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Wednesday, September 26, 2018

Orthotic Cast Correction on Cast Fill: Email Question

Good morning, Rich.  A quick question – regarding “cast fill” – do you generally prescribe the “normal” cast fill on the Root Lab form and find that leads to good patient outcomes?  My experience with other labs has been that their standard cast fill, seeking to make the device more “tolerable,” is so much that it significantly compromises the effectiveness of the device for people with excessive pronation issues.  That is far and away the most common problem I see with my PT patients who are referred to me because of other injuries, but for which excessive pronation is really the root cause -- e.g., runner’s knee.  I often prescribed “minimal” cast fill with other labs and I just wonder what your experience has been with Root lab with whom our practice is now working. 
Dr. Blake's comment: Yes, that is a big problem. Root Lab is truer to the arch than some labs for sure. You do want to have a grinder since some plantar fascial bowstringing requires a groove when the arch is true. If you are using vertical cast correction, how much change (transition modification at the first metatarsal head) will you ask them to do to a 5 degree vs 10-degree forefoot varus? I have found you have to go to a 25 degree inverted cast correction if the forefoot varus is over 5 degrees and you want great support (or at least modified forefoot correction for comfort but ask them to use a 2-3 mm Kirby skive and some extra medial column support (minimal fill proximally in the arch not distally). I will send this to Jeff Root to see if he responds. I hope this helps. Rich 

Any experience you can impart would be very much appreciated.

Thank you.

Sesamoid Injury: MRI report.

Hey Dr. Blake, 

I found an article you had written where the Drs said a girl had broken her sesamoid bone but it ended up being a cyst. I am still waiting to hear from my dr and I am no radiologist, but based on my MRI results, I think  I may have the same thing.  I am so glad I found your article.  Here are my MRI results, any insight?  This is my 2nd opinion.  The first dr taped me up and told me to go run and let him know how it felt, I quickly sought a 2nd opinion.  Both of my Drs did think I broke my bone though.

History: Sesamoid bone.  Abnormal ultrasound.  Cyst.

Technique: Right forefoot MRI with and without contrast.

Sequences: Axial T2 proton density fat sat, coronal STIR, sagittal T1, coronal T1, sagittal T2 proton density fat-sat and coronal T1 fat sat sequences were obtained.  The patient was intravenously injected with 6 ccs of Gadavist contrast and post contrast multiplanar T1 fat sat sequences were obtained and submitted for review.

Comparisons: None.


The bone marrow signal: Heterogeneous T1 dark signal with a near serpentine appearance of the fibular sesamoid bone.  There is a corresponding increased T2 signal.  There is an enhancement with contrast.  There are no diastases.  There is an adjacent T2 bright signal with enhancement of the surrounding soft tissues.

There is a small first MTP joint effusion.

The plantar plates are unremarkable.

Tendons are unremarkable.

Impression: Nonspecific enhancing T2 bright fibular sesamoid bone signal with surrounding soft tissue enhancing T2 bright signal.  Question changes of sesamoiditis, AVN, or an intraosseous mass.

Dr. Blake's comment: The MRI report clearly shows the fibular sesamoid is hot and trying to heal. There is no indication of anything else. There is no definite diagnosis of sesamoid fracture, only that the bone is swollen for some reason. It could be a stress fracture, and you have to treat the worse case scenario with these. I would be happy to review the MRI scan if you want to mail to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca 94109. Rich

Tuesday, September 25, 2018

Sesamoid Injury: Email Advice

First off I wanted to extend my appreciation for your amazing blog showing so much 
dedication to helping patients heal. The most frustrating thing for me on my
 sesamoid journey has been feeling like I don't have the right team of doctors/resources
 to begin 
healing from such a complex injury. I am willing to do anything but need to feel I am 
moving in the right direction to stop obsessing and focus on healing. 
Dr. Blake's comment: Thanks for the compliment. I am probably trying to pay off sins 
of the past. 

I am a 22-year-old, active, healthy female who rarely spent any time on the couch
 until recently. I am a Veterinary Nurse who works 8-10 hour shifts on my feet 4 days a week. 

I began having sesamoid pain in my left foot in early May 2018 likely caused by 
hiking at a quick pace, uphill, for long distances. I stayed active and ignored it for
 about a month as it wasn't bothering me until I came home from a two week trip to 
Colorado during which I was more active than ever. After coming home I realized I 
had a serious issue as I couldn't walk up my driveway without pain or otherwise dorsiflex
my big toe without pain. I went online and self-diagnosed myself with "turf toe" and
 taped it accordingly. I wore this tape for two weeks but didn't take more than a few days 
off hiking as it wasn't bothering me much with the help of the tape. While the taping helped 
I kept having the feeling that padding under the area I now know contains the sesamoids
 would have been helpful. After the two weeks in the tape, I was discouraged by not 
having more progress and made an appointment with a local orthopedic/sports medicine 
clinic. I saw the PA at this clinic on July 17th, 2018 and had xrays done on foot. The PA 
looked at my xrays, watched me stand, and felt my foot a bit. She said I likely injured the
 area (no specific diagnosis or fracture) and aggravated it by not resting and made the
 healing process take longer (2+ months at this point). She also said I had pronating feet 
with high arches and needed to do arch strengthening exercises and rest. If I didn't improve
 in 4 more weeks I was told to come back. 

I was encouraged by a lack of fracture and overall it definitely felt better than when
 I initially injured it (likely due to changing my gait and overcompensating) so I still did
not stop exercising and in fact began doing more. From the time of that appointment until
3 weeks ago I continued hiking and began more intense yoga (more planking/lunging/balance)
and started a new running hobby. I wore old, worn out running shoes and did not work up
 to running properly at all. I mostly ran on asphalt and the same trail I was hiking on (hilly)
and did not notice much pain except for when lunging/planking/dorsiflexing the toe, or
 running over a rock in the sesamoid area. In general, the foot was always irritated when
I would think about it but not so much so that I pursued further treatment. 

On Sunday, Sept 2nd, 2018 I went on a run at a park on concrete for the first time 
and then came home to do housework for a few hours in my bare feet. I sat down 
after all this and realized I had a throbbing pain in my sesamoid area that did not 
improve with anti-inflammatories and knew I needed to address this once and for all.
 I began researching and decided upon sesamoiditis as my new self-diagnosis. 
I called the same orthopedic/sports medicine clinic and scheduled a follow-up 
appointment with the surgeon himself but they couldn't get me in until October 5th. 
I attempted some home treatments with varying success that made walking bearable.
 During this time I also started developing issues with my other foot (right foot). 
 Eager to get some real answers and a real treatment plan going with the help 
of a doctor I tried calling another clinic. 

Yesterday, Sept 24th, I went to see the podiatrist specialist. He took did more
 imaging (fluoroscopy) and examined my foot a bit. He diagnosed me with
sesamoiditis, saying that the tendon between the two sesamoids was stretched
 out and having trouble holding them in place. He also said there was a shaded
 area on the lateral sesamoid (the one I have issues with) and he wasn't sure if 
it was a stress fracture or not. He prescribed an air cam walking boot for the foot
 and told me to come back in 3 weeks. I was diagnosed with general metatarsalgia 
on the other foot from overcompensating (no imaging or palpation was done). I asked
 many questions regarding MRI, orthotics, physical therapy, why this happened/gait,
 etc. Basically, he was most concerned with getting me in the boot and addressing
 anything further after rechecking my progress in the boot. He said an MRI may be 
helpful but it wouldn't change his course of action so it is just an additional expense.
 After going home and taking this all in and reading further I had him order the MRI
anyway and will be having that on Friday, Sept 28th. I am still going to keep my 
appointment with the orthopedic surgeon on Oct 5th as well. 

I am willing to do anything but I am getting discouraged that I do not have the right
medical team or diagnosis to begin this healing journey properly. I am hoping after
hearing my story and hopefully reviewing my MRI very soon that you will be able
to help me develop a treatment plan that can aid my current doctors in treating me. 

My main questions are:
- Would you definitely suggest I have the MRI as the treatment plan should be
 different if I have sesamoiditis vs. a sesamoid fracture? 
Dr. Blake's comment: Yes, this injury is 4 months old now and the MRI is the most 
subtle at looking for bone injury. Plus, if it is a fracture, you may need a comparison 
MRI 6 months from now, so might as well get that first one. I love PAs, but they do 
not have the foot training of podiatrists and a lot of orthopedic surgeons. The podiatrist
 in my mind has made the right decision to put you in the cast. If there is a break,
 typically 3 months in the boot is needed, and a bone stimulator as soon as 
insurance allows. 

- If I will be in the boot what physical therapy/exercise would you suggest to
begin to regain the strength I have already lost and likely will lose? Do you have
 any tips for finding a physical therapist who is familiar with this condition? 
Dr. Blake's comment: Most physical therapy places have PTs that like feet. You start
 there by calling and find out who deals with the rehab of foot fractures the best.
 Don't accept "we all do." The restrengthening of the foot and leg will be directed 
by the therapist. You need to protect your sesamoid by not putting full weight on it 
with various exercises. The exercises include single leg balancing, heel raises,
achilles stretches, metatarsal doming, posterior tibial and peroneus longus theraband work. 

- How can I decide if the boot is properly placed to help the fracture (should it be one)?
I can definitely feel the area when wearing the boot and I would still say it is in the 0-2
range of pain but I can't tell if I should dancer pad the sesamoid or not? And if I do pad it,
how can I make sure the padding is right other than by feeling/trail and error? 
Dr. Blake's comment: You can place a shoe insert into the boot, then use lipstick to mark
 the sore area, put the foot in the boot and tighten and walk down the hallway a few times.
 When you take the insert out of the boot, it should be obvious what area to protect
 with the dancer's padding. 

- How should I address the developing issues in my other foot if I am not sure it is the
sesamoids? I'm not sure what to have the doctor evaluate if the pain is just general
tightness and soreness. Also, I'm not sure how/if I could have developed sesamoid issues
 in the other foot if I'm not doing any impact exercising?
Dr. Blake's comment: Most likely strain from placing too much pressure on the other side.
 Some sort of OTC arch support or arch wrap may help. You should be doing daily contrast 
baths for the sesamoid and you can do both feet together. Make sure they evaluate 
everything. Please have your Vit D blood level drawn, because having low Vit D 
can make you start breaking things. 
- I see you have lots of suggestions about healing a sesamoid fracture but if it is
just a tendonitis issue what do you suggest for treating this? 
Dr. Blake's comment: Thus the MRI, since you have to make sure it is not a 
broken sesamoid. The tendinitis is treating with spica taping, icing, some physical
 therapy, metatarsal doming, and FHL theraband strengthening. Some of this will not
 be good with a sesamoid fracture. 

- Do you have any suggestions for doctors in North Carolina who you know have had experience/success with this issue?
Dr. Blake's comment: I am only acquaintance with Dr. Milch in Asheville, and Dr. 
J Barry Johnson in Winston Salem

I'd be happy to wait to get full answers to the questions after having my MRI and 
hopefully having you evaluate it. I am just looking for some encouragement that I
 am moving in the right direction and some advice from someone who is experienced 
with this condition. Dr. Blake's comment: Happy to review. Good luck. It can be a 
long road, but usually successful. The long part of it can drive people crazy, but not
 crazier than me I promise. Create your 0-2 pain level, and do not do anything that
 threatens that as you work through the rehab process. Rich

Thank you so much for your time and dedication to this issue.

Monday, September 24, 2018

Excessive Supination Video with Orthotic Modifications  Dr. Kevin Kirby  Dr. Rich Blake

If you supinate, these videos may show you the motion and tell you what should be in your orthotic device

Sunday, September 23, 2018

Stage ll Posterior Tibial Tendon Dysfunction: Give Conservative Care a Try

Dr. Blake, 
 This is the original post back in March 2018 when the patient contacted me. I referred her eventually to Dr. Matt Werd in Florida. 
I wanted to share with you a follow up on my progress with physical therapy. 

I am seeing Dr. Werd and he was very helpful in prescribing PT. Not only that but of all the doctors I have seen for this condition (4 so far), he has by far spent the most time with me analyzing my symptoms and going over the diagnostics and various alternatives. 

I had 5 months of PT. I was very blessed in finding an experienced therapist. I can tell you that it was not easy. It was sometimes painful and discouraging. However, I stuck with it daily, sometimes an hour or more of exercises every day. I had a couple of setbacks but am so thrilled with the results now. I am walking without pain, have full range of motion and full strength. I can easily do 50 single foot heel rises! Although it wasn't easy, I can also say that it was much easier for me to do PT than the alternative of surgery (with the post-op of being non-weight bearing, on painkillers all while trying to take care of my children.) I would have done surgery if absolutely needed but was so glad to have an alternative. 

I'm so thankful to God to lead me to this path. Thank you so much for your help along the way!


P.S. Do you have any advice for me how to keep my foot healthy (exercises to do? any to avoid?) Dr. Blake's comment: This is your weak spot, but over the next year you will get it stronger and stronger. I pray that you are doing the posterior tibial theraband work level 6 2 sets of 25. Did you go through them? If you did, you need to do twice weekly to maintain the strength and make sure the tendon stays strong. Focus on activities until April that you can do with orthotics like hiking. I would wait another year before starting a walk-run program. Modified Yoga with orthotics on would be wonderful. I hope this gives some direction. You want to keep it strong forever so it will have minimal effects on your overall life.

Big Toe Bone Spur: Email Advice

Hello Dr. Blake,

I am very glad to say that searching on the Internet trying to find information about the problem I have I came across your blog. Thank God you have opened my eyes and gave me a better understanding of what I'm about to do.

I am about to have cheilectomy in my right big toe because I have developed a spur, which annoys me a lot when jogging. This is what my doctor here in Athens, Greece has suggested to me.
I am wondering if the simple movements on self-mobilization you are proposing for the big toe joint in your videos, might help and alleviate me from the burden of having the surgery.
Best Regards,

Dr. Blake's comment: 
     Yes, the conservative treatment can prevent or delay the course of surgery on the big toe joint. It is at least valuable information in the postoperative setting to see what helps take the pressure off the healing joint. Give yourself 3 months to see if it works. Self-mobilization is only one thing to try. My blog has been treatments for Hallux limitus which these spurs fall under. Try to skip the eyelet above the spur to help in any shoe you get pain. Try to place padding just to the bump, not over it. This is called proximal padding. I use 1/4 inch adhesive felt, but any soft material can be used in an inch square shape to tape down. Try spica taping to restrict the motion of the big toe joint. Try dancer's padding to off weight the whole joint from the bottom. Ice the area for 5 minutes twice daily for the next month to see if some of your pain is inflammatory, and not just mechanical. You can also experiment with shoes with bigger toe boxes depth-wise, or shoes with rocker to decrease toe bend like Hoka One One. Hope this experimentation helps you. Rich
PS. My wife and I have been to Athens, Mykonos, Delos, Paros, Naxos, and Santorini. Can not wait to go back in a couple of years. We want to see Crete and Rhodes for sure. Beautiful area. 

Friday, September 21, 2018

Nerve Pain: Possibly Treating the Wrong Area

Hi Dr. Blake,

I too experienced severe pain/side effects after my first alcohol injection. It has now been 7 weeks after my last injection (7 in total) and I'm STILL in pain - as a result, from the shots. I didn't have this type of pain, or in this location prior. Here is a summary of my story leading up until this point:
  • Stubbed/fractured/broke/ right pinky toe Nov 2016 (was pain-free prior)
  • Went to podiatrist May 2017 who suggested tape and increase vitamin D dosage due to deficiency
  • Toe seemed to make progress into Nov 2017 but then healing plateaued and eventually worsened
  • The orthopedic surgeon said they couldn't help since X-rays/MRI showed no damage(Normal results - Morton's Neuroma was NOT shown)
  • Podiatrist suggested 9 laser treatments on the bottom/side of the pinky toe (not the neuroma since this wasn't diagnosed at the time). All 9 were performed by 2 physical therapists and no long-term relief was evident.
  • Podiatrist performed an ultrasound and diagnosed me with Morton's Neuroma. Found interesting since the pain I was experience was not where the 2 neuromas were located. I did not have the typical symptoms listed for MN at that time and the diagnosis didn't match MRI...but he convinced me this was causing my issue.
    • Podiatrist suggested 7 ultrasound guided alcohol injections on my right foot. (30% in both neuromas per session).
    • The 1st shot had horrible side effects: increased pain, numbness, tingling. Caused common symptoms of Morton's Neuroma, which I hadn't experienced prior.
    • 2nd shot provided relief to some of those symptoms.
    • Started noticed an improvement in injection 4/5. Feeling optimistic!
    • The pain started to come back slightly after injection 6
    • Injection 7 was now 7 weeks ago. The pain came back both in my pinky and neuroma. There was visible external bruising after this injection which has subsided but I'm still in pain.
  • Dr. Blake's comment: The initial reaction is unfortunate, but probably one in 5-6 patients, and always resolves. The series should stop at five to rest the tissue. Not sure why you kept going. Actually, from your explanation, many neuromas never hurt ever, so why wake up a sleeping dog? 
  • I'm now in more pain today than I was prior to treatment! (although less so specifically in my pinky toe...and the pain comes and goes more frequently than prior)
    • Prior to injections, I did not have any typical Morton's Neuroma symptoms (no burning, tingling, etc.) But now I do, in addition to my chronic toe pain.
    • After injection 7, my right foot now physically looks/feels swollen underneath my toes. I'm not sure if this is the neuroma, pools of alcohol from the shot, or hematoma. 
    • Dr. Blake's comment: I hope you are in a removable boot to rest the tissue for the next month. Sometimes 5 minutes of ice frequently is best, and sometimes several warm water soaks of 30 minutes each twice daily is very smoothly. The MRI taken should tell you if the swelling is anything to worry about, but swelling from pain is normal with this type of problem. It is telling you to quit irritating me!! 
      • My podiatrist didn't have an answer for me and said this has never happened before. He Rx Lyrica to reduce the pain but I didn't feel good on it and the pain relief was minimal
    • I got a new MRI. And my podiatrist says it looks like one neuroma shrink over 50% and the other is marginal compared to the other...But again, I'm not in more pain since starting the injections.
    • I've had pain every day of my life for almost 2 years. I thought these alcohol injections were going to be the answer but now things are worse.
    • Dr. Blake's comment: Definitely get the MRI report to read. You can send me the report because you need to know if there is anything else to be concerned about. Probably not. This pain should cool down over the next month if you do not keep irritating. Do you know the alcohol percentage used? I just do not think from what you say you are treating the right thing. I am not saying to switch either yet. Please wait the next month, go in a boot. Try to topically cool it down with ice or soaks. 
I've attached an image of my current pain/discomfort. The skin is still sensitive in that area when touched.

My podiatrist has presented some alternative "plan B" options (laser treatments on the neuroma or stem cell, amnion-chorion membrane injection) but these are not covered by insurance, costly, and I'm afraid it would only provide short-term relief if any. Based on my MN support groups - most people said this was a waste.

Please share any thoughts and suggestions you have regarding my case.

Thank you for your time.

Dr. Blake's comment: I need to know if you are off-weighting the area with Hapad or Dr. Jills products. My blog has many examples. You should be massaging three times a day Neuro-Eze cream (online product) and doing neural flossing until the new symptoms better. Get in the boot and relax this. Rich

The patient responded:

Hi Dr. Blake,

Thank you for your quick response! 

Some follow up information/questions:
  • I was told they were 30% alcohol sclerosing injections with the intent to shrink the neuromas. 
    • I was given 2 injections in my right foot for each of the 7 sessions. I have attached images of the injection areas. As you will see, this was not near my original source of pain (pinky toe).

  • Dr. Blake's comment: This is a lot of irritation. The highest percentage that I have gone is 20%, which is what I have found podiatrists in the UK are using. Plus, giving it in 2 places at once is more chance of irritation. This may be fine, but no more shots, especially since it was done for MRI findings, and possibly not for the reason you needed to be treated. 
  • I kept going with the injections because my doctor suggested all 7 for my case. I felt maybe 80% relief after the 5th injection so it made sense to continue on my doc's advice thinking it would get me to 100% relief instead of reversing and causing more/new pain.
  • Dr. Blake's comment: With any injection series, and probably for most treatment protocols, you try to get the patient to 80% better, with the remaining 20% allowed to father time. 
  • "Many neuromas never hurt ever, so why wake up a sleeping dog?" - Only because my doctor believed the MN diagnosis was the cause of my chronic pinky pain.
  • Dr. Blake's comment: If you give a 5-hour lasting local anesthetic into the neuromas first, and for that 5 hours the pain in the pinky toe disappeared, then addressing the neuromas in some way would make sense. 
    • If my chronic wasn't wasn't from MN - what else could have been causing it? Perhaps RSD/CRPS?
    • Dr. Blake's comment: When you stub your toe, and then have chronic pain and negative xrays and MRIs, you may have some version of CRPS although the injury could just be missed in the films due to its superficial location. Besides the laser treatments by the PTs, you really have not had a thoughtful approach to where you hurt. Once the pain goes away from all these shots, you may have to investigate various options like joint mobilization, ultrasound as a treatment, acupuncture, off weight-bearing padding. Just sending me a photo of what types of padding minimize your symptoms would be a good start. 
    • Is it possible for these injections to cause more long-term harm than good? (My fear is that my chronic pinky toe pain has turned into chronic foot pain)
    • Dr. Blake's comment: In December, as long as you have had no more shots, a new MRI will be done if some of the injection pain lingers. 
  • No one has recommended a removable boot until this post. Happy to give that a try. Is there a specific brand/model you would recommend? Dr. Blake's comment: yes, anklizer by Bird and Cronin is a good one or the short style (just going above your ankle) by Aircast.
    • Is this something my doc could Rx and be covered by insurance, or am I better off just buying on my own online? Dr. Blake's comment: Your doctor's office will know. They are around $60-70 self-pay.
    • In the meantime, I've spent most of my time at home in slippers with custom Rx orthotics. When I'm out, I'm in wide sneakers with the Rx orthotics as well
  • I've tried both hot Epsom salt baths and ice without luck... In the past the bath would make the sensation further "radiate" and the medical ice pack would cause a "burning" sensation. But if you suggest one over the other I can try to do that more consistently.
  • Dr. Blake's comment: We have to assume you may have an internal burn. The general rule is no ice on a burn, so some warm compresses are probably best. Try a warm slightly damp facecloth on the area when you sit and wrap saran wrap around for 30 minutes at a time. The saran wrap allows the heat and circulation to get deeper. Whatever you do, you should at least immediately feel better. 
  • I have a copy of the full digital MRI on CD. Happy to send this to you to review if you suggest a certain file type. (can your computer read a .iso CD image file or anything else you recommend? I can also try taking some screenshots from it)
  • Dr. Blake's comment: I am not sure which ones. Can you have a disc burned and sent to me at Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109? Any screenshots as photo images are fine also. 
  • I do not have a copy of the report. I will request this next week. When I asked my doctor about the results, this is what he told me:
    • "The MRI shows only mild residual neuroma remnants following the injections. No other major boney or soft tissue pathology. Dr. Blake's comment: Hooray!!!
    • [The size of the neuroma is not indicated on the MRI Report] When I looked at it myself, it looks to be 6 MM or less which is small and over 50% of the one neuroma and marginal on the other as compared to the original ultrasound I did on April 2nd which showed:
      • Findings body of the report. We noted a 14.0 mm ovoid hypoechoic ill-defined nodular density seen on sagittal view in the right 2nd interspace. And also a 6.9 mm ovoid hypoechoic ill-defined nodular density is seen on sagittal view in the right 3rd interspace. No evidence of bursitis, capsulitis, or plantar plate tear in the right 1st, 2nd, 3rd, 4th, or 5th MTPJ's."
  • I was Rx a couple of different topical anti-inflammatory cream. I was told to use these simultaneously but they failed to provide relief. Dr. Blake's comment: Makes sense, your pain is nerve pain, get one for nerve pain and also try Neuro-Eze. 
    • I have not tried or heard of "Hapad or Dr. Jills products" . Which would you recommend for my case? Dr. Blake's comment: Both companies sell online. You could ask the podiatrist which one offloads the area best. I would try a small longitudinal medial arch Hapad support as a metatarsal support. But we have these right in the office. 
    • I haven't heard of neural flossing. I found an older blog of yours with a video. Is this what you recommend I do in my situation, or is there another type of neural flossing suggested for MN? Yes!!
  • What are your thoughts on Dr. Blake's comment: I think acupuncture right now makes sense as long they do not stick the sore area. You have a nerve problem, and acupuncture addresses that. 
    • MLS Laser treatment?
    • Amnion chorion membrane injection?
    • Acupuncture?
    • Nerve decompression surgery?
I rather not seek any other type of treatment if you think I simply need more time to heal...but my doc said my symptoms should have resolved 4-6 after the last injection and it's now been 7. Maybe the boot would have helped but I've been fairly inactive during this time.
Dr. Blake's comment: You can not use time, because everyone is different. That being said, get in a boot, start treating the nerve pain without increasing pain, be nice to yourself, see how you are in 3 weeks. I want a report. 

Thanks again,

Another note from the patient:

Hi Dr. Blake,

Thanks for your last 2 e-mail. I hope you had a great time in Spain!

Here's an update on my situation. Questions in bold.
  • Feeling extremely optimistic after using the Neuropathy Pain Relief Cream + Aircast Boot for 3 days in a row. Substantially felt better. I was convinced this was going to solve my pain!
  • Tried 4 acupuncture sessions...Wasn't sure if it was helping at all but wasn't hurting. Maybe helped with the improvement.
  • Days later, the pain came back, and on strong.
    • I had some extra pressure on my feet, carrying my 6-month-old in her car-seat for maybe 15 minutes...Nothing too intense but could something this simple make my pain that much worse? Dr. Blake's comment: Leaning forward with weight can be hard on the nerves coming off your back. 
  • Over the next few days, the pain got worse, got a bit better, and then worse again. Dr. Blake's comment: Probably should be 3 days in the boot, 3 days out, alternating if the boot consistently helps. 
  • I went to an orthopedic surgeon to get another opinion... the trip was a waste.
    • He didn't have any answers/explanations for me.
    • Suggested a CT scan to see if it gives us more info. Do you think this is necessary? - Anything else it may show? Dr. Blake's comment: CT Scan shows only bone, so not sure if he was just grasping at straws. Maybe he saw something in the xray. 
    • He inserted a Metatarsal Bar below the pain area to take pressure off...Pain has been worse since.Dr. Blake's comment: I rarely ever use those, since they are difficult to place, and may put to much pressure no the metatarsals.
  • I've had pain during my last 2 acupuncture sessions (This past Tues and Thurs)...Treatment didn't seem to resolve. How many sessions should I try in total before I stop? Dr. Blake's comment: Typically, 3 sessions of acupuncture and you know if it is going to help. 
  • I've continued to use the pain relief cream + the boot with no luck. I just tried Neuro-Eze for the first time today and did not receive any relief from it.
  • I've tried Neural Flossing along with watching your video every time. This usually (but not always) provides at least some short-term relief.
  • But I'm less focused on temporarily relieving pain and more focused on figuring out what I need to do to prevent the pain from coming back at all!
    • You provided a number of great suggestions in your last e-mail. What type of doctor should I see to explore these options with? Dr. Blake's comment: Typically a podiatrist should be the primary with referrals to pain consultants if nerves are to be treated. We need to have nerve treatment to calm the nerves down. Probably need some oral med and better topicals. 
      • I no longer trust my podiatrist since it appears he mistreated my condition. (5th toe pain still present and new pain caused from injections)
      • The orthopedic surgeon I saw didn't have any insight
      • Perhaps a rheumatologist or pain medicine specialist? Or just start looking for a new podiatrist? (You've been the most helpful so far - I wish I was in your area!)
    • I've tried Lyrica - It provided very minimal relief with many negative side effects...Not worth it.
    • I have a home TENS unit - do you suggest I try that? If so, where should I place the pad(s)?Dr. Blake's comment: You need a PT to help you with application and intensity. 
  • A couple other questions:
    • Based on my most recent MRI, are we sure the doc didn't "wake the sleeping dogs (neuromas)" from the injections? Dr. Blake's comment: For the reader's sake, this patient sent me the MRI and no sign of damage was seen!! But alcohol is a destructive agent, so we are probably dealing with a deep burn, but it should get better, or surgery to explore the area, remove the nerve (permanent anesthesia), and hope for the best. I am not recommending at this time, but it is an option. 
    • Can this resolve itself on its own with time? If so, when should I expect to see progress?
      • It's almost 2 years since the original 5th metatarsal fracture
      • It's been about 10 weeks since my final set of alcohol sclerosing injections Dr. Blake's comment: The reason we need treatment is left on its own it can take months until you start to feel better. I hope November feels overall better than October. You can speed up feeling good, but we need some consistent treatment that helps. Stay with the boot, by alternating, stay with the original meds (until you have others to try). Many times injections into the nerve with just local anesthesia can relax the nerve. You can put it one inch closer to the ankle, not at the same spot. You are in my thoughts and prayers. Rich
Thank you again for your help

Wednesday, September 19, 2018

Peroneal Tendinitis: Email Advice

Hi Dr. Blake,

I developed bilateral peroneal tendinitis from overuse earlier this year (lots of walking). Despite a reduction in sports and addition of light physical therapy, the tendinopathy slowly worsened to the point where I couldn't walk without significant pain. This happened over several months. The pain was mostly behind my lateral ankles, sometimes extending up into my calves.

I finally took off a couple of weeks from work, saw a podiatrist, and was referred to physical therapy for more aggressive treatment, including mobility and functional exercises, stretches, and ASTYM. During this time I was able to start walking every other day with only mild pain on rest days. I'm not sure if the PT was helping, but the rest days definitely were.

On my first day back at work I had soreness in my feet and intense pain behind my left lateral malleolus that night, which had never happened before (typically I had no pain when in bed). The next two days at work were similar, though not quite as bad. I then took off another week and was recovered on my first day off, followed by having no pain at all when I returned to work days later.

However, I relapsed after a few days. I was still performing my physical therapy exercises and increased my previously band-assisted heel raises to bodyweight. This had aggravated my tendons before, and I think this was what precipitated the relapse. By the end of every day, I was incredibly sore in my lower legs and feet and had trouble performing ADLs (activities of daily living) at home. I could barely rest and recover on weekends for each following week.

I continued to work for another month with minimal walking (less than a mile/day total) and standing. During this time I started developing early PTTD (posterior tibial tendon dysfunction) in my right foot, probably from compensating for peroneal pain by overpronating.

Finally, I took a full month off work. Most of the pain subsided within a few days. I gradually started resistance band inversion/eversion exercises every other day with some walking and seated heel raises. I've been off for three weeks now. My lateral ankles have been feeling pretty good, but my right posterior tibialis is now limiting me. It seems to get easily irritated by very short walks or from standing. Custom orthotics are uncomfortable and seem to provide too much support, which stresses my peroneals. I'm also still getting dull aches/soreness in my ankles and lower legs following any physical therapy exercise. I'm not sure if this is from becoming weak from minimal walking, or some kind of sensitization?

I'll be following up with my podiatrist next week and will also see an orthopedic surgeon for a second opinion later in the month. Until then I'm really not sure of the best course of action in terms of rest and strengthening.

Thank you for reading! It's been over 6 months since this all started, and writing this out is somewhat cathartic. It takes a lot to stave off a feeling of complete hopelessness.
Dr. Blake's comment: Please do not lose hope as the universe is not picking on you. This is an all too common scenario of injury, inadequate rehabilitation, progressive weakness with new pains developing, and improper timing of events. First of all, I am going to any pain like the PTTD that is not along the course of the peroneal tendons is just compensation and will get better. What do you do at work? Is there something that forces you to use the outside of your foot a lot (called supination)? Rest for weeks and months does not normally help unless you are using the time off work to get the 5 treatments below accomplished. 
     Any tendinitis has to be treated concurrently with 5 treatments. The mnemonic is BRISS--biomechanics, rest or activity modification, ice or anti-inflammatory, strengthen, and stretch or flexibility work. For the peroneal tendons, the number one biomechanical task is to control supination (movement to the outside), and number two is to overall stabilize the ankle with braces, boots, taping, high top boots. There are a lot of options in getting achieve this stability. From the sound of things, you have to get in an orthotic that is stable and does not supinate you. You can find my video of orthotic modifications for the supinator, although I am not sure you supinate normally or only with high arched orthotics. But, you can not get better if you supinate. 
     Rest is activity modification since rest in general in these cases can really work against us in allowing weakness, nerve sensitivities, and tightness to settle in. You have to keep your body strong if you have to limit walking to elliptical, swimming, cycling, floor programs. This is even if you have to do it with tape, orthotics, braces, or boots. Typically straight rest is a killer if you get my point. We are trying to get the pain down to consistent 0-2 while we slowly increase activities, and gradually get stronger. The sad fact is one day off normal activities, especially physical activities at work, after one month can take 2 days to regain that strength. 
     Ice or anti-inflammatory is to be used after activities if you flare them up, but physical therapists have a lot of tricks to cool tissues down, as do acupuncturists. Oral NSAIDS like Advil are used after workouts not before to allow you to workout. 
     Strengthen is key. You want some activities to mimic work related, most functional, but also isolate the peroneal tendons. My blog has peroneal tendon theraband exercises to isolate the peroneus brevis vs longus, since one may be more involved. 
     Stretch is achilles mainly. The achilles, when tight, is a powerful supinator as you lift your heel. You have to check with the physical therapist or podiatrist to see if you are tight, but I would start doing normal achilles stretches three times a day. 
     I hope this helps. You have your work cut out for you, but you seem to respond to things well and should get over this. Keep strong, but do not push through the pain.

Tuesday, September 18, 2018

Injury to Fibular Sesamoid in Rock Climber: Email Advice

Hi Dr. Blake!
I've been reading your blog and thought I'd try and see if you respond to my questions. I'm desperate for answers and I've seen 2 DPMs and 1 Ortho surgeon with foot/ankle specialization. Each of their prognoses is different and so is their proposed treatment. I'm going to get one more opinion from an ortho too but if you have any insights, I'd love to hear them.  I'm a 34 yo female construction manager, rock climber, dancer (ballet growing up, lots of Latin dancing in heels as an adult). I hate running so I'm not as concerned about losing my ability to compete in triathlons.

Summary of the condition:

  1. initial injury occurred in rock climbing in late March 2018. There was no impact, but I was standing in a precarious position for over 45 mins standing over a chasm and didn't have much room to move. My weight was mostly evenly distributed between my feet but my toes were hyper-extended and all the weight was on the balls of my feet. I was in instant pain in my left foot that felt like a hit a pressure point. My foot became instantly numb and remained that way for the rest of my 6 hours climb and hike down the mountain. the feeling in my foot came back the next day but my toes stayed numb for 6 weeks. I did not go to the doctor because I had no idea I could have broken a bone by just standing on my foot. It's common for climbers to complain about toes going numb so I just rested for a few weeks and didn't think much of it.  (Dr. Blake's comment: The numbness is either from compressing a nerve for too long as you describe or from the intense swelling internally from a fracture or sprain, that pulls pressure on the local nerves. Or, a combination of course). 
  2. Fast forward 3-4 months to July 2018 (I've been continuing to run, lunge, climb, and wear high heels to work all day).  I should also say that I drive a standard transmission vehicle with a stiff clutch and sit in traffic constantly for work. By the end of July, my left MTP joint would be swollen, most of the pain was on the side of my MTP joint, not on the ball of my foot. Eventually, I started having numbness in my toes again and finally went to a podiatrist. (Dr. Blake's comment: I am assuming the numbness went away and these months were not painful, and you did not have to limp.)
  3. Aug 3, 2018, I was diagnosed with a lateral sesamoid fracture. I wore a boot and unna wrap for 4 weeks while my DPM was taking x-rays every 2 weeks telling me it was healing. 
  4. By Aug 28, 2018, my pain was increasing not decreasing and the ball of my right foot is now hurting because of me trying to offload the left foot. The DPM Xrays both feet, says the left fracture is still healing and the right foot shows no signs of fracture. The DPM put me in the iWalk crutch and ordered an MRI of both feet since I was still having pain. 
  5. I've had J pads in the boot on the left foot and orthotics also with a J pad on my right foot because I was starting to have pain in that foot now. (Dr. Blake's comment: I am sure this is Dr. Jill's Gel Dancer's Pads or something similar).
  6. After the MRI I saw an orthopedic surgeon (who recently operated on my mom's foot with success) and a leading podiatrist in the state. Both of these doctors agreed that the Xrays showed NO signs of healing and that the original DPM was wrong. MRI indicates no sign of healing and is inconclusive as to whether or not it's a bipartite sesamoid or a nonunion fracture.  There are signs of AVN and edema. (Dr. Blake's comment: Yuck!!)
  7. Here's where I'm confused:
    1. Ortho surgeon says he doesn't know if it's a fracture or bipartite but it doesn't matter because it's not healing and shows no sign after almost 6 months (the last 1.5 was immobilized). he says surgery is inevitable but he'll wait as long as I want. He gave me a cortisone shot and suggested within a week I transition to regular hiking shoes until I'm ready for surgery. he doesn't want me to stay in a boot that will cause muscle atrophy and all other sorts of problems while I decide on surgery. My question is, is 1.5 months enough time in a boot to be sure it won't heal. and if it's not a fracture, is there another cure than surgery? (Dr. Blake's comment: Sorry this is confusing. These time frames do not apply to sesamoids or a lot of other injuries. The wait with sesamoids can be a one year process, and sometimes more.)
    2. DPM #2 says it's fixable with 6 months in a boot and exogen bone growth stimulator. Do I really wait 6 months in a boot with an expensive contraption waiting for the bone to heal (what if it IS bipartite?). Will the exogen doing anything for bipartite sesamoid? (Dr. Blake's comment: I agree sort with the DPM #2. I will look at the images you sent below to comment on the bipartite aspect).
  8. I have an active lifestyle but more importantly, I have to walk at work a lot. I can't afford to waste 6 months in a boot for a bone to heal that isn't even broken.  I also can't afford to have sesamoiditis in my right foot as a result of offloading for multiple months on the other foot. What do you recommend? (Dr. Blake's comment: Work can force people's hands at having the surgery, since the prolonged rehabilitation may not work for them. That is one of the huge reasons patients will have some foot surgery.)

Additional Questions:

  1. No one has commented on the right foot having a bipartite sesamoid or not. It was not specifically mentioned in the radiologist's interpretation but when I look at the Xray it looks possibly bipartite to me. I've been researching this a lot and I've seen that 90% of bipartite sesamoids are bilateral and occur on both feet. Can you see from my Xrays if both my right and left foot of bipartite lateral sesamoids? 
  2. Should I be considering selling my car? From what I read about surgery, it'll be a long time until I could press the clutch with my left foot again. Maybe I should buy an automatic transmission. (Dr. Blake's comment: Whether you end up in surgery or not, switching from manual to automatic makes sense right now. Can you rent one for a week to convince yourself?)
  3. I'm worried that if I get a sesamoidectomy that my fibular sesamoid will fracture too. Should I worry about that? (Dr. Blake's comment: This is at the root of why we try to avoid the first surgery if possible. It is a rare occurrence because people are so protective of their remaining sesamoid. But, with rock climbing positions, who knows? Make sure your Vit D is at 55 with low normal at 32 or so, halfway on the normal scale. You would not want transient Vit D deficiency to cause a fracture.)
  4.  I don't know who to believe the orthopedic surgeon or the podiatrist? How do you choose? (Dr. Blake's comment: First of all removing the sesamoid is technically simple, but the decision to do the surgery is not at all. Also, who is going to provide you will the best post-op course, orthotics, taping, etc? )
  5. How long is too long to wear this boot? (Dr. Blake's comment: My golden rule of thumb is 3 months with the bone stimulator for 9 months total. The transition from boot to shoe can be tricky with the need for orthotics, perhaps rocker shoes like Hoka One One, taping, padding, bike shoes with stiff soles, etc.)

I've attached my L and R foot Xray from 8/28/18 and summary of the MRI interpretations, in case you have time to look at these. (Dr. Blake's comment: Please send me a disc of the MRIs to Dr. Rich Blake, 900 Hyde Street, San Francisco, Cal, 94109. Please email me at when you think I got it. I want to see how inflamed the sesamoids are). 

Thank  you in advance for your time!

This does look like a lateral or fibular sesamoid stress fracture with irregularities where the junction between pieces area. Bipartite usually look more symmetrical and rounded borders. To me, it is the incredibly long first toe and metatarsal that makes this prone to injury. Yes, removal of the one sesamoid could set up problems for the other.
Here the lateral sesamoid looks more like it is bipartite, which shows you have the bone overlap from the first x-ray distorted things. If it is bipartite and began to hurt with prolonged hyperextension, I wonder if you have a turf toe situation. Has anyone mentioned that?

I read this as mild injury to a bipartite sesamoid junction leading to a mild reaction of the tissues. Maybe once I see the views the mild level will look more like moderate. The biomechanics of Turf Toe, where you hold the toe on the ground, and you stress various things, like the bipartite junction to cause injury or one of the muscles or ligaments (not noted) makes sense here. If you switch to turf toe protocols, it may make more sense then sesamoid fracture protocol. The treatment can be some the same and some different. Create that 0-2 pain level consistently.

More obvious bipartite. A CT scan should be ordered for your left. Again, the long first metatarsal and toe (called Egyptian Foot in ballet)  which takes more stress than normal. 

 Again more bipartite looking with the two parts of the sesamoid with smooth borders and unequal in dimensions

Sesamoids look different on MRIs. They are wrapped up in ligaments and tendons, and unless they are abnormal (as in your left side) they look normal. Your workups have been good. Until I see your films, 3 months in the boot, with an EvenUp on the other shoe to keep the weight normal. If it is Turf Toe, spica taping is key, and probably advancing gradually to bike shoes with embedded cleats. 

  1. Should I cut back on my glass of wine or a beer most evenings? No, unless it causes you to stumble.LOL