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Saturday, September 30, 2017

Turf Toe: Very Disabiling!!

Hi!  I found you through Youtube and have spent some time on your website.  The more I read, the more I realize I am in trouble.  I do not know if you still answer emails, but I thought I would send this.  I have nothing to lose, only to gain; right?
Dr Blake's comment: Hopefully, right?:)

So...  A year ago, I had a serious "Turf Toe" type injury, resulting in two fractures at the top-side of both joints of the big toe, one fracture, each.  I had ligament, tendon sprains, and nerve injury.  Eventually, it began developing into possible CRPS symptoms, which a physical therapist noted and got right on top of.  (I am very happy to report that those symptoms have been resolved.)
Dr Blake's comment: That therapist needs to be in your will, or at least a thank you!!

Because there was so much going on and pain and swelling everywhere, I didn't realize the pain under my foot was any different than the pain everywhere else, in the first couple months.  Through the entire year, except for wearing a boot for two weeks, around the clock, my instructions remained that I walk on it at home, with no boot (which, for me, meant barefoot, since I can't tolerate slippers or even a sock - nerve stuff) and only wearing the boot when I leave home.  

During this time, I have gradually turned into a shut-in.  Life as I knew it, stopped.  My job, gone.  As the months passed and pain, swelling, and inflammation persisted, I began asking about an MRI.  For months, my podiatrist kicked the can down the road, citing the expense for the insurance company.  Six months after the injury, he finally conceded.  The MRI showed that I also fractured both sesamoid bones.  And my resulting treatment?  IT REMAINS THE SAME!  Just keep on walking on it (booted only when I leave home, which is pretty much never)!  99% of my life is now lived banished to my recliner - but bootless, as instructed!!
Dr Blake's comment: One of the hardest things for docs in the short office visits we have is to fully understand the disability someone has! It is sad, and the patient gets into this predicament. Rehabilitation is a balance between pain and function. Sometimes we actually have to ignore some pain to increase function. It is also the role of cross training. Many patients can not walk but can build up to 2 hours a day on a stationary bike, and this can be emotionally and physically so healing. With a stationary bike, none of the weight has to go through those joints. 

A month and a half ago, I re-injured it while wearing the boot - toes being violently propelled over the top of the bootstrap, resulting in a fulcrum effect, at the base of the toes.  I fractured a new place in my low, big toe joint and the new MRI shows both sesamoid bones, still fractured.  

The doctor says he cannot tell if they are new fractures or old ones, that never healed.  My vote is the old ones never healed.  The pain and swelling never went away!  

And now...  I have de-mineralization (rated as moderate to severe) throughout my entire foot!!  I just saw a sports medicine podiatrist for a second opinion.  After seeing the two MRIs, he ordered a CAT scan, which I had done today.  He said, depending on the results, he may recommend removal of one or both sesamoids.  (He said recovery will only involve non-weight bearing on the front of my foot for 4 - 6 weeks, then I'll be good to go!  I suspected that wouldn't be enough, which I have learned from your site, is true.  Common sense!  But none of this last year falls under the category of common sense, for me.  Why not treat my fractures like fractures, instead of having me walking on them for a year??)
Dr Blake's comment: Please send the CT scan disc to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. It will be good to have a clear view of the injuries since my mental picture is getting foggy. I am from San Francisco known for our fog. 

At this point, I am at home, unbooted, with crutches - why not just use the boot, right?  I CANNOT walk bare-foot on the front of my foot, as instructed by the original doctor.  It seems like I will never be given the chance to let the bones heal through immobilization, because of the bone de-mineralization (that was NOT on the first x-rays/MRI, last March).  I would think that immobilizing, the way it should have been done, now, would make the state of my de-mineralized bones even worse.  If he recommends surgery, I will never know if my sesamoid bones COULD have healed, if given the chance.  This is so not right!
Dr Blake's comment: Docs are given mere thumbnail prints of your last year in one visit. This can make the correct decision clouded by the need for pain reduction and mobility so I can see why anyone with a heart would at least entertain the thought of surgery. 

Am I seeing this correctly?    

Then...  I followed a few sesamoidectomy video diaries on Youtube and the experiences of these poor people were awful!  Do I even want to do this to myself??  ONE AND TWO YEARS LATER, they were still giving updates about their continued pain and limitations!!  Is that my future if I have surgery?  Then, of course, comes the next question.  After a year of this, already, is THIS my future if I do not have surgery???  It all looks so hopeless.  I feel trapped, with no way out!
Dr Blake's comment: Surgery has complications, but sesamoidectomy is a very successful surgery overall. When I struggle with my patients, some do eventually need surgery, and I am sorry, but they do well. I tell my patients that all the skills you learn trying to avoid surgery, help you if you eventually need surgery. You have an unusual case that needs a lot of thought. You have not walked for far too long, and you had a second injury. Also, total healing comes from too many factors that I have time for, but you work through them. But, do not focus on the 1-2% of patients that have major problems post surgery. That will serve no purpose in your attempt to heal. 

(One woman had the surgery, her big toe crossed the others, corrective surgery did not work, they fused her big toe joints, there were complications with that, then the last post was that she had the advice of two doctors to amputate!!!  Scary stuff!!!)  

Does this surgery benefit anybody???  I haven't found that story, yet.  Is it possible to have a life without permanent pain and dysfunction after this??
Dr Blake's comment: Yes, but you have to find a good surgeon if it gets to that

Maybe the biggest question is, "How many doctors do I go through before I find one that listens and knows what they are doing?"  THAT is the greatest futility of it all.  (The two ER docs, from each injury, missed it, which is incredible to me.  The very first podiatrist recommended two surgeries based on x-rays that were not mine!  He is known for unnecessary surgery, apparently.  I ran from that place and into the care of an orthopaedic surgeon who said it was no big deal.  He literally said I was not to modify my life, in any way, and to walk on it until I saw him, six weeks later.  At that point, he re-x-rayed one of four fractures, missing the other three, then announced it hadn't healed and I needed six more weeks of un-modified walking.  "Call if you have any problems."  No follow-up appointment.  The next doctor is the one I spent the rest of the year with, until the second opinion, I just got.)
Dr Blake's comment: I am sorry. Let me know what cities you are around, and I will send you a recommendation or two. You will at least need another opinion at some point. 

Another question.  The in-office x-rays (second opinion doc) shows the toe fractures have healed, but I still have pain that shoots out of the joint at the base of the toe (where the fractures were) when I walk.  Is there any correlation to the sesamoid fractures?
Dr Blake's comment: Of course, they are in the same area basically. Occasional sharp pain which quickly disappears is not considered damaging.  The real job now is to create that 0-2 pain level as you begin to walk more. This typically needs some form of off weight-bearing padding and an arch support. Sometimes you need crutches to help. 

And, I am getting this weird internal/external swelling that both doctors don't have an answer for.  When I rest my foot on the floor, my big toe is elevated/suspended more than half an inch off the floor.  The toe next to it (which is also still having joint pain, swelling, redness) is lifted off the floor a little less than the big toe, then the third toe is almost on the ground, while the fourth and fifth toes are on the floor, as they should be.  It has been like this since the first injury, but improving, as time went on.  The second injury brought it right back and it is not improving, at all.
Dr Blake's comment: Anytime that there are positional changes you think of tendon or ligament tears (common in Turf Toe), and these may eventually necessitate surgery. Swelling in the big toe joint typically does not cause these toe positional changes. I would find out what ligaments are torn from the MRI, the bottom or plantar ones causing the toe to go up, and the top or dorsal ones causing the toe to go down. If you lose a ligament, you have to ask the tendon in the area to try to get stronger and compensate. You can initially tape the joint so it stays in the right position. 

It also feels like I did something to the tendon at the center of my toe, travelling over the top of my foot and into the ankle.  It hurts just to touch it.  If it is the tendon, it has been very painful (with swelling).  No one responds to my concerns, at all.  I talk to the wind and the wind doesn't speak.  I wonder if that tendon could be pulling things upward, except the other two toes are involved, so probably not. 
Dr Blake's comment: No, the tendon could be in spasm, being partially damaged. Or there could be nerve issues causing the tendon to contract. Think of seeing a neurologist or physiatrist to evaluate the nerves. Send me the MRIs if you want another look, or I can give you the name of someone in your area, if I can find someone. 

From the moment of the second injury, I instantly became unable to move my big toe, at all (physical therapy had freed it up into an almost full range of motion, before the second incident).  I can get it to flutter a little, but nothing more than that, in either direction.  No one seems to think that means anything or that it needs any kind of intervention.  The MRI apparently says nothing about it, either, which is confusing to me.  (The previous doctor suspended physical therapy, to date.)

Doesn't it seem like doctors should diagnose/treat everything that is going on, rather than choosing the obvious spots to focus on, while ignoring the rest?  That's how I got here, to begin with. 
Dr Blake's comment: I agree. You probably need someone working on the exact injury, someone working on the pain, and perhaps someone overseeing it all to make sure each month you are moving ahead with progress. 

I guess I am sending a message in a bottle, so to speak.  If you have read this far, I deeply thank you for your time.  God bless you for bringing information to patients that wouldn't be able to find it, otherwise, because I am one of those.


If I walk in a boot, is that enough weight -bearing to help the increase of de-mineralization from occurring?
Dr Blake's comment: For sure. Take some photos of your feet and put some xs on where they hurt. Unfortunately, thru this conversation, I still only have a small idea of what is going on. Thanks Rich

 It's got to be better than not walking, at all, or so I would think.  Maybe if I get mobile, in a boot, at least I am walking.  I really do not know who to trust or how to proceed.  (This so sucks.)

Thanks, again...

Monday, September 25, 2017

Posterior Tibial Tendon Injury: Email Advice

Good afternoon Dr Blake. I am writing you from New York City. First I want to say THANK YOU for the wonderful blog that you have created. I will be as short and concise with my situation. Like you I have a long history of playing basketball and also running wind sprints. I have sprained my ankle numerous times from basketball. This current injury is different as its the inside side of my left ankle that has PTT (posterior tibial tendon). 

In January I was running wind sprints up a hill in the park on concrete. After my workout, I felt some pain and swelling. I thought it odd that it was the inside side and I don't recall twisting my ankle.  I went to the doctor and he prescribed physical therapy. I went to 5 sessions over 3 weeks and all the pain went away. I did NO home exercises. Fast forward to July and I did the hill workout again. I felt tightness in my calves and some slight swelling but not pain. 2 weeks later I did a sprint workout at a soccer field. After my 4th sprint, my foot locked up on me. I thought it was the dreaded Achilles tendon tear and it hurt and I could barely walk. I elevated a few days, not too much ice. Went back to the doctor. Got a script for physical therapy. I STOPPED all jogging, skipping rope, doing wind sprints.  I went to one clinic 4 times over 2 weeks. I wore no brace. The therapist didn't believe in braces. I took Aleve for 10 days. I switched to another physical therapy clinic. Went there 5 times over 2 weeks. I wasn't getting better. I then went to an orthopaedic surgeon. I believed I needed an MRI. He took Xray and said no stress fracture. He did some manual tests and concluded I had an Unstable Ankle and Posterior Tibialis Tendonitis. He suggested one of the more expensive over the counter Orthotics(hard plastic type). He said I had flat feet but only when standing. He said I might only need the Orthotic for 3-4 weeks. He did not think I needed surgery at all anytime soon. He said 3-4 sessions of physical therapy would be beneficial. 

After 2 weeks of the swelling/inflammation not going down, I went to a new physical therapist. He concluded I didn't have swelling/inflammation and needed heat and home exercises. Things like calf raise (2 sets of 12 twice per day). Theraband for inversion (2 sets x 12 twice per day). The one legged balance for 30" (2 sets x 30" twice per day). Stretch the calves and soleous twice per day for 30". After 2 weeks of still the swelling not going down I went to a podiatrist. He ordered MRI and after the MRI he got me a knee high walking boot. He said to use the boot for 3 weeks (follow-up visit after the 3 weeks

Highlights of MRI:

Chronic postraumatic deformities of the tips of the medial and lateral malleolar are noted 
There is a chronic full-thickness tear of the anterior talofibular ligament 
There is marrow edema within the talar head and neck. Different considerations include a bone contusion or stress reaction. 
There is increased fluid in the posterior tibialis sheath consistent moderate tenosynoviitis with intermediate signal in inframalleolar component of the tendon consistent with mild tendinosis. 
A type 2 accessory navicular is noted with marrow edema within. 
A ganglion is noted with Kager's fat pad measuring 1.9 x 1.1 x 1.4cm 

I have yet to find a physical therapist who actually knows what to do for PTT. Also as nice as the podiatrist was I dont think he fully understands/emphasizes with my frustration as to what to do at home to best heal, strengthen, stretch.

The last physical therapist session was with a new person who suggested to STOP doing calve raises and to stop doing the soleous stretch. To do the theraband in the 2 directions that dont put any strain on the Posterior Tibialis Tendon. I am to return to that therapist in 2-3 weeks. They also said do NOT use heat but to ice 1-2/day. 

I dont know how long to wear the boot. I also dont know what is safe to do strengthening wise. My frustration is not getting the inflammation/swelling completely gone

Have you heard of Tendex Fast surgery?

Oh yeah

What specialist would be able to tell if I have muscle weakness or tightness in my hips, thighs, hamstrings, or calves? I think the PTT is the result of some other problem in the chain.

I have placed the Orthotic in my walking boot. I will be watching all of your youtube clips regarding PTT. I wonder if even walking in a boot puts some stress/pressure on the PTT. Currently its is around a portion of the ankle bone where I still feel inflammation/swelling and some pain. The pain flares up when I walk too long. I am wondering if staying at home just reading and watching movies for say a week or two would be truly resting the PTT.

THANK YOU for your time. I appreciate any and all feedback

Dr Blake's comment: Thank you so very much for emailing. I will try to give you my impressions with the info you provided. The MRI was very helpful, and you need another one 6 months from now to check on the edema. I see no place now to consider a surgery. Surgery typically would be a year from now if you are not able to get back. I know it sounds long, but you have to get rid of the underlining talar head and neck bone edema due to impact stresses. It probably is the cause of all your pain with secondary posterior tibial tendon issues. If you rush a talar injury, the stress fracture or stress reaction which is there now could become a full-blown fracture. I have seen fast recoveries from these, but I can not predict. You have to go one month at a time. You want a 9-month course of Exogen bone stim, and a current bone density and Vit D test. You should avoid all impact for 9 months and work on your ankle strength. The ankle sprains could be coming back to haunt you with instability and abnormal stresses. As long as you can avoid painful exercises, do the posterior tibial strengthening program, also Single Leg Balancing, and the peroneus longus and brevis therabands. Do contrasts each evening as a good flush to the superficial and deep bone swelling. 
     The basic routine is to avoid deep ankle flexion as with landing from a jump or deep plie in ballet. Avoid stretching your Achilles for the next month, then one month only with the knee straight, and no negative heel stretching where you drop the heel off the stair. Contrasts each evening, and evaluate bone density for issues. Bone stim for 9 months, and repeat MRI in 6 months. Start a super strengthening program. Stay in the boot 3 months, and then transition to shoes. Monthly evaluations should be done to check progress. I hope this helps. Rich. 

Jay just answered. I read this as a talar injury first and foremost, with secondary PT changes. Keep me in the loop. Rich

Hi Dr Blake
Thanks for reading my email. Do you know of any good podiatrists or Orthopedic foot surgeons in the New York City area?
Dr Blake's comment: In the New York area, I tend to recommend Karen Langone, David Davidson, Tom Conenello, and Joseph D'Amico. I know Joe is in New York City at the podiatry school there. 

I have read quite a bit on your blog regarding Posterior Tibialis Tendonitis. 

Right now I am in a walking boot (for at least 3 weeks). I have Spenco orthotic inserts in the boot. I am icing 2-3 times per day.

What, if anything, would you recommend in terms of healing and recovery? Is the swelling/inflammation from the issue with the PT or the talar?
Dr Blake's comment: I think addressing the talus is the most important right now, although any inflammatory measures will affect both areas. Contrast baths each evening are great for deep swelling. A bone stimulator from Exogen will help with bone flow. I try to get patients doing some form of strengthening of the area, without producing pain, and some sort of both core and cardio work. 

Is there anything I can do for healing the talar? Maybe stay in boot longer than 3 weeks
Dr Blake's comment: The talus finding directs healing right now. The boot will be for 3 months with a new MRI to check progress. Can not see past that. One of my blog patients just told me about a good boot. Check out 

If there are any posts on Talar in your blog I can read em too.

Do you take Medicare by any chance? Physical therapy for the Talar issue?
Dr Blake's comment: Yes, I do take Medicare. Physical therapy once a week to help you decide on exercises, cardio, anti-inflammatory is a good idea. 

I will be getting your book. 

Thanks again

Tuesday, September 19, 2017

Sesamoid Injury: Email Advice

Hi Dr. Blake,

I am a 24-year-old, healthy female. Last month I was on vacation with my sister for 3 days and we walked about 5 miles each day. On the last day of vacation, the ball of my foot started hurting gradually, no big deal. The next morning, the pain woke me up and it was extremely swollen. It did not improve so I made an appointment with a podiatrist for 3 days later.

The podiatrist did an X-Ray and explained some foot anatomy to me. She said it looked like I had a bipartite sesamoid bone because though it was in two pieces, the pieces looked smooth rather than jagged. She then said that on the very edge of one of the pieces, she saw some shading in the X-Ray. "I'm not sure it's a true fracture, but we're going to treat it as one so you can get feeling better."
Dr. Blake's comment: This is the right idea. You are forced to treat the worst case possibility since under treating sesamoid injuries can be harmful to you. 

She wrapped my foot in a compression wrap and gave me a walking boot. She said to stay off it as much as possible (crutches or knee scooter) and to come back in 4 weeks.

My 4-week appointment was on Thursday, and I guess I was expecting that I would be done with all this. She did another X-Ray, poked around my foot to see where it was still painful. It does still hurt a bit, but only when I walk and maybe only 25% as much as it did at first. She told me I could begin walking regularly with the boot and ease into tennis shoes.
Dr. Blake's comment: Sounds wonderful so far. The off-weighting can make swelling collect in the tissues, not be pushed out by weight bearing, and the pain worse even though the injury is healing. This did not happen to you, so I feel blessed. Need to get into some dancer's pad arrangement in your shoes to wean out of the boot, but still be protected. It can take several more months to wean out of the boot, so bring it with you wherever you go. 

I did some walking around the city this past weekend in my tennis shoes. It did hurt a bit - also on the outside of my foot where I think I was putting more pressure. I decided to go back to the boot. I have another follow-up in 4 more weeks.
Dr. Blake's comment: Smart, see if you can get an earlier appt to start the design of off-weighting it. Remember that there are 3 types of pain at play in these situations: mechanical (so off-weighting helps), inflammatory (so icing twice daily for 10 minutes, and a 20 minute evening contrast bath for deep flushing), and neuropathic (so non-painful massage to the tissue and gentle range of motion of the big toe twice daily for 2 minutes is great). 

Long story short, I started reading about sesamoid injuries today and I guess I didn't realize how serious they could be. I'm reading horror stories of how it never heals for some people, and I'm panicked thinking about the fact that I could go the rest of my long life without being able to run, or jump, or even walk comfortably!! I have a history of anxiety and this is a lot to bear. I just want to get back to normal.

If you have any words of advice or comfort, I would be glad to hear them!
Dr. Blake's comment: You sound you are in good hands, and you are responding wonderfully. Create that 0-2 pain level, gradually wean off the boot, work on the 3 levels of pain daily, and read the general rules of sesamoid fracture treatment. Get an MRI if possible because that can be followed better than x-rays. If you get an MRI it will be clearer what you have, and another MRI can be done if needed 6 months down the line to check progress. Good luck. You are doing good right now!!


Sunday, September 17, 2017

Electronic Medical Records are not my Friend

    Hi, this is Dr. Blake and I need to express my thoughts on the electronic medical records that I was forced to adapt in February of this year. I do not want your sympathy, but it has added an extra day to my practice per week just trying to keep up. I spend the same amount of time with my patients which I know many doctors are forced to see patients faster. But, my tradeoff is longer and longer time doing my records, and I feel I am very dedicated to doing them right. This article at least shows that I am not alone. I see patients for 40 hours per week (around 40 or so) and spend 13-14 hours doing their chart work on the electronic medical records. Since all medical practices have 2 hours a day or normal paperwork also (insurance, DMV, disability, etc), this now puts me at 65 hours per week of normal routine stuff. I like to do my own orthotic work, work on my blog, read to learn, etc, and how I am at 75-80 hours without blinking an eye. 
     Why am I telling you this? Just be kind to all the docs in the country that this has been forced on. The 3 hours a day additional work brought on by the computer is handled differently by all: less patient time with less satisfaction, fewer patients overall with less satisfaction, working longer hours with less satisfaction with less time with your loved ones, total burnout, leaving the medical career, or a combination of strategies. I tend to work harder and longer because that is what I have always done, but it is not healthy, and I am not getting younger. I think the younger docs, that do not know any different, may not be as grumpy as I feel. If you pray, I accept all donations in this sphere. Thanks for listening.

Wednesday, September 6, 2017

Podiatry Blogs Listed in Order of Greatest to Least

Guess who is #1, alright a guy can brag once in awhile!

I figure that many of the blogs would also have good information for my readers!!

Tuesday, September 5, 2017

Can I wean off my full time use of Orthotics?

Hi, Dr. Blake!

I've been reading your book and need your advice. 

Long story short, I have been wearing orthotics pretty much all the time (even stay In my shoes at home) for about a year and a half.  I went to see a PT for bilateral knee pain and he told me my feet were causing a dysfunctional gate cycle leading to overall tightness and knee pain.  He took a mold of my foot and sent them to a sports podiatrist he works within Iowa that made me some orthotics.  He also said that there was really no workaround for me with regard to improving foot function on my own and I pretty much-needed orthotics 24/7 for me to move correctly.  They do make a drastic difference with regard to the knee pain and tightness but I still have some issues and am questioning some things, specifically that my foot is structurally so messed up like he said it was.

I have attached the sheet rationale for the PRI orthotics that I received if you have interested in reading it.  The PT said the human foot was not made to function on flat ground like concrete and functions better on undulating terrain which the orthotics provide and also keep me from overpronating by stabilizing my left heel when I walk which allows me to push off my toe instead of pronating.  He said when my foot over-pronates when I walk (mainly the left one) it anteriorly tips my pelvis and basically throws me out of alignment and puts me in a bad position for when I start lifting or try to work out or lift weights. 

I've been active my whole life and never had knee pain until I started dental school where I was sitting the majority of the day and was forced to wear dress shoes.  This is in contrast to my previous 7 years as a personal trainer walking around all day in athletic shoes. I always had insoles that my podiatrist made because I would get pressure calcifications I would have to go have picked out but I never had any biomechanical issues like what started a few years ago.  Obviously, I don’t want to have to keep wearing my shoes all the time for the rest of my life, as that doesn't seem like a fix IMO.  I’m not sure if my left foot overpronating is due to a handedness pattern type thing or if I really have developed an alignment issue, maybe an x-ray would help this or show if I had an alignment issue?

What direction should I take from here to fix my feet?

Dr. Blake's comment: I have found that moderation with the use of anything is normally best. Some use of orthotics when you need them for activities, some walking without orthotics, and some barefoot is normally a great recipe. You could take some photos of your feet standing, especially looking from the front, looking towards the back of the heel, and then the arch from the side. Best to have another take these so you can normal with your feet firmly on the ground.
     One of the keys to great feet is strong feet. My blog is filled with information on strengthening the intrinsics with met doming, the Achilles with 2 positional heel raises, and the arch with single leg balancing and theraband work for the posterior tibial tendon and the peroneus longus. You will find as your feet get stronger there is less need for orthotics and the most stable shoes. I said less need, not no need!
     Various types of orthotics give different support. Various types of shoes give different support. Various types of activities need different support. So, this is a lifelong challenge of all of us wanted to stay upright and exercise. What do I need to protect my feet and still participate at a high level? Many use pain as their guide, many have such a high pain threshold that they have to use educated guesses.
     Besides strengthening, the tightness you mentioned may play a major role in symptoms. Almost everyone should be on a daily regimen of Achilles, quadriceps, hamstring, iliopsoas, and low back stretches. These should take 5-10 minutes to do before and after your workout, never with pain, and done at least once on your rest days. If you find tightness, stretch 3 times a day until it resolves. If you find you are tight on one side of your body more than another, stretch that tight side 50% more than the looser side. 
     I hope this gives you my general philosophy. Next time you see the physical therapist ask for a lower extremity tightness and weakness evaluation so you can know the pattern in your body and can work to fix it. Good luck. Rich

Lis Franc Injury: Email Advice

Dear Dr. Blake, 

I (myself) have what I think is an interesting Lis franc injury and if you have a moment I would greatly appreciate your opinion. 

Athletic history, 10 years of ultra-endurance running (trail 100 miles) and Ironman triathlons. 

MOI: Outstretched leg on the boat dock with the boat moving towards the dock. Arch placed on edge of dock, the force of boat bent foot at arch (plantar surface towards the heel). immediate “pop” swelling over medial cuneiform, tender to palpation.  

Date of injury ~June 1st. Initial X-ray negative, circumferential swelling/bruising (medial and plantar, mainly) and the majority of pain subsided by day 3-4. Walked but with slight limb but continued to improve slowly over next 4-weeks but still had difficulty running (pain around 1st/2nd metatarsals and medial arch with push-off. No pain with stairs. At 4-weeks had MRI 

MRI: tiny non-displaced fx at the medial aspect of navicular, small cortical avulsion fx from the second metatarsal base. interosseous Lis franc “compatible with high-grade disruption, A torn stump of fibers remain attached to the medial second metatarsal base and distal lateral aspect of the medial cuneiform. It is difficult to appreciate intact interosseous Lis Franc ligament fibers at this time. Complete disruption of the dorsal Lis Franc ligament. The plantar ligament is at least partially detached from the second metatarsal base, in the setting of the tiny cortical avulsion fx.”

presentation at 4-weeks - near normal ambulation, minimal pain (except attempting to run) and very little instability
Due to lack of instability Ortho Rx: non-weight bearing in boot x 4 weeks, ambulating in boot x 2 weeks, then 2weeks in stiff soled shoes, then follow up. 

Currently, I’m in my 1st week of walking in stiff shoes. Very little pain around Lis franc/dorsal part of the foot, other than the feel of stretching. Occasional pain in 3rd/4th phalanges. Occasional pain around the anterior portion of ankle/malleolus, (navicular/cuboid area). There is a firm “nodule” about the mid portion of the foot in-between the plantar fascia and medial portion of the arch. A majority of the pain (nearly constant) is in the area of the medial side of foot near the top of the arch. Occasionally it occurs distally, and other times it's more proximal (in/around the fleshy area between the medial malleolus and calcaneus). Pain is reproducible by full dorsiflexion and eversion. Pain is felt along the medial arch and pulls (causes pain on top of medial cuneiform. Little to no instability, but will occasionally “lock-up” and feel a "knuckle crack" (no pain). 

when performing single leg toe raises slight pain from arch/nodule area and “stretching” around medial cuneiform. I can run, but the pain from arch and ankle area increase post-run. My follow-up is next week and although considering the severity of the MRI, I feel my presentation is not remarkable. With the ultimate goal of returning to running,  I’m curious on your thoughts if surgery sounds like it might still be necessary? Or other options you might suggest at this point. 

I appreciate any advice you might have!

Thank you, 

Dr. Blake's comment: Thank you so very much for emailing this problem. Typically, we will have a surgeon have the first crack at deciding if the foot should be repaired. With your wonderful athletic life, if the wrong decision is made, the arch could collapse the next time or even the thousandth time you put a tremendous load on it. So, 2-3 independent surgical opinions to protect you from yourself and your goals are in order. This is different from a fracture we can follow pain wise as we rehabilitate someone. And, you have to treat the worse case scenario possibility. If you do have it repaired, even though there is a time for rehabilitation, there should be no reason you can not get back into full activity. 
     Please have a stress test x-ray put on the Lisfranc's to check its integrity. This is particularly important if they decide to let you go back to athletics. Athletics should be with KT arch taping to stabilise the joint, along with the highest arched orthotic that can be made to stabilise without throwing you to the outside. I hope this helps somewhat.

Here is the section from my book on Lisfranc's Joint Injuries which emphasizes the conservative.

2. Lisfranc’s Sprain

    Across the instep, where the metatarsals meet the arch, is a series of joints called the Lisfrancs joint. It involves all the metatarsals, with the most severe injury under the first and second metatarsal bases. Here lies the Lisfranc Ligament, and when torn, can cause the entire arch to collapse.
     A complete tear of the Lisfranc’s ligament, a diagnosis made by MRI, is a surgical injury. It is one of the most serious sprains in the whole body and must be over treated. This is not the topic of our discussion here. For the many Lisfranc injuries, not involving a complete tear of the ligament, conservative treatment works well. Remember a sprain occurs with some twisting motion or sudden acute jarring force. Without a history of this, most likely pain in this area is some other diagnosis as we will discuss later.

The Lisfranc Ligament runs between the base of the 2nd metatarsal and the first cuneiform.

    The top 10 conservative treatments for Lisfranc’s sprain/injuries (without complete rupture of the Lisfranc Ligament):
  1. Arch supports (typically custom) with as high of a medial arch as possible/comfortable.
  2. MRI for ligament testing. Also, make sure patient can do a one sided toe raise. This can be impossible with a complete ligament tear.
  3.  Kinesio taping in a circumferential wrap around the entire foot for 2 months longer than you think you need to.
  4. Avoid activities that lift the heel off the ground initially.
  5. Ice Pack 2 times daily for 20 minutes to reduce the inflammation.
  6. Create a pain-free environment with crutches, removable boots, other assistive aids.
  7. Pain over 5 in the area of the Lisfranc’s Joint should be over protected until you are certain it is not a ligament rupture.
  8. Begin metatarsal doming, 2 positional inversion/eversion therabands, and Single Leg Balancing. Go to YouTube and type drblakeshealingsole foot strengthening exercise playlist. Remember no exercise should hurt.
  9. There is really no stretching for this injury that helps directly. However, massaging the arch to move the swelling that collects there can be very helpful.
  10.     Stretching the Achilles tendon indirectly takes the tension off the arch. When done, do both gastrocnemius and soleus stretches but only with the heel firmly on the ground. Go to YouTube and type drblakeshealingsole Achilles stretches.
Lisfrancs and Sesamoid Injury: Email Advice

Hi Dr. Blake,
First, let me say what an incredible resource your blog has been for me - and how grateful I am that you take the time to advise and treat patients simply because you believe everyone has the right to heal. So thank you.  As for me, I've seen far too many doctors - who all have very different opinions (and seemingly different levels of commitment to my healing). I'm desperately seeking a treatment plan - and some patience with the many questions that I have.
Now here's my story… I'm 30 years old and live in New York City. Back in late MARCH, I tripped up (yes UP) the stairs -- and injured my toe/foot. I seemed to only have pain in my big toe (top of my foot) - in the phalange and metatarsal. The first podiatrist I saw didn't catch anything in the x-ray and believed it was a stress fracture. After 3 weeks of it not seeming to get any better, he still gave me his blessing to go on my 2 week Europe trip. I should have listened to instinct...but alas. I went, wrapped my foot, threw it in a hiking boot, grabbed a cane, and went on my way. The trip was great - but by the last day, I couldn't stand. And my foot was purple.
Came home beginning of May - switched doctors. Got an MRI (and another x ray) - and it was confirmed that I have a fractured tibial sesamoid, as well as a Lis franc ligament sprain. The doctor seemed to pay little regard to the Lis franc injury - saying that a sprain isn't serious.
Dr. Blake' s comment: A Lisfranc injury is one of the most severe foot injuries I treat, with one of the highest percentages for sprains needing surgery.  
Now here's where things get even more complicated. I was heading to Los Angeles for a gig a few days later. The doctor advised me to non-weight bear for 3 weeks (in a removable walking boot), use a dancers pad, then see another doctor (doctor #3).  I continued to have swelling - but iced and did contrast baths daily. Saw an ortho in Los Angeles - who perhaps due to my desire to be as conservative as possible - decided to keep me non-weight bearing for 8 weeks. The last thing I wanted was to look back and wish I would have committed to more time. He also thought that the bone might be dying, and thought that when I'm back in NYC I should have a CT scan (or bone scan?)
So now...I'm back in NYC. Saw a new Ortho (doc #4). He said that I should start putting weight on it and to stay in the boot until my next appointment -- in 4 weeks. And he said no CT scan.  Unfortunately, I had no advice on how to wean off the crutches - it was implied that it would easy to just start walking. Not really the case for me. So...I started weight bearing while still using the crutches for a few days, then went down to one crutch, and now to a cane. I seem to be doing pretty well -- except that I keep getting a shooting pain in my ankle every time I step a certain way (which isn't that often - but when it happens it HURTS). Been happening now for the last 4 days. The sesamoid, however, seems to be ok. Still a little swollen - but doesn't seem to have very much pain at the fracture site.
Also, my whole body seems pretty out of whack (my hips have a very strange turn out right now).
Dr. Blake's comment: Typically this out of whack feeling is part of any cast regimen.  It is helped greatly by using an EvenUp on the side without the cast and never going to one crutch.  It should be 2 crutches or no crutches since one crutch and sometimes canes throw your back and pelvis into strange tilts.

So now that you know my story, I have so many questions...

1. My big toe still feels so strange. Like it weighs 5 pounds. Which is how it felt when I first injured it (why I assumed I broke my toe). I can barely bend it down - and can't bend it up at all. Is this normal? The pain/stiffness/heaviness goes from the joint of my big toe down to the middle of my foot. Often times I have strange twitching there as well...
Dr. Blake's comment: For what I know, this is all normal for your injury and being in a cast and non-weight bearing for a while. You are gradually progressing from the Immobilization Phase of Rehab to the Re-Strengthening Phase. During this phase, you need a lot of physical therapy guidance to work on the remaining swelling and increase the range of motion, strength, flexibility, and balance. There is a lot of hard work ahead.  

2. At this point, should I be forcing my toe to bend? Or is it all still healing that it should still be immobilized most of the time?
Dr. Blake's comment: For these injuries, you never push the toe bending part of rehab. You let that come naturally. It is always fun to measure the range of motion at each stage if you have a therapist you will be working with. Typically you come out of the cast with almost no motion in the joint. Definitely, you can start doing some of the self-mobilization movements. Go to YouTube and type drblakeshealingsole Self Mobilization Hallux Limitus. You can gain 20-30 degrees as you begin to walk normally, and another 20 degrees as you begin to run.  Keep the joint pain free when you are working on it, you never know if more healing is still going on it there.

3. What about ankle exercises? Could that also interfere with the healing of the sesamoid/toe? Any physical therapy for the rest of my body? Or should I still wait?
Dr. Blake's comment: Core and other lower extremity strengthening that does not hurt the injury can normally be started right after the injury.  There is a benefit to riding a stationary bike with one foot even when there is no tension on the foot in the boot. There are so many core, hip, knee, and ankle movements that you should be doing right now, and that is why a PT or Personal Trainer can help. The stronger the core, the more normal you are lifted off the foot, and the faster the rehabilitation goes.
4. This Lis franc sprain - is this really something that should be so swept under the rug? I finally researched it and it sounds like it could be a big deal. How do I find out if the sprain has healed?
Dr. Blake's comment: Lisfranc Injuries are big deals. You need to wait 3 months for your first MRI  to get a repeat MRI to document healing.  I treat all Lisfranc Sprains very seriously with a 2-year commitment to orthotic devices, arch taping, and a gradual progressive re-strengthening program on all the important intrinsic and extrinsic muscles/tendons that support the arch. Go to YouTube and type drblakeshealingsole foot and ankle strengthening playlist.

    The middle of my foot definitely hurts right now - but I assume a lot of it has to do with the fact that I'm putting weight on it for the first time in 8 weeks. I also have a bony bump in the middle of my foot - under the big toe. The doctor assumed it was from the boot. Does that sound right to you - or could it have something to do with this Lis franc thing?
Dr. Blake's comment: Lisfranc's Injuries hurt in the middle of the foot. If you are weight bearing, get an orthotic ASAP to stabilize that area and learn to tape your arch (Chapter 4).  I am not sure what the bony bump is. You could send me a photo of you pointing it out, and another of the same spot on MRI.  

5. Does walking in the walking boot for 4 weeks after being non-weight bearing for 8 (and in a hiking boot for 4 weeks before that) seem like the right treatment course?
Dr. Blake's comment: Yes, but 16 weeks of immobilization means 32 weeks minimum more to get your foot healthy again. Go slow, go gentle, but persist. You are still in the hands of the docs for direction, but PTs and Personal Trainers and Athletic Trainers should have the most prominent role in your recovery now.  

6. My left foot has also been hurting quite a bit - since it's been doing most of the work the last couple of months. Is there an insert/insole you can recommend helping this? Mostly the middle of my foot. What about Superfeet?
Dr. Blake's comment: When you get custom made functional foot orthotics from a sports podiatrist, they are always made in pairs. Consider seeing Dr. Karen Langone, Dr. Robert Conenello, and Dr. David Davidson in New York. You can also see the AAPSM website for all the New York members. I am typically safe recommending from that list.  

7. I've been using the bone stimulator twice a day on my sesamoid - which is why I haven't been taping. Should I be taping and just removing it daily?
Dr. Blake's comment: The bone stimulator has a 3-inch penetration. You can aim the beam from the top of your foot where you do not have tape, and it will still work. That way you can tape also. This is at least my understanding of the Exogen bone stimulator but check with the local rep.
8. I'm not 100% sold on this ortho I'm seeing in NYC. He's just so rushed - in and out in 5 minutes. Do you know a doc (ortho or DPM) here that you would recommend? I had been recommended someone at the hospital for special surgery - but unfortunately, they don't take my insurance (GHI/Emblem)
Dr. Blake's comment: See my recommendations above. Even if they are a distance, it is worth it. They can refer you to a local PT to do the lion's share of the work.  

9. Would it be possible for me to send you my MRI from the beginning of May? I would love to know your thoughts.
Dr. Blake's comment: Yes, Dr. Rich Blake, 900 Hyde Street, San Francisco,
         CA, 94109.  

    Thank you so much for taking the time. As I mentioned, I generally need to be on my feet all day (although this last one in LA was thankfully pretty low key). I'm so anxious for my foot to feel normal again, but I'm also committed to recovery and can be as patient as I need to be. However, I just need to feel like I'm doing what's "right". And with so many different doctors over the last few months (all with very different opinions) - I'm left fairly confused and rather discouraged.
Any thoughts/advice would be so greatly appreciated.

Jill (name changed)

Sorry, one last question!!  I've been using 1/4" adhesive felt applied directly to my foot for the dancer's pad. Is this correct for use in a boot?
Dr. Blake's comment: See if you can place as an insert in the boot. Somewhere in my blog “drblakeshealingsole” I have an example of this. Get working on your orthotics ASAP and then just place that in the boot. I sure hope this helps you.