bear to build bone strength. Inside the shoe you can take 1/8th adhesive felt (like from and build a base that has a float for the fractures. Need alittle experimentation, but important for weight shifting and gets you walking faster. 

A second hand exogen dealer gave me your blog and I have read about the hot cold stretching.  How soon can I do that?
Dr Blake's comment: You can use ice pack for 10 minutes twice daily now, and begin each evening with one minute hot one minute cold alternating for 20 minutes. It is not stretching, but range of motion in the hot water with your foot. You can start that now. 
   Also the good pain bad pain I am so unsure at this point.  can you please help with some advice?  It has been six days  since the x-rays and vibrator machine.  a couple since stretching. 
Dr Blake's comment: Bad pain is pain that is above level 3 that you ignore and push through. An occasional sharp pain that last 10-30 seconds is nothing. If you start doing something that starts to hurt, you have to listen to your body and stop. If you do something that does not hurt until later or the next day, you have to wait to the pain subsides for a day, before you can do the same activity. Since this is a bone problem, at some point consider a Vit D blood test, and a Bone Density Screening Test. Hope this helps some. Rich

Friday, June 16, 2017

Nerve Pain: Email Advice

Dear Dr. Blake , Thank you so much for your blog I just wish that I had found it 7 months ago!. Can you please help me? I have been a labour and delivery nurse for 30 years. 12 hours days and nights on  my feet. Last year I broke 2 toes on my right foot and very stupidly continued to work . I could not wear a closed shoe so I foolishly wore flat shoes with no support and flip flops all summer.  7 months ago I started to wear my new supportive work shoes and a 7mm  lift. ( During the summer my osteopath diagnosed me with a 7mm leg length discrepancy as the cause of my lower SI joint pain). Within weeks I started to have pain under my 2nd Metatarsal on my left foot ( the foot I limped on for 4 months).
Dr Blake's comment: Is it also the foot with the lift? Very important because, if it is a heel lift it can transfer the weight to the metatarsals, and if it is full length it could be too stiff in that area. 

 I went to a podiatrist and he recommended a metatarsal pad. I tried to wear the metatarsal pad but it seemed to make things worse.
Dr Blake's comment: Met pads can make nerve pain in that area worse, and tendon pain worse, since those structures run back into your arch. Met pads normally help bone and joint pain unless too far forward. Did you try to move it around? 

 The pain soon was at the base of my 2nd and 3rd metatarsal . I went to physiotherapy and they diagnosed me with plantar fasciitis both feet ( no heal pain but pain under arches and below ball of feet worse on the left foot. Also they diagnosed me with possible capsulitis and neuroma. I ordered custom orthotics at this time. While waiting for the orthotics I continued to work. I started to experience intense burning and tingling shooting neuralgia. My feet were so painful the sheet could not touch them. 
Dr Blake's comment: The orthopedic problem had become neurologically over sensitive to protect itself. You now had the original problem, and nerve hypersensitivity, together. You have to take this very serious because it can lead to CRPS, so creating a consistent 0-2 pain level is crucial. 

I went back to the Podiatrist and he gave me a celestone cortisone injection between my 2nd and 3rd and 3rd and 4th metatarsal. After a couple weeks I started to get alot of relief in the burning and nerve pain the inflamation went down considerably. The cortisone allowed me to  receive physio therapy ( ultrasound and aggressive manipulation of my feet) I did all of the exercises I was given. 3 months later the symptoms returned with a vengence.
Dr Blake's comment: Unfortunately, it is common to have these long acting cortisone wear off and you need boosters. I tell my patients that they may need 3 total to address the nerve pain. While you are injecting a nerve, since it may wear off, consider oral nerve meds like Lyrica, topical Neuro-eze, neural flossing, ice pack 10 minutes twice daily. 

 I got another steriod injection this time Depro Medrol same locations.
Dr Blake's comment: Celestone is 6 mg per ml, whereas Depro is 20, 40 or 80 mg. It is very strong cortisone, as should not be used alot in the foot unless diluted. 

 After a very uncomfortable steriod flare 7 days later my foot started to settle down. I still suffer with the intense dull pain under my 2nd and 3rd metatarsal and my toes feel " out of joint" I can flex them but it feels swollen behind them and I cannot extend them without great ripping pain. I finally got an appointment with an orthopedic surgeon and he did xrays which showed no fractures, small heel spur. He diagnosed me with Tenosynovitis of the 2nd and 3rd metatarsals and plantar fasciitis . I agreed to PRP injections . I had a 2 week inflammatory response from those ( very painful) but my plantar fasciitis is 75% better  and the  Tenosynovitis is finnally settling down. I am icing several times a day. I was doing calf stretches but stretching irritated the tenosynovitis so I have stopped. The only advise I was given from this doctor was to rest and return in 5 weeks. I have been wearing a very flat firm slipper that my orthotic fits in I can't seem to wear my running shoes because they make my toes flex. It has been 3 weeks with very little ambulation in the day I am couch bound. I tried wearing a Budin Splint but it seamed to irritate the tenosynovitis on the toes. I plan to remain on the couch another 2 weeks then I see him again for the 2nd PRP injection if needed.

My questions are. 1) I think my orthotic is making it worse. When I walk I feel like I land right on the 2nd metarsal and when I tried a met pad it seem to cause the plantar ligament to pull on the capsule and the 2nd and 3rd metatarsals making the tenosynovitis worse. What do you recommend I wear on my feet? How long should I wait to try a met pad? How long should I wait to try the Budin splint again.
Dr Blake's comment: Orthotics are tricky for metatarsal issues since the end of the plastic is where you hurt. You can try a full length Sole (I prefer the red ones) with or without a loose fitting Budin Splint. Use a single loop Budin and open it up and place around the 2nd and 3rd toe, or the 3rd and 4th toes together. Yes, avoid met pads when there is nerve hypersensitivity. 

2) What types of shoes should I wear with this history.
Dr Blake's comment: Definitely try the Hoka One One Bondi or similiar to give you rocker. You may also need a Hike and Bike shoe for the rigidity right now.  How do you feel in a Danco clog, for cooking or short spurts?

3( Should I give up on the orthotic?. I pronate on both but much worse on my right foot . My arch is falling on the right. And the right foot is my good foot.
Dr Blake's comment: Give up on it right now, until we experiment with full length ones from Sole, Powersole, Lynco, etc. 

4) How long  should I remain off my foot? Should I completely immobalize my foot? How would you recommend I do this?
Dr Blake's comment: Nerves like warmth, motion, not prolonged stretching, non painful activities like walking. So, being immobilized is may help orthopedic injuries, the nerves hate it. I would have to know how you feel walking with crutches in a removable boot.

5)How will I know it is time to start restrengthening and returning to normal activities ie work?
Dr Blake's comment: Strengthening should be happening right now. This is usually organized by the PT. If you can not balance on one foot due to pain, you at least should be able to use a stationary bike with your weight in the heel for an hour a day. You should be doing a gym program for at least ankle strengthening, knee, hip, core, cardio, some upper extremity. Consider experiment with various beginner yoga poses or pilates exercises. Over the next month, every day find one exercise that does not hurt, and keep building.

6) I'm sure the 7mm lift in my right shoe has changed the weight distribution between my feet and has probably caused the perfect storm. I have been wearing the lift for 7 months now and it has been the answer for the S.I. joint pain I have had for 7 years ( GONE !!!) Should I have new orthotics made with no lift? I could get a separate lift made and add height a bit at a time.
Dr Blake's comment: The relief of the SI pain is pretty striking and emphasizes the need for the lift. I am glad the lift is not on your injured side. I love orthotics and lifts separate, so you can experiment. If the lift is only a heel lift, try to take that off and use a 1/8th inch full length lift (spenco insert) for the next month on the one side to see what happens. Hope all this helps some. I do want to say that lifts under your foot on one side have a very dramatic effect on the base of the spine. If I was treating you, I would order an MRI of the injured foot, and a Standing AP Pelvic xray with your 7 mm lift and orthotics to see how the spine, hips, and SI joints look. How level are they?

Please help me I am desperate to return to work and my life I love walking. I have been limping for 12 months now!

When Something is not Plantar Fasciitis: Email Condition

Dr. Blake,

I've been diagnosed with Plantar Fasciitis 3 months ago,  however I'm not sure if  I actually have that condition.

The Doctor did zero testing. I had googled heel pain and up came Plantar Fasciitis and I have high arches.  I found a local podiatrist and I sent a message asking if she treated this condition as well as plantar warts.

Turns out I don't have plantar warts but I definitely do have heel pain which came on suddenly for no apparent reason and has gotten steadily worse. 
Dr Blake's comment: Typically plantar fasciitis (an inflammatory condition) has a gradual onset over weeks, and usually months. 

I've been told that usually PF cause pain first thing in the morning but not for me. I have no pain in the morning. My pain appears after I been walking slowly and gently for a limited period. 
Dr Blake's comment: Definitely this is not plantar fasciitis, more like a heel bruise, heel bursitis, or some tendinitis/myositis of the local muscles. 

The doctor suggested the following treatment which I have done.

I purchased a compression sock and I wear it .
I take Aleve on off for selected period of times.
I soak my foot in Epsom salt until its a prune
The doctor taped my foot (made it more painful).
The doctor wrapped my foot in gauze with a cushion inserted and then applied a lite casting plus another wrap on top for a sprain. This was a disaster because the cushion had slipped to a position on the top of my foot where the foot and ankle meet.  I took it off in two days it was supposed to stay on for 7.

I have a prescription for PT but have yet to attend as I am not convinced about the diagnosis.
Dr Blake's comment: Sometimes PTs just blindly follow the Rx, and sometimes they try to give you an independent diagnosis. They can still follow the doc's RX if it is general enough. Definitely ask around to find a good independent thinker. 

The doctor has also suggested cortisone shots which I have declined.
Dr Blake's comment: Good for you. If you have a small fracture or small tear, these can be made worse. 

I also have all sorts of inserts which maybe ​contributing to making things more painful.
Dr Blake's comment: You have to try these, and sometimes you will be surprised what feels good, and what increases your heel pain. Amazing how many people continue to wear inserts that bother their feet in some way, although sometimes they have no other option. 

The issue  is that this condition is getting worse a case of the creeping pain, which is now gone up to the ankle and calf in the affected​ foot and also to a lesser degree in the other leg/foot which I believe is responding to my change in gait. I am hobbling around almost to the point of immobile.

Can you help me. I live in Emeryville CA . I have Medicare and AARP Supplemental policy. This situation is rapidly becoming debilitating and I really need to do something.
Dr Blake's comment: I am just across the bay. Come see me after an MRI if you can get it, and bring anything you have. 


Fractured Sesamoid: Email Advice

Hi Dr Blake!

After scouring the internet in a desperate search of hope for my sesamoid injury, i have stumbled across your blog (thank goodness)!

I am dealing with a fractured sesamoid that i believe may have occurred in April 2017. When i originally felt the pain from the fracture, i did not think anything of it , as i have suffered from PF for years ( I am a 24 y/o female ). 

The pain began to increase in my left, big toe, so I finally made the decision to visit an orthopedist on May 12th. I was beginning to worry how my pain would affect my 1 year work trip to an unsafe location in the middle east, where i would be on my feet 7 days/wk , ~12 hrs/day. 

The orthopedist x-rayed my foot and told me, "you have an old split bone in your toe". Because he did not go into any further detail and simply told me to cushion my foot better, I continued on thinking this was an injury i had acquired many years ago from dancing ( and that has simply flared up temporarily ). 

As the pain became more severe, and my time in the US limited to only a few wks, I found a podiatrist. He immediately diagnosed my problem as a fractured sesamoid (left, big toe) and put me in a Cam Walker (which i have been wearing now for about 3 weeks). He wanted to over-treat the injury as he knew i was intending on leaving the US very soon.

I was also given 2 separate EPAT treatments to help with my PF.

Fast forward to my appt. this week, I told him i was  not getting any better and i had doubts that my foot would improve before my deployment. We both decided I should tell my employer that i needed to delay 2-3 weeks and they were OK with that.

My podiatrist ordered an MRI (which i had just a few days ago) and the results are disheartening. It says it is looking like a non-union and i am devastated as i have been planning for months to move overseas for this work trip.. I am now unsure what kind of time-frame to put on this injury and do not think i will be ready to leave in 2 weeks.

I am still in the cam walker (about a 3 pain level, i mostly feel a constant dull ache), i am trying gentle massage, cold/hot therapy, etc. I do get nerve pain/tingling in my toes when i lay down/ sit down. And my big toe has definitely lost its range of motion (which i am now starting to work on).

I am at a loss. Do you think this has any potential to heal in the next 2 months? 

I really don't know what to do at this point.

I really appreciate any insight and thank you so much for your time!


Dr Blake's comment: These injuries can take quite a while (6-9 months) to heal, and if you rush them for whatever reason, you risk starting over. You are in the right boot now. You need to maintain a 0-2 pain level over the next year. You need an orthotic with dancer's padding to off weight the area, and can allow you to get out of the boot faster or get into a Hike and Bike shoe. instead of the boot. These shoes are not to be bent across the ball of the foot in an active pushoff, but are easily adapted by my patients and will protect the sesamoid. So, if you can get a protective orthotic to shift from boot, to Hike and Bike, to normal athletic shoes (consider Hoka One One Bondi), over the next two weeks, you should be well protected and can go on your trip with the Hike and Bike shoes, and a removable boot as a backup. Continue to ice twice daily, and do a deep flush with contrast bathes in the evening. Good luck and I hope it helps some. Rich

Wednesday, June 14, 2017

Fractured Bipartite Medial Sesamoid: Email Advice

Dr Blake

My 14 year old son was hit during a soccer game and fractured his bipartite medial sesamoid in his right foot. They are still in the same two pieces but considered fractured from each other.

We know he naturally has bipartite sesamoid a due to an unrelated X-ray 3 years earlier.

He was in a boot for 4.5 weeks but is now in a tennis shoe w custom orthotics.

We are supposed to wait 4 more weeks.
This is a unique injury, and I pray I am doing the right things.

He is resting for the most part. He says he is not in pain in his shoe or if any at a low level.

I would fly to California or anywhere to help him.

You are an expert on these injuries so any advice is appreciated.

He is eating healthy. Vitamin c, calcium, magnesium for calcium absorption, etc.

Should I be icing his foot or anything if he seems to be resting calmly.

Thank you

Dr Blake's comment:
     I am just back from vacation, and alittle jet lag, but I hope this makes sense. First of all, everything sounds fine as you are creating a 0-2 pain level for healing. I am assuming this is all x-ray based decisions, and not MRI, which is fine for now. Make sure you are icing the foot twice daily for 15 minutes and doing contrast bathes for a deep flush in the evening. If he walks with the shoes and orthotics, you should feel that he can walk through his foot, but the orthotics take some of the weight off the sesamoids. If not, the doctor should experiment now with higher arch, dancer's padding, or cluffy wedges. All of this is found in the blog. Once he can walk comfortably for 2 weeks straight, he can start a walk run program. That will typically take 10 weeks, and there should be no increased pain. Once you start the walk run program, you can do sports specific non-running activities, like free throws in basketball, volleying in tennis, etc. Nothing to increase pain. The walk run program is typically accompanied with Hoka shoes and spica taping (as needed based on pain). I hope this helps some. Rich