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Thursday, June 28, 2018

Clinical Biomechanics for Podiatry (Post #5): Think about Pain Syndromes and Mechanical Causes

     Certain mechanics produce certain pain patterns or syndromes. The 4 common types of mechanical faults which can produce predictable pain patterns are:
  1. Over Pronation
  2. Over Supination
  3. Poor Shock Absorption
  4. Limb Length Discrepancies
     Every bio mechanical oriented practitioner looks at these 4 areas when initially evaluating an injury for cause. Could it be from Over Pronation? Could it be from Over Supination (also called Under Pronation)? Could it be Poor Shock Absorption? Could it be tied into one leg being longer than the other?

     It is important to note here that there can be more than one issue going on at once causing symptoms, or confusing the treatment plan? Since 80% of patients have one leg longer (either structurally, functionally, or both), and 99% of patients are have dominant right or left sides (right handed vs left handed), and 10% or so of patients I see have a past injury which affects mechanics (ie. old knee injury), the complexity can be intense, but treatment can logically work through the issues.

     The treatment of these 4 common areas can also be complete or partial for many reasons. Some injuries need 100% correction of the mechanical fault to get better, another injury requiring 20% or so. I tend to personally shoot to correct a problem close to 100% if I think it is the cause or major contributor to the pain syndrome. I can give you hundreds of examples when treatment  near the 100% level was extremely important, but also hundreds of examples when 20 to 30% correction of the mechanics was all that was needed. An easy example of this is low back pain and short legs. If a patient has an 1 inch short right leg with lower back pain, they normally present to my office with 1/4 inch heel lifts. Patients tend to say it was helpful, but they still have back pain. Why are they left with this 25% correction? Because it is much more difficult going to the next level of lift therapy when some or all is placed in the mid sole or on to the outer sole of the shoe.  This same problem is seen in the treatment of over pronation, over supination, and poor shock absorption.

With the onset of very unprotected shoes, we may see a new category arise of Poor Foot Protection, or over protected shoes that weaken our feet!! . I have 3 patients now injured in these less protective shoes that I am unsure if the cause was poor protection, over pronation, or poor shock absorption. Perhaps each factor played a role in the injuries and they all had to be present for the injury to occur. And perhaps it was poor training techniques, the jury is out at this time.

Plantar Plate Tear 2nd MTJ: Email Advice

Dear Dr. Blake,

I was wondering if you could help me with answering some of my questions.  Firstly, I'll describe my situation.  Right before Christmas last year I stopped running due to extreme pain I endured in my last two runs. I struggled even to walk so I altered my gait to take pressure off the top part of my right foot. I can say that after 5 months I can now walk without pain but that is because I walk without using the front part of my foot and no longer using winter boots as it's warmer.  Now I am using Merrell vibram normal shoes which I find comfortable and I can detect which part of my foot that I can use. My second toe on both feet are longer than my big toe.

I have had an xray of my foot and an MRI.  The results of my MRI are as follows:

Irregularities seen in 2. Mtp-joint with a few very small subchondrale cysts with basis of prime phalanx. Implied hydrops and small periarticulare deposits dorsally. Suspected a small avulsion cortical fragment from basis of phalanx. Also markedly edema lateroplantar along course of lateral part of the plantar fascia and lateral collateralligaments so could be the state after avulsion of the plantar fascia with a small cortical fragment from the base of prime phalanx. No enhanced intermetarsal bursa, no Morton's nevrom. Normal flexor and extended tendons. Unremarkable sesame bone complex plantate for caput of 1.metatars. 
In 2. MTP-joint suspected sequelae after avulsion of the plantar fascia with a small torn cortical fragment from basolateral part of prime phalanx, and some synovitt changes and beginning small degenerative deposits
Dr. Blake's Comment: Yes, from you image above, the lateral aspect of the plantar plate is torn causing the 2nd toe to drift medially (toward the 1st toe). 

I have attached a photo of my foot, where toe drifting of the 2nd toe is quite apparent (please excuse the look of my sticky taped toes).

I will be meeting with a surgeon in October in discuss options for surgery.

In the meantime i have been recommended to use Hoka arachi runners to avoid pain and the ability to walk normally. I have tried a pair on and when I try to walk as normally as I remember I do not appear to have pain.  I was wondering, if I should purchase these shoes? If I do, the main reason would be so that I could resume running until my surgery. I tape my toe regularly.  I do pronate and have used orthotics in the past but not since my injury. My main question here is, will I cause more damage to my toe if I start running in the hoka arcachi runners , more so than if I wait until the surgery and resume running again then? 
Dr. Blake's comment: As long as you maintain the 0-2 pain level, you are okay to run. The joint has arthritis starting (all the bone cysts and periarticular deposits), but hopefully the surgeon will clean that out at the time of surgery along with fixing the ligament. There are so many types of surgery for this, it is hard to know. 
     So many of my patients wait and wait on surgery, some preventing it, and some having it eventually. The pain is from the joint not lining up and the joint lining gets irritated. This is the same as the knee cap tracking slightly off line laterally, and the pain is unbearable to some (called "runner's knee"). Normally, we can get rid of the pain overtime with icing routinely, rocker bottom shoes to avoid toe bend (like Hoka), Budin splints (in your case a single loop is opened up and put over the 2nd and 3rd toes together, maybe even taping the 2nd and 3rd toes in buddy taping fashion, and using an insert like an orthotic to off weight the bottom of the 2nd joint with accommodative padding (I have many examples in my blog). I have so many patients that have the surgery after years of these treatments, not because they are in pain and disabled, but they just get tired of the daily process and they hope the surgery makes them better. Normally it does. Good luck. Rich

I really appreciate your advice on this matter.

Thank you,

Wednesday, June 27, 2018

Clinical Biomechanics for Podiatry Series (Post #4):Taking a Good (Biomechanics) History

This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Followup visits work off the success or failure of the treatment plan set on that first visit. If the information collected is inadequate, the entire sequence of events following may be subpar. I refer the reader to a post I did earlier on giving a good history. Please review it now before we go further.

The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

  1. Do you know if you have a short leg?
  2. Do you believe you have weak or tight muscles in general, or around the injured part?
  3. Do you have loose ligaments in general?
  4. Are you right or left-handed?
  5. When you were a child did you have to wear braces or shoe inserts?
  6. Have you ever been prescribed shoe inserts?
  7. Have people told you that you walk or run funny?
  8. What has your history been of overuse injuries (nontraumatic)?
  9. How all or most of your injuries been to one side of your body?
  10. Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?
  11. Do you have any arthritis from your hips downward and wear?
  12. Do you feel unstable in any joints?

A skilled practitioner knows the relevancy of the answers. The answers will help point the course of treatment in the right direction. 

Monday, June 25, 2018

Bike Shoes for Walking to Limit Metatarsal Bend

These are Chrome Bike shoes with the embedded cleat for bikes. They are the best looking ones I have seen. I use them in almost every treatment plan for chronic plantar fasciitis, or plantar fascia tear. They are also used for many ball of the foot problems that you want to avoid toe bend. Of course, you should have your orthotics and padding, etc, in the shoes. 

Foot Massage Balls: Patient Recommendation

This was highly recommended by one of my patients as a great way to stretch out the arch and loosen trigger points.

Clinical Biomechanics for Podiatry (Post #2): Foot Orthotic Devices: General Principles

There are many types of foot orthotic devices for the consumer. They fall into 5 categories based on the needs of the patient. These 5 categories are:

1. Corrective (or Controlling)
2. Stabilizing (or Balancing)
3. Shock Absorbing (or Cushioning)
4. Accommodative (or Weight Transferring)
5. Combination (or Multi-Functional)

How is the correct orthotic device ordered or purchased? The orthotic device that you prescribe, or that you recommend purchasing in a store, may or may not help if it is not the correct type. At its best, the correct orthotic device will successfully make the necessary change in mechanics, but it may still be crucial to work on all the other aspects of rehabilitation (anti-inflammatory, flexibility, strengthening, etc.) in order to relieve all your symptoms. It is important when prescribing the orthotic device that you are familiar with the many different types of orthotic devices available. It is also important for the patient/customer to be somewhat clear on what type of orthotic device is needed. And, unfortunately, the type of orthotic device required today may change in the future with different sports, different symptoms, different shoe types, and different age. You need to be willing to change to a different type of orthotic device if the patient's symptoms are not improving with the present pair of orthotics, and if there is another type available that may help them. Sometimes, practitioners don’t like discussing this type of change due to the added cost to the patient, but it is important that they know there are options.

Corrective or Controlling Orthotic Devices do what they say---correct or control excessive pronation or supination (the inward collapse of the arch, or the outside roll of the ankle, respectively). This type of orthotic device produces the most dramatic change in function, and may take the most time to get used to wearing.

Stabilizing or Balancing Orthotic Devices normally do not change foot position much, but the patient/customer feels more centered, more balanced. The weight of any point can become so distributed that only a small fraction of the original weight bearing still exists. This can be vital for heel pain, some arch pain, fifth metatarsal base pain, and many metatarsal problems.

Shock Absorbing or Cushioning Orthotic Devices take the stress out of the pounding of heel impact. Runner’s versions need to have equal cushion at the heel and forefoot. These can dramatically reduce the stresses which cause or aggravate stress fractures, joint pains (knee and hip), and heel pain. One of the best shock absorbing orthotic devices is the Hannaford which will be discussed later.

Accommodative or Weight Transferring Orthotic Devices try to transfer weight from a painful area to a non-painful area. These orthotic devices have probably been around the longest of all orthotic devices prescribed by podiatrists. If you have heel pain, you need an orthotic device that transfers weight into the arch. If you have sesamoid pain, you need an orthotic to transfer weight back into the arch and onto the 2nd and 3rd metatarsal heads.

Combination or Multi-Functional Orthotic Devices are probably the most prescribed type of orthotic device. The prescribing practitioner attempts to accomplish multiple tasks with one type of orthotic device. This is why there are so many types of orthotic devices out there. When you really study them, most primarily do one of the 4 basic functions really well, and then 1 to 3 of the other functions somewhat or not at all. A good practitioner will try to get the most out of orthotic therapy. This means that the practitioner tries to combine different functions into each orthotic device on a routine basis. Sometimes, however, doing too much sacrificing the most important function.

Hopefully, this post helped you understand some of the basics of orthotic therapy. When discussing with a patient, try to understand what we want the orthotic device to do. Ask yourself these questions:

1. Do I need to order a corrective device to change foot positioning?
2. Does the patient primarily need to feel more centered and stable?
3. Do they need cushion/shock absorption as they walk or run?
4. Do they need to transfer weight from a painful area to a non-painful area?
5. Do they need a multi-purpose orthotic device with many functions to help the problems at hand?

Perhaps the patient will need several orthotic versions since their activities, shoe gear, etc. vary so much. The doctor and patient must be on the same relative page, and the patient must be aware that there may be a plan B. 

Sunday, June 24, 2018

Clinical Biomechanics for Podiatry (Post # 1): Orthotic Designs: Positive Casts before Balancing

In designing orthotic devices, to achieve positive functional changes, and positive symptom outcomes, the prescribing health care provider needs to be fluent in orthotic casting, orthotic prescription variables, etc. I took 20 casts of my wife Pat's left foot to show common variables in orthotic prescription writing. The first cast I poured with plaster and left it uncorrected (the yellow positive cast below). The other 19 casts of her left foot I corrected various ways to achieve various functional results. I will try to show you that even though a good cast is taken (podiatry's Gold Standard in Root Biomechanics), your goals of what you are trying to achieve functionally and symptomatically may require a wide range of orthotic variables.

These 3 positive casts were made for 3 different patients: Orange for high degree of Forefoot Varus, Pink for high degree of Forefoot Valgus, and Yellow (my wife Pat) for a Neutral to Slight Varus forefoot to rearfoot relationship. 
Here are these 3 feet seen from the back of the heel. These represent the negative cast which were taken of three left feet. The Orange cast of a high Forefoot Varus deformity shows the heel collapsing into valgus to get the front of the foot to the ground. The Pink cast of a high Forefoot Valgus foot type shows the heel falls into varus to bring the forefoot to the ground. The Yellow cast (my wife) represents the more Neutral Forefoot to Rearfoot showing the heel position more near a vertical position. The orange and pink foot types are simple to analyze and correct and untreated can lead to devastating foot compensations and pain syndromes. 

Here is a blow up photo of two left feet positive casts. The one on the left shows FF Varus where the forefoot is inverted on the rearfoot. 20 to 50% of patients have this problem. After the foot lands on the ground, to get the big toe to the ground, the arch must collapse and the heel roll into valgus causing severe over pronation. The cast on the right (pink) shows a left foot of FF Valgus. This foot type must roll the heel out to get the metatarsal weight evenly spread and the foot stable. However, this outward roll of the heel, also called over supination, under pronation, or lateral instability, causes a very unstable foot. Try standing on the outside edge of your foot and see how stable you feel. The goal of orthotic devices with these 2 foot types is to get the feet balanced, centered, with the heel straight up and down. This is the goal for what is called Root Balance Technique. 

The Yellow cast of my wife's left foot shows a very Neutral foot. It is very stable. All the negative casts are poured with the heel vertical by propping up one side or the other to get the vertical heel position marked on the cast to be perpendicular to the top of the foot. This is the Gold Standard of Root Balanced Orthotic Devices, but can be your reference in other cast corrections such as the Inverted Orthotic Technique. 

This is a soft based orthotic device made directly off the uncorrected positive cast. By uncorrected, I mean no attempt was made to change the position of the foot. I will demonstrate in some of the upcoming posts, how simple changes to the positive cast correction can make powerful changes in the foot position. This soft based orthotic device is called an Accommodative Device and more correctly called a Hannaford Device (as first invented by Dr. David Hannaford).

Wednesday, June 20, 2018

External Hip Rotator Strengthening Videos

When performing external rotation exercises, which is a great core muscle group, and also very helpful if you excessively pronate, you typically want to avoid putting the resistance down at the ankles and bend the knee. As you get more and more resistance, the torque on a bent knee can be damaging. These 3 versions seem very safe.

Yoga for Beginners: Amazing for Strength and Flexibility

These videos were highly recommended by my patient. I think we all believe that there are benefits to be gained in yoga. These beginning yoga videos may just be the ticket for us to learn and have it enrich our lives. Start simple and go slow. Namaste (I bow to you)!!

Sunday, June 17, 2018

Sesamoid Injury: Controlling Inflammation while Transitioning from a boot

Dr. Blake,

Unfortunately, like many of the other readers of your blog, I have suffered a non-displaced medial sesamoid fracture in my right foot in November 2017. Since December 2017 I have been in a walking boot. A few months went by, and after making zero progress I started digging for more information and found this blog along with a bunch of other resources regarding bone health. Even though I knew I was getting more than adequate amounts of calcium each day, I started taking Vitamin D in March 2018 and my symptoms started radically changing, and the injury finally started to feel like it was 'healing'. To confirm my suspicion of low vitamin D, I ordered a blood test myself (via, if any of your readers want to get one done without going to a Doctor) and found out my level was at 26 ng/ml. After finding this out, I increased my dosage, and I have been maintaining it around 50-60 ng/ml for about 3 months. 
Dr. Blake's comment: Thank you for the info on Vit D testing. 

Over these last 3 months, the pain has been primarily due to the inflammation and blood flow going to my forefoot, which I have been able to mitigate by keeping my foot elevated and icing it occasionally. I've done a decent job maintaining a 0-2 pain level as you suggest, and I feel like I am able to slowly transition out of the boot. At this point, I am able to (in the boot) put more weight through the ball of my foot simply because the inflammation is a lot milder than it was 3 months ago. My main question is, as I transition into a stiff-soled shoe with orthotics, what are the primary signs to go back into the boot temporarily?
Dr. Blake's comment: You have to maintain the 0-2 pain levels throughout. Look for patterns of what increases your pain and avoid for one month before retesting that benchmark again. As you transition from boot, you should ice twice daily whether or not you feel you need it, and contrast baths each evening. 

 During this transition period and after the transition period, is it common to have the area swell up still? I just want to get a good idea of how much inflammation I am supposed to expect as I transition into walking normally, and then transition into jogging and running months down the road.
Dr. Blake's comment: Swelling produced by an injury is a bell-shaped curve. Some people swell a lot and others don't. Swelling per say is not that important, but pain is. So, if it swells, but does not hurt, no big deal. But, the icing and contrasts and nonpainful massage are important on a daily basis. Good luck. Rich

Also, I want to say thanks for starting the blog, it looks like it has grown quite a bit and it is jam-packed with a ton of good information. I am making a donation for sure.


Sesamoid Injury: Email Advice

Hi Dr. Blake,

I came across your blog while researching fractured sesamoids. Thanks for all the great information! I wanted to tell you about my experience and see if you had any additional insights int my condition or thoughts about my treatment thus far.   

I’m a 45 year old male and fairly active. I woke up in March with some pain and discomfort in my big toe. I wasn’t paying very close attention to it but my impression at the time was that I thought I had slept on it funny, maybe did something like hyperextend it in my sleep or slept with it bent back for a length of time that caused me to wake up sore. It wasn’t incredibly painful though, so I didn’t think too much of it. In fact, I sort of figured the best thing to do was to work and stretch the toe as I normally would. That day I did the orbital machine at the gym as well as some shadow boxing and weightlifting, all of which put pressure on the toe.
Dr. Blake's comment: In some ways, this is a good sign. You did something in the presiding 3-4 days that the big toe did not like, but it took several awhile for the swelling to collect enough for it to hurt when you got up. The morning is the classic time to hurt since all night long when you are still, the swelling from an injury has time to settle into the tissues. The pain is for the inflammatory part of the pain. The injury happened without you noticing it a lot, so maybe a good sign!!?? Can you think back to these 3-4 days? Did anything stress the joint out of ordinary? 

I went to bed that night and maybe an hour or two after I fell asleep, I was awoken by excruciating pain. Throbbing, sensitivity etc.. I took some anti-inflammatories and iced it but could barely sleep. I hobbled to work the next day and taped my toe to restrict the movement of the joint for, what seemed to me, maybe some sort of turf toe but I did not see a doctor at that time. The taping helped and the pain subsided over the next few weeks. I was able to do yoga and box and was in a little discomfort but not bad pain.
Dr. Blake's comment: Again, good sign!! Most joint flares, if arthritic, occur over 4 days to 2 weeks if you are treating the flare-ups. They can last longer if you choose to ignore or to select inadequate treatments. We do not know what you did, but this pain is still inflammatory and not the injury itself. Inflammation is the response of the body to heal. You are trying to heal something? Perhaps it is gout or arthritis? Have you had recent uric acid levels? 

Maybe 5 or 6 weeks after that episode ( after 2 long intense bike rides which definitely put pressure on the toe and another intense workout) the toe pain came back and I was again having trouble walking. At this point, I found a podiatrist and went in for an appointment.
He took an X-ray which didn’t show anything and said his hunch was that it was gout, but that he would send me for both a blood test and an MRI. I also was given a 5 or 6-day pack of prednisone anti-inflammatory steroid.
Dr. Blake's comment: The thought was good. You do not want to take prednisone, even NSAIDs if you are suspicious for bone injury. Do not make this your way of handling bone/joint injuries in the future. 

The steroid cleared the pain up very quickly. I was hopping around barefoot and everything seemed good. The blood test came back before I could schedule an MRI and the uric acid read 8.1 which all seemed to point to a gout attack.
Dr. Blake's comment: First, do you know what the range is of normal for this lab. Please send. Gout attacks can occur with high uric acid when trauma occurs. So, just because there was a possible gout attack, you still could have a stress fracture that caused inflammation that sparked the gout attack. A twofer!!

When the course of prednisone was over, the pain came back with a little swelling. I was then able to get the MRI, which showed a comminuted fracture on the medial sesamoid. 
My podiatrist put me in a darco low top shoe with a few cutouts to isolate the sesamoid and told me I’d be in that shoe for 4 weeks. From everything I read that seemed optimistic and sure enough, I'm at the 5-week mark now and after an appointment yesterday, the doctor suggested 2 more weeks based on the fact that the area was sensitive to the touch yesterday. He says that progress is really just based on clinical diagnosis of comfort. The problem with that is, the more I try to give the area with attention, massaging and movement, the more sensitive it is after. 
Dr. Blake's comment: Here I will comment on the some of the images you sent me. First of all, when you use Prednisone, you should ice for 10 minutes three times a day after for the next 2 weeks. This helps to make the effects of the Prednisone last longer. 

Noting the inflammation in the first metatarsal above the sesamoid

When you push down, the sesamoid can push up against the first metatarsal causing injury. The arrow points to the darkened or inflamed first met head. This is a stress reaction, bone bruise, or stress fracture of the first metatarsal head. The stress fracture can actually heal much faster than the others!!

This image shows that the bone edema of the first metatarsal head is the most significant injury, not the sesamoid. 

This is not a fracture, but a bipartite sesamoid with a smaller piece nearest the toe. It looks a little inflamed in this view. What is also interesting to me is that the joint is not really inflamed. Gout usually shows intense inflammation, another reason to get the MRI when things are still inflamed (not being drugged up!!)

I wear the darco shoe whenever I’m outside but mainly I’m trying to stay off my feet and not walk a lot as the darco alters my gait enough that it’s uncomfortable for other parts of my feet, knees, etc...
Dr. Blake's comment: As long as you have something with a dancer's pad to off weight the sesamoid area, various the stresses with stiff soled mountain bike shoes, anklizer removable boots, Hoka One One shoes, stiff hiking boots. You must maintain the pain at 0-2. You should spica tape and cluffy wedge. You should get an Exogen bone stimulator for the next 9 months for the first metatarsal, not the sesamoid.

I still go to the gym but am doing the stationary bike in a way that puts no pressure on the upper foot or other exercises that do not involve the foot. When I'm home I’m barefoot but I walk on my heel and side of my foot and don't ever let the sesamoid hit the ground. 
I also got an exogen bone stim and am using that twice a day along with calcium supplements. 
Dr. Blake's comment: At home, try the Oofos sandals as house slippers. Hopefully, you can put down more normal weight. It is okay to put a dancer's pad in the oofos. Get your Vit D levels. Any osteoporosis run in the family? Bone health may be the issue in any bone injury. Consider a bone density screen if your diet is irregular, or chronically low Vitamin D, etc. 

I am trying to massage the area a bit and introduce a little motion to the joint but the times give done that, there is pain and more swelling the next day. My thought is that it should be ok to bend the big toe down but that I should not flex it up as that would pull the tendon tighter against the healing bone. Is that right? Yes

I’ve read about people in casts and much more restrictive boots for a fractured sesamoid. Is the darco shoe not conservative enough? I will say that I do not put pressure on the sesamoid nor do I flex the big toe when I’m walking. 
Dr. Blake's comment: You have to do whatever to create the most normal gait with a 0-2 pain level. I love also having three possibilities for shoe gear to alternate because you never really know if something is working if you are only trying one. See my comments above. The bike shoes and anklizer are both about $50 each (if you look around). 

Any insight or suggestions you have would be really appreciated! I'm a little unsure of my podiatrist's ability to provide nuanced advice based on what I’ve experienced thus far and if I don't get this healed properly I won't be able to work. I’m also unsure of his approach in taking additional x rays to monitor progress when an x-ray did not find the fracture in the first place.
Dr. Blake's comment: Definitely, you can go on symptoms, and then repeat the MRI if needed in 6 months. Hopefully, you do not need to. Follow up xrays could be taken once, and if it shows no change, it verifies that it is not the sesamoid. Also, if your symptoms keep flaring, consider the CT Scan which just looks at the bone to see if the bone injury is subtle or more involved. However, if it shows a change, then the sesamoid is more involved. Good luck. Rich

thanks a lot

I'm attaching some frames form the MRI as well as the report form that MRI:

"There is nondisplaced probably comminuted fracture involving the medial sesamoid with associated diffuse bone marrow edema within the and focal edema within the articulating plantar metatarsal head. There is trace focal edema within the plantar aspect of the lateral/!fibular sesamoid. The intersesamoid ligament and bilateral sesamoid phalangeal ligaments are intact. There are thickening and heterogeneity with a linear increased T2 signal at the origin of the medial collateral ligament (series 6, image 11). The joint spaces and alignment are maintained. The articular surfaces are intact. There is no aggressive osseous destruction. There is no joint effusion or synovitis. 
Tendons: The visualized extensor/#exor tendons and ligaments are intact. 
Miscellaneous: Ill-de!ned soft tissue like signal intensity within the second intermetatarsal web space possibly represent small neuroma. Plantar plates are intact. There is no abnormal signal in the musculature to suggest atrophy or denervation. The subcutaneous tissues are unremarkable. "

Dr. Blake's initial response:
     Thanks for reaching out. I will work on my comments over the next several days. I would definitely get a CT scan since the bottom of the first metatarsal looks injured above the sesamoid. Rich

The Patient's Response: 
Hi Dr Blake,

Thanks for the response on your blog. Here are my responses to your questions :

I can't recall anything specific that I did to the toe in the days immediately before the first symptoms but I suspect that I sometimes exert a lot of pressure on that toe area when I ride a bike so perhaps that is related. I had definitely ridden that week. I will be mindful of my technique in the future and perhaps get different shoes for riding.  

I do have a history of low vitamin D and had taken extra vitamin D in the past but not faithfully. in 2016 my vitamin D was 22.6 when normal range was described as 30-100. Clearly, a possible culprit here and I wish my primary physician had described the risks of low vitamin D. There is no history of osteoporosis that I know of. 
Dr. Blake's comment: This is such an epidemic, and at your age of 45, I would get the Vitamin D level, and a bone density test. These can change the course of treatment if abnormal. 

I think my podiatrist gave me prednisone because his initial thought was that it was gout. It seems like it was either was not gout or it was a secondary ( first time) gout attack brought on by the bone injury. The lab says that uric acid levels up to 8.5 falls in the normal range but elsewhere I've read that one should really keep them below 8.0. Mine was 8.1 at that time. The MRI was done about 11 days after my initial visit and 6  days after the prednisone schedule was over ( also about 7 weeks after the initial pain) and I was walking with some, but not major pain at that point. 
Dr. Blake's comment: In gout attacks, which can be brought on by trauma like breaking a bone, the uric acid levels in your bloodstream drop over 1 point. So, if you were 8.1 in a gout attack, you were really running at 9.1 to 9.6. The key now is to retake the uric acid one month later and see what is happening. If you are still 8.1 then you just run high, but if you are 8.7 or higher another gout attack is in the making. 

I realized I probably have a bipartite sesamoid but are you saying you don't see any fracture in the sesamoid?
Dr. Blake's comment: From the views I see, there is evidence of bipartite, not fracture, although the bone is bruised. The main bone problem is in the first metatarsal head, and it treated the same as a broken sesamoid. It is the sesamoid pushing on the metatarsal that causes pain. This will take a while to heal. 

Here the tibial sesamoid lights up on T2 imaging meaning it is bruised. This is not the intensity of bone inflammation you typically see in a stress fracture. The uniqueness of this situation is the bone edema in the first metatarsal head signifying arthritis or stress fracture. The sesamoid pushes up right on the inflamed first metatarsal.

I've been slightly altering where I line up the Exogen bone stimulator. Sometimes under the sesamoid pointing up and sometimes more on the side pointing toward the joint. Is there a specific place you’d recommend to address the metatarsal?
Dr. Blake's comment: Since it has a 3 inch penetration, you can place on top of the metatarsal head and then walk around and multi-task. But, where you are putting it (bottom or side) is closer and either are fine. 

How do I know when I can start flexing the toe and pronating again? I dont want to inhibit the healing process or cause any further damage but am anxious to get everything working again in a way that wont make it worse. How will I know when I can put normal weight on the sesamoid without a pad? 
Dr. Blake's comment: This is the typical rehab question for any injury as we increase activity. It is important to make one change at a time, and probably one month apart is safe. Most athletes with this stay with the mechanical supports well into their athletes, and when they have leveled out the activity, start lessening the things that helped them get there. With sesamoid injuries, you can have cluffy wedges, spica taping, rocker shoes, orthotic devices, dancer's pads, etc. You have to stop one at a time in a logical order when you are doing all your activities and feel you are healed. 

I think/hope I am almost ready to segue out of the darco boot but how will I know for sure? I had bought some hoka one one bondis last week so I will start with them with a dancers pad. 
Dr. Blake's comment: This is how us rehab people find out what people need to move forward. What does it take to achieve a 0-2 pain level while we move the patient back towards a normal existence? If I had 100 patients at one time with the same injury, they would all be slightly different in their needs. There are general rules, but each individual has to be individualized. 

I went to the gym a few days ago and made a sesamoid relief platform so that I could work on my balance and address atrophy in other areas of my foot. It felt great and contrast baths helped with the swelling afterwards.

Below are the pics of the ( very simple) workout platform and some additional MRI images just in case they show anything additional.

Thanks again!

Tuesday, June 12, 2018

Sesamoid Injury in Soccer Player

Dear Dr. Blake,

I came across your website while researching my son’s injury.  I wanted to reach out to you to ask for your opinion on his injury.  I have mailed you a copy of his MRI and CT for your review.  I am so grateful for the information on your blog and would really appreciate it if you could take a look at his MRI and CT when they arrive at your office.
Dr. Blake's comment: Will do. 

My son, Ben (13 years old), is a very competitive soccer player.  He plays soccer on average 5-6 days a week.  During a game this past Spring (March 11th), he felt pain in his left foot.  He did not suffer any direct trauma to his foot but thinks the pain started when he planted with his left foot and went to cut right.  After the game, it was hard bearing any weight in his left foot.  We thought that perhaps he had turf toe (he was playing on turf, but wearing hard spiked soccer cleats) and had him rest for a few days.  When it appeared that he wasn’t improving, I took him to see a podiatrist on March 15th (4 days after the injury).
Dr. Blake's comment: One of the culprits is the cleat right under the sesamoid pushing up hard. Please consider removing it as part of the treatment. 

Find the Cleat right under the Sesamoid to remove or file down

The podiatrist’s X-ray showed that the medial Sesamoid was in 2 pieces.  He was not sure if it was a bipartite sesamoid that was inflamed or a fracture.  He recommended an AmnioFix injection, saying that if it was sesamoiditis is would help speed healing and it could do the same for a fracture.  I was not familiar with AmnioFix, but at the time I felt that if it could give Ben a better chance at healing, we should do it.  Looking back on it, I am upset at myself for going through the injection because it caused Ben an intense amount of pain and swelling for about 3-4 days and with the information that we found out later, I wonder if it made things worse (edema causing poor blood flow which impacted the development of AVN?) The podiatrist put him in a walking boot after the injection. I purchased a dancer’s pad for him to wear with the boot.
Dr. Blake's comment: I am not doing any of the regenerative medical treatments, like PRP or Stem Cell, or AmnioFix. I have always thought AmnioFix as a skin substitute, or collagen former that would be helpful in achilles tears or plantar fascial tears or diabetic ulcers. I, therefore, have no idea why it was put into your son. Sorry. It is hard to get info on it but it should be degraded by now. The acute inflammation should not cause any long-term AVN problems. 

I decided to take him to see a Foot and Ankle Orthopedist the following week.  He thought that the distal fragment of the medial sesamoid “looked funny” so he ordered an MRI.  I have enclosed the MRI.  The MRI showed edema, sclerosis, and avascular necrosis of the distal fractured portion of the medial sesamoid.  I’m wondering if the swelling/inflammation from the AmnioFix injection caused the AVN or made it worse.  Can AVN happen so quickly-9 days passed from the date of injury to the day the MRI was taken? Could he have had this injury “brewing” for a while (he never complained of foot pain)? The doctor told Ben to wear the boot and dancer’s pad for the next month and return for a follow-up.  I asked the doctor if an Exogen Bone Stimulator was a good idea and he said that it was okay to use and gave us an order for the machine.  He has been using it daily for 20 minutes since March 29th.
Dr. Blake's comment: Please talk to the Exogen rep for me about the age restriction. I know the bone has to be skeletally mature, but not aware of recent studies on age. Did see some studies that 13 was the earliest including in the Exogen study. It is hard to imagine in a child that some short-term swelling will lead to AVN. I have not seen it. I have seen AVN occur when a year has passed and the inflammation was never under control due to inadequate treatments.

We returned to the orthopedist on April 23 for a follow-up.  He did a CT scan in his office and said that “the bone did not fragment, but still showed AVN” and Ben could transition into an orthotic as soon as possible and if he felt good, he didn’t need to return to his office for any follow-up.  He didn’t indicate that Ben should be restricted in any way or need physical therapy.  Because of what I read on your website, I thought that 6 weeks was a little premature to be out of the boot, especially with AVN.  
Dr. Blake's comment: Yes, first of all, you need the boot to achieve the 0-2 pain level? Sometimes you need an orthotic or dancer's padding to accomplish that. If I can good pain wise, and I have good 0-2 pain control, I will begin weaning from the boot and orthotic to shoe and orthotic at 10 weeks. As long as the pain does not go higher. Keep him in the foot for at least 4 more weeks. 
     If we are worried about AVN, then contrast bathing twice daily, Exogen bone stim if good for his age, and weight bearing as long as we keep the pain between 0-2. Also, bone health should be important with proper Vit D, Calcium, protein, perhaps asking a nutritionist if there are diet changes to make to ensure stronger bone. 

I was disappointed to have Ben discharged from his care without any type of follow-up or plan for returning to play.  Instead, I decided to follow your recommendations of 12 weeks in the boot with dancer’s pad, daily bone stim,  and daily contrast baths.  I’ve had him on Vitamin D3, calcium, and magnesium since the beginning of the injury.  Ben has also been doing body weight exercises and using the rowing machine while wearing the boot.  
Dr. Blake's comment: Great, what pain level are we having?  

Ben reached the 12-week mark on June 3rd and his been weaning out of the boot and into a Hoka shoe with the orthotics.  The orthotic had to be a very low profile in order to eventually fit into a soccer shoe. The orthotic has a carbon fiber plate with the metatarsal cutout and dancer’s pad for the left foot.  The right orthotic does not have the carbon fiber plate or dancer’s pad (only has the metatarsal cutout). Ben has very high arches which probably contributed to his injury (along with wearing hard spiked cleats on turf and perhaps overtraining).  This past week, Ben says he feels good and has no pain with walking.  He says he gets a little bit of pain if he puts a lot of pressure on his left foot to “test the orthotic”.  He has some pain with palpation of the area to the side of the medial sesamoid (along the base of the big toe)-he describes it as “tingling pain”.  He has not done any running or jumping.
Dr. Blake's comment: Wow, this sounds wonderful. You are doing a super job. All of those symptoms fit in the 0-2 range. Palpable pain can be normal well after a person is back running with full activity due to some nerve hypersensitivity. Massage the area for 2 minutes twice daily with the palm of your hand. The massage is for desensitization and cannot be painful. 

Thank you for taking the time to read this and look at Ben’s scans.  I want to make sure that we haven’t missed anything and if there is anything else we should be doing.  Do the orthotics that he has sound appropriate for his injury/needs? Should I also be spica taping him? Continue with bone stim and contrast baths? Any recommendations that you have on how to progress his activity from here would be greatly appreciated.  He is tolerating the orthotics and can walk about 1 mile without pain.  
Dr. Blake's comment: Definitely needs another pair for normal athletic shoes that can have more bulk (more padding, more dancer's protection, more arch?) As he begins to increase activity (longer walks, then walk-run program) experiment how spica taping and cluffy wedges feel. Check about the bone stim for his age. Contrast bathing until a new MRI 6 months after the first one, or we have stopped worrying about AVN (bone death). 

How do we know if the bone has healed and no longer has AVN?  I’ve read that it can take up to a year for a bone with AVN to come back. Is it safe for him to play soccer before we have proof that the bone is okay?  It has been extremely difficult for him to sit out the last 3 months and the competitive nature of his team/league makes it difficult to come back after a prolonged injury.  However, I’d rather be safe than sorry.
Dr. Blake's comment: It can take one or two years to know that a devitalized bone has revitalized (I know big words for me). Typically, we first follow the symptoms, as long as we are doing the above bone stim, contrasts, bone health, weight bearing. If the symptoms and disability (inability to play soccer) are stalled at 6 months, a CT scan and another MRI are ordered. The signs of AVN are bone fragmentation and no marrow signal from the bone. This is getting the buggy before the horse right now. 

Thank you for taking the time to read this long message!  I so appreciate it.  The information from your blog has been so helpful!
Dr. Blake's comment: Thank you. Sounds like you are doing wonderfully. Look forward to seeing the images. Good Luck. Rich

The Patient's mother responded: 

Dr. Blake,

Thank you so much for your recommendations.  Looking forward to hearing your thoughts on Ben’s films.

I spoke to the Exogen rep about the age limitations on the bone stimulator and he said that studies have not been done on children, but it has been used in kids Ben’s age without any negative effects (that we know of).

Side View of the Tibial Sesamoid with 2 fragments looking nonfractured and smooth edges, but the distal fragment (closest to the toe on the left side) looking sclerotic (sign of AVN) brighter white than other fragment.

Take care!

Dr. Blake's review of the images sent: CT, and MRI. Selected images presented. 

                                                               Again the tibial sesamoid on the left side looking more sclerotic in its distal or bigger fragment, but the two pieces look typically bi-partite (round, smooth edges). The trauma appears only to the distal fragment.

These are side by side comparison of the tibial sesamoid in T2 MRI where the normal bone is dark and inflammation shows up as white, and T1 where normal bone is white. See this distal fragment does not change consistency. This is very unlike a new injury where trauma to a bone would make it white on T2. Possible AVN? Probable old AVN! MRI after 6 months of Exogen, contrasts, weight bearing will be conclusive. Long wait I know. 

 Here the arrow above points to a medial collateral ligament irregularity. Also, note the tremendous swelling on the whole joint. This points to a Turf Toe injury which is acute (3 months old). Taping of the joint crucial to allow healing. This could be a reason to do surgery to sew up the ligament or consider PRP or prolotherapy. However, no joint instability has been found, so again I would wait for the followup MRI. I would do even if the joint is doing well.

 These 3 CT scan reconstructions are conclusive to me. The 2 fragments have the classic appearance of a bipartite sesamoid, round, different sizes, smooth edges at the junction. The distal fragment with the possible AVN looks healthy, nonfragmented, just like the uninjured fibular sesamoid. Good sign!!

Monday, June 11, 2018

Sesamoid Injury: Email Advice

Hello Dr. Blake,

 I am a 26-year-old female from Windsor, Ontario, Canada. 

I am struggling with a fibular sesamoid injury which occurred in January 2018. I read your posts regarding sesamoid injuries on your blog and found them very helpful! 

I've had two x-rays, a bone scan, and an MRI so far and unfortunately, I have not been able to get a clear answer from the health care professionals here in Windsor. The radiology reports from both of the x-rays and the MRI indicated no fracture or focal bone lesion, however, I have gone to see three podiatrists who all claim that there is a fibular sesamoid fracture. The report from the MRI (which I finally had in May 2018) stated that there was lateral sesamoid bone marrow edema and the conclusion was sesamoiditis. One of the radiologists also thought there might be a "crack in my big toe." 
Dr. Blake's comment: Sesamoiditis with bone edema can be the same treatment and injury as a stress fracture. You can not see a small stress fracture, but it causes bone edema as your body attempts healing. So, they can look the same, and we are really forced to treat the possible fracture because that has long-term complications like the need for surgery that we want to avoid. 

I admit I did not stay off of my foot when I was originally injured in January since the diagnosis was unclear. I am very active and do a lot of walking at work (sometimes wearing heels). However, despite staying off of my foot for the past month I am still in a lot of pain and have not seen improvement. I am also struggling with circulation issues (despite trying contrast baths). I am wondering if there is underlying etiology that may have been missed. 
Dr. Blake's comment: For bone health and tissue strength, along with swelling reduction, weight bearing to tolerance is crucial. Yes, you can not push through pain, but rest (getting off your feet for an extended time, does not help either. 

Due to our healthcare system in Canada, I am not able to get in to see a specialist until September 2018. I was wondering if you would be so kind to have a look at my MRI or x-rays and give me your clinical opinion? I could mail or e-mail them to you and I would be happy to pay you for your time as well! Please let me know if this would be okay with you. 
Dr. Blake's comment: Yes, please mail a disc to Dr. Rich Blake 900 Hyde Street, San Francisco, California, 94109. No charge for this. Contact my friend Dr. Shannon Frizzell at OOLAB (Ontario Orthotic Lab) in Hamilton, Ontario to see how you can get a good orthotic to protect the sesamoid. 

Thank-you for providing such thorough and detailed information on your blog. It has helped me immensely so far! 

Thank-you for your time,