Total Pageviews

Followers

Search This Blog

Paypal Button for Donations

Sunday, August 18, 2019

5th Metatarsal Pain: Email Advice

Dear Dr. Blake,

I have been following your blog with great interest for a while as I've been dealing with a complicated injury to my plantar plate over my 5th metatarsal for more than 2 years. I was pleased to see that you are now accepting questions again, so I'm contacting you with the hope that you might give your perspective on my situation. Here are some facts about my injury: 
  • I'm a 33 y/o man, 160lbs. I began running in my early 20s and ran moderately (usually ~20 miles/week), though I've run more at times training for specific races (1 marathon, 4 half-marathons). 
  • I stopped running when I was 31 in May 2017 with a feeling of pain/fullness in my 5th metatarsal on my right foot with no memorable trauma. I was about running 15 miles a week and going to boot-camp-style exercise classes, getting back into it after a busy schedule and time off because of IT band issues in both legs. I immediately stopped running/jumping on the recommendation of my GP.
  • In September 2017, an MRI showed that I had a partial tear in my plantar plate. On the recommendation of my podiatrist, I began taping the toe down and continued to not run. 
  • In about February 2018, a second MRI confirmed the previous diagnosis. An orthotic insert was made by my podiatrist and I mostly refrained from running. I discontinued taping.
  • In May 2018, a sports medicine doctor discovered via x-ray that I in fact had rare sesamoid bones in my 5th metatarsal and that one of them was fractured (there was a development in the fracture between the X-rays taken in 2017 and 2018). This along with the partial tear was later confirmed by ultrasound imaging. 
  • Since this diagnosis I have added a Hapad to my orthotic insert to reduce pressure on my 5th metatarsal head. Other treatments I've tried have included wearing a surgical shoe (2 weeks) and full-ankle boot (about 20 days). 
  • Today, the pain is persistent, though more annoying than debilitating. I can often ignore it and I've even begun running in the last year some. I can usually run pain-free, but after building up for 3 to 4 weeks I often run into some type of setback. In general, my right ankle, arch, and achilles feel tight and often sore, and more recently in the last two weeks I started developing pain in my left metatarsal similar to the right one (I added a Hapad to my left insert and it's mostly taken care of it, though I still sometimes have fullness/aching or sharp pain). 
  • In the last year, I've seen two two surgeons (one orthopedic and another podiatric) and both were hesitant about performing surgery because of the location on the 5th metatarsal, though they both said they were willing to do it. My treatment plan at the moment is basically to wear orthotic inserts all the time and hope it goes away. Around the house I wear Hoka One One recovery sandals.
I apologize for the volume of information here--part of the desperation I feel from this injury is that I don't know where to start in thinking about what caused it or how to address it. A few specific questions might be helpful in addressing your feedback:
  1. My podiatrist and one of the surgeons both told me that they thought physical therapy wouldn't do much. However, I can't help but think something about my walking/running form and/or mobility is causing this. I've always been pigeon-toed--maybe after 10 years of moderate running (I'm 33) my ligaments just couldn't take it anymore? Do you think PT could help me now? 
  2. Related, I'm starting to question whether wearing the orthotic inserts with arch support at all times is really the right move here, especially given how weak and achy my right foot and ankle feel. Do you agree? 
  3. Anything you can do to make sense of these new symptoms I have in my left foot in the same area? Should I be treating this aggressively as a new injury? Or should I just keep doing what I'm doing with my right foot? 
Thank you for your time and please do let me know what information I could provide to give you a clearer picture of this situation. 

Best regards,

Dr. Blake's comment: Thank you so very much for emailing. The pigeon toe gait is supinatory, with excessive weight on the outside of your foot. The orthotics that you should be wearing are for off weighting the painful area and getting your weight centered on your foot (typically with more support on the lateral arch then the medial arch). The orthotic can be full length of soft materials with a float for the sore area (like a big cutout) or it can be typically plastic but with protective padding as much as allowed by shoe room and comfort. I always find that these tendencies to supinate or pronate happen on both feet, with one foot coming on first and being the worst side. Running shoes like Brooks Dyad or Glycerin or Saucony Triumph, or New Balance 1540 are typically good for supinators. If you can take a photo of the inserts from an old running shoe before orthotics that would help. Find a good PT or Running coach that watches gait and can help you decrease the stresses through the 5th metatarsal via gait changes. Downhills of course are the worse at picking on the 5th metatarsal. Even being conscious of running habits, like running with traffic is worse on the right 5th metatarsal than running against traffic due to the cant in the road. There are important muscle groups to strengthen if you are trying to supinate less-peroneals and medial hamstrings in particular and stretching iliotibial band and lateral hamstrings. Talk to the podiatrist about anti-supination (anti-5th metatarsal) prescription changes to your present prescription. Some circumferential KT or Rocktape over the metatarsals may help on both sides for a while, but pull the tape to lift up on the 5th metatarsal or counter clockwise on the right side as you look at it. You can experiment with using Dr. Jill's gel dancer's pads for the 5th metatarsal alone at times to get away from the orthotics to see how you feel. Here is a little horseshoe hole on the pad normally for the sesamoid but you are going to reverse the idea for the 5th metatarsal. I sure hope this helps somewhat. Rich

WeTransfer steps in sending MRI or CT images easily for me

This is from a patient who was able to send my her images off an MRI where I could just scroll through. Very hard if I only get individual thumbnail images. 


 For the WeTransfer I basically had to save each MRI image one by one from the files made available by the radiologist. Then, once I had them saved locally on a folder in my computer, I just went on the WeTransfer homepage, and filled out the form on the left side with your email, my email, and uploaded my images to the form clicking "add your files." Once the attachments were uploaded into the form, I just had to press transfer and it was done. I did not have to make an account with them to use it.  

Blogger Contact Question #3: Rehabilitation from Metatarsal Stress Fracture


Dear Dr. Blake, 
 
     July 2, 2019 put in walking boot for pinpoint pain/circle of swelling over  

4th metatarsal shaft. Crutches, non weight bearing with boot.

    July 12, 2019  MRI
    July 16, 2019. MRI showed increased T2 and subtle diminished T1 marrow  
signal mid 4th metatarsal. Discrete fracture line not identifiable.

    Was put non-weight bearing for 5 weeks with boot; begin adding weight on  
week 6, 25% and then one crutch for 50% week 7 to start 8/16/2019. 

    Began using Exogen 4000 Ultrasound machine; 2X daily Aug 14, 2019.  Have some  
swelling in ball of foot, goes down over night.  Is this normal to add  
weight progressively?
Dr. Blake's comment: Typically with 4th metatarsal stress fractures you do not need non weight bearing, but I will assume your doctor wanted to protect you very cautiously for some reason. The boot, if you are to bear weight must have some accommodation to protect the metatarsals with either metatarsal padding for off weighting and straight off weight padding to place weight on the 1st through 3rd metatarsals and 5th metatarsal. This takes a lot of work and time, so many facilities just off weight the patients. Yes, you want to go from non weight bearing to full weight bearing in the boot gradually, using the 0-2 pain level as a guide. You can not have more pain as you increase weight bearing. Consider doing contrast bathing each evening for a deep flush for the swelling. 

When might I possible be able to walk for recreation/health?
Dr. Blake's comment: Based on your progress, when you are 2 weeks full weight bearing in the boot, you begin a 2 week gradual weaning out of the boot. When you are 2 weeks out of the boot, and having no setbacks, you start 30 minute walks every other day, then add 10% per week. This way you gradually add more stress to the tissue and see how it responds. 
During non-weight bearing swam (no pain), rode stationary bike 30-30 minutes  
(no pain) and weightlifting on gym machines to maintain some fitness/core.
Dr. Blake's comment: Great, as much pain free cross training you can do for cardio and leg strength is wonderful. As you get out of the boot, begin metatarsal doming and some single leg stance strengthening work. A PT can advise. The bone stimulator in this case is a 3 month commitment. Good luck my friend. Rich
  Thanks!

Regards,

Saturday, August 17, 2019

Sesamoid Injury with Plantar Plate? Email Advice

Dear Dr. Blake,
First, thank you SO MUCH for all of the resources you have made available on your website. After I broke my sesamoid bone I struggled so much with conflicting medical advice (or a huge lack of familiarity with this issue) and was wobbling around for two months on a broken swollen foot until I found your site. I followed the suggestions on your site and within 3 weeks the swelling and the pain were totally gone! It was a miracle and I was in tears of gratitude for what you’re doing and how you’re helping people like me. After 2 months in a boot, I weaned onto a pain-free environment on a thick sneaker with a sesamoid cutout, but 3 months after the break, X-rays still showed a fracture line. Six months later, my MRIs seem to indicate there is no longer a fracture - however I am still unable to walk without the sesamoid cutout in my shoe without pain and swelling, while my big toe is still frozen and relatively immobile so many months later. 

Your opinion at this point would be heaven sent as my doc was very vague in explaining my MRI and just told me to come back in a few months. He said keep the foot in the cutout at all time to maintain healing, but then the physical therapist he referred said this was wrong and I need to get moving barefoot. Could I pay you for a little email consultation to interpret my MRIs and guide me on what is safe to do next? I’m confused RE if it safe for me to push myself in bearing weight on the sesamoid or pushing the extension of my toe (the MRI report also said something about a full tear of a plate on the first MTP joint?..I don’t even know what this is but apparently that is not healed) 


Thank you so much,

Dr. Blake's Response: It is not possible to record how strong the healing is going via xrays, so I typically go with every 6 month MRI if they are needed at all. I watch the patients monthly and gradually increase activity, and toe bend, while they work on strength and keep the area protected and keep the inflammation under control. Barefoot pressure on an injured sesamoid is sore for several years, even when the patient is back to marathon running so it is not a sign of poor healing. The initial treatment is to freeze up the joint unfortunately, and now you have to unfreeze it with painfree stretching, walking, PT if you can get it. Please no barefoot for several years as a rule, but you may be ahead of the curve. I just read the part about the tear. That adds some more complexity. Spica taping is great for now. How did the tear and sesamoid fracture happen? I am doing a project in September and will not be blogging, so please rush the CD of the MRI to Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. All payment is voluntary and through blog donations and is never required. Rich

Dear Dr. Blake,

Thank you for your response. I'm enclosing all the MRI report and images in this email as I only have them on my computer. There are a ton and I'm sending them all in a compressed folder since I'm not sure which ones show what we are interested in. Another option would be to send them in a separate email so you can see all the images as smaller thumbnails and just open the ones that look interesting (please let me know if this would work better). I'm also enclosing the initial x-ray from March 2019 for reference (their finding was "a longitudinally oriented fracture through the lateral sesamoid bone underlying the first metatarsal head). 
Dr. Blake's comment: I have trouble always opening up files zip compressed. It may be the firewall at Dignity Health. Please send CD or you can try WeTransfer that has worked for some patients. Also reading an MRI with 144 thumbnail images is hours of work which I do not have. Rich

The initial fracture occurred (get ready for this one) after kicking myself repeatedly in my sleep during a nightmare, I kicked myself until I bled, must have hurt the sesamoid or joint somehow but never imagined anything serious, then proceeded to walk on it in heels for 2 weeks until one day I woke up and could not even stand on it. That is when I went in for x-rays. The first doctor had me walking on a flat surgical boot and soft cast for a few weeks with worsening pain and swelling day by day, until I found your blog and put myself in a cam boot with sesamoid cutout and went minimal weight-bearing on crutches, doing contrast baths daily and soft massaging the area with arnica cream. It was after those 3 weeks that the swelling went away completely and I was totally pain-free, enough to begin to wean onto the sneaker with the cutout, which I've been on for months ever since. Even for the shower, I wear a water shoe with a sesamoid cut-out. Recently, the two times I've tried taking slow steps barefoot since (1 month ago for progress check and a few days ago after my first PT consultation) I don't really feel pain while I'm doing it, but the pain and swelling comes the next day with a vengeance. 

My first question is, if you suggest no barefoot as rule for several years unless I'm ahead of the curve, how do you normally determine when it's safe for the patient to start barefoot?
Dr. Blake's comment: You can begin to try to walk flatfooted barefoot after 3 months out of the boot, daily painfree massage to desensitize and daily icing and contrasts to keep the inflammation under control. 

 How would I determine this on my own if the associated pain and swelling comes after and not during? 
Dr. Blake's comment: See above

This PT is really pushing me towards that (and dismissing my doc's more conservative recommendations i.e the cutout) saying I can't be afraid and breaking down of scar tissue will always involve pain, but after so many months of dealing with this, of course I'm afraid to undo any progress - especially after finding out about the plantar plate issue of the MTP joint. The PT has been pulling and stretching the toe joint as much as he can and now I'm a little paranoid if I should be moving it at all!
Dr. Blake's comment: I agree with you and you have to be cautious. I have never found that approach to be helpful when you are still with only partial diagnosis on the plantar plate. Is it grade 1,2 or 3, and is the plantar plate injury 50% healed, 90% healed, or 10% healed? Is there any chance you will need surgery for the plantar plate tear? I could not answer these questions. If the PT can with certainty, and you have total trust in him/her, they should be allowed to go for it. But, if there are unanswered questions, a bit of caution is advised. Nothing should hurt either while doing or after for more than an hour that ice does not help. Sorry. 

As far as the plantar plate tear, do you see it? I don't even know what a plantar plate does. How can/does this fully heal and is it normal to still have this 6 months post-initial injury? Does this complicate the sesamoid healing and/or impose any limitations in PT, like toe extension?
Dr. Blake's comment: Sorry about not seeing the images. Even with the nightmare, and it must have been a bad one, it is hard to image a plantar plate tear or a sesamoid fracture (bruising or sesamoiditis yes!) The plantar plate is the ligaments under the ball of your foot that keeps the joint together and the joint fluid contained. Tears in the plantar plate will cause the joint fluid to leak out of the joint, and can lead to chronic symptoms, and many times need to be repaired. 

Finally, what do you think of the sesamoids in the MRIs? Dr. Blake: sorry.

I am looking up spica taping on your channel and am definitely going make the donation to the blog. It has been such a TREMENDOUS help, thank you so much for lending us your expertise.
Dr. Blake's comment: Thank you. 


EXAM:  MRI RIGHT FOREFOOT WITHOUT CONTRAST
HISTORY:  Pain. Evaluate for sesamoiditis versus fracture of the first MTP joint.
TECHNIQUE: Multiplanar, multi-sequence noncontrast MRI of the forefoot was obtained on a 1.5T scanner according to standard protocol.
COMPARISON:  None.
FINDINGS:

Bone marrow edema signal within the tibial and fibular hallux sesamoid without disruption of the cortex or discrete fracture line compatible with sesamoiditis. The sesamoidal ligamentous complex is intact. Discontinuity of the plantar plate of the first MTP joint. Mild osteoarthritis of the first MTP joint and mild hallux valgus deformity.

The rest of the visualized MTP joints are intact without evidence of arthrosis or Freiberg's infraction. The medial and lateral collateral ligaments of the visualized lesser MTP joints are intact.

Small nodular isointense signal lesion in the plantar aspect of the second intermetatarsal web space, measures approximately 3 x 2 x 3 mm compatible with an intermetatarsal (Morton's) neuroma. Trace, physiologic intermetatarsal bursal fluid within the first, second and third web spaces.

The visualized extensor and flexor tendons are intact.

Intact intrinsic muscles of the forefoot. No selective muscle edema or atrophy.

The visualized plantar aponeurosis is unremarkable.
IMPRESSION:  MRI of the right forefoot demonstrates:

1.  Bone marrow edema throughout the tibial and fibular hallux sesamoids without fracture line or cortical disruption in keeping with sesamoiditis.
2.  Full-thickness tear of the catheter plate of the first MTP joint.
3.  Mild hallux valgus deformity and mild osteoarthritis of the first MTP joint.
4.  Small neuroma of the second web space measures 3 x 2 x 3 mm.

Dr. Blake's comment: So now reading this, and listening to your story of how it happened, I think the injury was probably a plantar plate tear with bruising of the sesamoids. The physician may consider fluroscopic evaluation with dye injection into the joint to see if it leaks out meaning the tear is still present. Carbon graphite plates for "Turf Toe" should be given as you progress to normal shoes. Surgical repair of the tear may very well be needed, another reason not to have the PT keep stretching things too far. Careful measurement of the big toe joint range of motion up and down today versus 3 months from now is important. Strengthening of the long and short flexors and extensors to his joint is important and a 6 month task. Please show this post to the PT and have them record the measurements, start the strengthening, and make comments. I am sorry I will be gone 8/30 to 10/15 to help. Rich
PS. I still need to see the images, as this may be totally incorrect, since plantar plate tears leak, that is what they do, and this report makes no mention of fluid collecting under the big toe joint. Perhaps, it is because the tear has healed. Here's to hope.
     

Tuesday, August 13, 2019

Blogger Contact Question #2: Sesamoid Pain




Blogger Contact Question #2
I have been diagnosed with sesamoiditis (pending the outcome of a MRI taken
yesterday).  I am not in a boot but I have stopped running (the likely
cause of the injury--overuse and improper footwear).  It has been a week
since I stopped running and my big toe and sole of foot are still
swollen/tender and that concerns me, esp the swelling.  Is that "normal"
and is there anything I can do to expedite the reduction of
inflammation/hasten the healing process other than icing/spica
taping/dancer's pads? Thank you for your time.

Dr. Blake's response:
     The MRI will give us more details to help. The swelling is at this point should be helped with contast bathing 1 minute hot water (100 F) and 1 minute cold water (with a tray of ice cubes) for 20 minutes total. This gets a great pumping action going. Elevation at all times you can think of it. Even having your toes in the air with your heel on the ground causes the swelling to drain from the toe. I like a 30 minute super elevation each day where you put your feet on the couch as you lay on the ground. The swelling is normal, typically for sesamoid fractures then sesamoiditis. It is part of the healing response of your body, but it can be very excessive. Pain free massage with the palms of your hands for 2-3 minutes 3-4 times a day can desensitize the tissue. When you review the MRI, have the doctor show you 2-3 images that are the best that you can take a photo of and send my way. Hope this helps. Rich

Monday, August 12, 2019

Blogger Contact Question #1: Hiking Shoes for Sesamoids


Blogger Contact Form Question: 
Hello,
I have been dealing with a healing R sesamoid fracture for almost a year
now. I have graduated to a custom made orthotic with a cut out about 4
months ago and now am interested in trying to attempt light hikes.

Do you have any specific hiking shoes you'd recommend for those with
sesamoid injuries?

Thank you!

Dr. Blake's Response:  It sounds like you are pass the stage where you need a stiff restrictive shoe. Here is the list we give out to our patients to try:

  • Keen Targhee
  • La Sportiva Nucleo
  • Merrell Moab
  • Salomon X Ultra
  • Vasquez Breeze
Of course, the fit is all different for each foot but one of these should help. Bring your orthotics and dancer's padding if separate (Like Dr. Jill's Gel Pads) when you are trying them on.  I hope this helps. Rich

     

Sesamoid AVN: Email Advice


Thank you for the email and song! And thank you for the blog. I know you aren't really accepting new messages currently but I'm emailing you my issue more for myself to track my thinking than in expectation of feedback. I didn't have a clue what a sesamoid was until a month ago and now I've read every scrap of info on your blog page on it! Mostly I'm just terrified of not being able to be the active person that is my whole life.

History:
Background: 37 y/o male - 5'11, 190lbs, extremely active athlete - activities include swimming, biking, running, soccer, surfing, snowboarding, hiking, backpacking. 2 small kids at home that I'm very active with.

** February 2019 felt mild pain and stiffening of the big toe in left foot for a few days - thought it might be related to gout due to previously being diagnosed with hyperuricemia and having family history. Tried tart cherry extract and turmeric supplement - gave bad stomach issues so stopped.

**Feb 21st - contact GP as pain has increased. Started on 100mg Allopurinol and 3 x 800mg ibuprofen daily. Acute pain subsided by early March and was able to resume normal activities, stiffness in toe remained.

**Mid March injured plantar fascia acutely playing soccer - worried about chronic plantar fascitis as pain did not subside for over a month - pain in heel continued through early May and dominated foot concerns.

**Early May - saw sports med doc for the heel and mentioned toe pain. Doc thought toe was arthritis based rather than gout due to minor joint narrowing on X-ray. Heel pain cleared up for the most part within a month with self-care and basic PT exercises.

**Early June - pain in toe worsens again (bad flare?) got referral to podiatrist. 

**Mid June - podiatrist diagnoses early osteoarthritis in 1st MTP toe joint from x-ray of left foot and sesamoiditis causing pain in ball of foot from pressing into sesamoid bones with his thumb. Notes bipartite tibial sesamoid from x-ray images. 
3 weeks of one a day Meloxicam (NSAID) and dancers pads to be worn in shoes. While on Meloxicam the pain is greatly diminished and am able to complete normal activities. Still feel the dull pain/stiffness in ball of foot though. During the time I was on Meloxicam I was able to play soccer with relatively little discomfort and went on a short backpacking trip with some minor discomfort in the sesamoid area. Biking and walking with the dancers pads (Dr Jills) was fine with minor stiffness feeling in sesamoid area. Discomfort never completely went away.

**Mid July - After a week of being off NSAIDs the sesamoid area flared up badly again. Tender to touch, difficult to walk on without pain. Favoring outside of foot and hobbling. Right big toe area has some minor stiffness also. I can't figure out if I'm freaking out unnecessarily. I haven't played soccer or done anything seriously aggressive on the foot and have continued to wear the dancers pads - I have however been barefoot a lot.

Current treatment plan:
Ice 3 x a day
Figuring out dancer pad/ inserts and shoes to ease pain while walking
Contrast baths every other day
Try to keep off toe and avoid pain (keep 0-2)
Follow up podiatrist appt July 29 - request MRI to rule out fracture vs bipartite and visualize inflammation; discuss steroid shot options (next step according to DPM).

Other things in my head:
What's the situation with surgery? When would that be considered? Who would do this?

NSAIDs seem to help - does this indicate an underlying inflammation issue - any other way to get that under control? Long term use of NSAIDs problematic?

Concern about injection? What kind of injection? How long to stay inactive? Need a plan for returning to exercise.. PT person to work with? Need to be able to do vigorous exercise - surfing in bare feet, skiing, snowboarding etc. Can give up soccer and running in favor of biking and swimming as a compromise but REALLY DON"T WANT TO GIVE UP BOARD SPORTS

Custom orthotics? Worth doing that versus trying to figure out what's needed on my own with customizing dancer pads and superfeet supports etc?

Spica taping? Helpful?

Toe spacers? Wider shoes?

Sesamoids out of alignment? Rolfing? Re-aligning sesamoid bones?

If you made it through the whole email then thank you!!! Even if you don't have time to reply. As I work through this issue I'll leave a comment on one of your blogs to let people know what helped and how I got through this.

Thanks again,

MY Response: Thanks for the email. Yes, life is too hectic for me until December, so I am giving the blog a rest. I did read the history. You need to get an MRI, and I would be happy to look at when you do. If your insurance will not get, they are typically $600 in the Bay Area. You want the MRI magnet around 2.0 Tesla or higher. Stay non impact for the next 6 months, or at least until the snow starts falling. Swimming, biking, elliptical if you have the padding in your shoes okay to off weight the sesamoids. You can just treat this as a fracture with 3 months in a removable boot with dancer's pads. The boot needs to drive the pain consistently to 0-2 for 3 months, and then it is 2-3 months to wean back into normal shoes. Bike shoes with embedded cleats or Hoka One One shoes can help the gradual transition. Masking pain with NSAIDs or cortisone is not smart. You have to feel the pain. No shots please. See if you can get an Exogen 4000 unit on ebay relatively cheap. 2 times daily with the bone stim for 20 minutes. Hope this helps some. Rich

The Patient's Response:

Thank you Dr. Blake - I've just re-read all of the blogs on your site pertaining to sesamoid AVN. I've requested copies of my MRI and X-rays which I'll mail to you this week at the following address. Is this correct?
Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 

I've convinced my Podiatrist that we should do bone stimulation so he is ordering the equipment for me. I'm not sure what his exact plan is but he is talking about a period of non-weight bearing and immobilization of the foot. Just wanted to check in with you regarding that as I've read in some of your posts the importance of continuing to exercise and be weight bearing with no pain (0-2). 
1. Is a cast or boot for a period of time a good idea for this treatment?
2. I have already established low/no-pain environment over the last few weeks with modified activities and have continued to exercise with dancers pads/arch supports/ spica taping etc. to ensure pain level (0-2). Is this enough?
3. I continue to walk barefoot in my house carefully and this has not caused me any pain - is this ok?
4. Other things I should be thinking about - calcium and vit D supplements? Dry needling? Contrast baths?

Thank you again for your time. I'll absolutely make the $50 donation to your blog as I've found the information there and your email advice invaluable during this time.

Regards,

MY 2ND RESPONSE:
Thanks again for the donation. It means alot, and means I can do this type of service more. I have a big project to complete by December 1st so I want to make sure everything is answered for you. The address above is correct. I love the boot and you can float the sesamoid way off the ground for no weight bearing with dancer's padding and metatarsal bars (all podiatrists to my knowledge understand this stuff). Way off the ground for non weight bearing is only 1-2 mm with the weight on the metatarsal and big toe. I prefer some protected weight bearing as long as the patient swears the pain is 0-2 since I think it helps strengthen the bone. Since you are at 0-2, stay there for the next 2 months with little change other than slowly increasing distances. Adding stationary bike is great for cardio. Barefoot is fine with no pain, but that goes bother every health care provider. See how you feel in some Oofos sandals with Dr. Jill's Gel Dancer's pads. AVN is treated with bone stimulation, contrast bathing, making sure bone health is great, and protected 0-2 weight bearing. The Big 4. Good luck my friend. Rich

Thursday, June 6, 2019

Medicare and Podiatry

Medicare and Podiatry how are you covered?
drblakeshealingsole.com
Podiatrists are doctors who specialize in conditions pertaining to feet and ankles. They can treat anything as simple as an ingrown toenail to plantar fasciitis. Aging adults are prone to chronic foot problems, especially if they have an underlying disease such as diabetes.
However, Medicare doesn’t cover all podiatry services. In fact, Medicare doesn’t cover routine foot care at all. For other podiatry services such as treating specific conditions and surgeries, Medicare has specific rules for coverage. First, let’s discuss what isn’t covered by Medicare.

Podiatry Services Not Covered by Medicare

Medicare doesn’t cover routine foot care except in situations where another health condition requires it, such as diabetic neuropathy. Routine foot card includes, but is not limited to, corn removals, debriding toenails, and maintenance care. Another condition that Medicare doesn’t cover any podiatry services for is flat foot.
Medicare also doesn’t cover supportive devices such as orthopedic shoes unless they are included in the price of a leg brace or the patient has diabetes. Medicare doesn’t cover these services because they are not considered medically necessary.

Podiatry Services That May be Covered by Medicare

Medicare will cover podiatry services that are considered needed to diagnose or treat a medical condition. Conditions such as hammer toes, heel spurs, and bunion deformities yield Medicare coverage for treatment.
Diabetes patients get a little more leeway when it comes to foot care because they have a greater risk of developing foot conditions. Therefore, if you have diabetes, you can receive a foot exam once every six months as long as you have been to a podiatrist for any other reason within those six months.
As we briefly mentioned above, Medicare will also cover services that are otherwise considered routine if you have an underlying disease. For instance, if you have peripheral vascular disease, a disease that reduces blood flow to your feet and other limbs, routine podiatry services may be covered. Other diseases and conditions that may validate routine foot care coverage are Buerger’s disease, peripheral neuropathies, and Arteriosclerosis obliterans.
Mycotic nails can be common in the aging community. Mycotic nails are nails that are yellow-brown in color, with a thick and brittle texture, and are usually infected with fungus. Medicare may cover treatment for mycotic nails if your doctor documents clinical evidence of infection, and you are showing symptoms such as pain or secondary infection.

How You’ll Pay for Your Podiatry Services Through Medicare

Podiatry services are usually performed in a doctor’s office in an outpatient setting. Medicare Part B covers medically necessary outpatient doctor services and therefore, will be in charge of your podiatry services.
Part B will pay 80 percent of your medical costs. You will be responsible for both an annual deductible of $185 and 20 percent of the bill. If you receive any treatments in a hospital as an outpatient, you will likely experience a copay as well.
If you ever require surgery to treat a foot condition and you are admitted in the hospital on an in-patient status, Part A will come in effect as well. You will have a $1,364 deductible for your hospital stay that will pay for your hospital services such as your room and meals.
This deductible will also cover your first 20 days in a skilled nursing facility (SNF) if your doctor recommends you finish your recovery there. Medicare will only cover your SNF stay if you were admitted to the hospital for at least 3 days.
When you apply for Medicare, you may want to consider supplemental coverage to help pay for things like this. Medicare plans such as Medigap and Medicare Advantage can help lower some of these costs. Medigap plans can help cover your Part A deductible and Part B deductible, copays, and coinsurance.
Medicare Advantage plans can help lower your out-of-pocket costs by setting a copayment amount that may be lower than your normal Part B coinsurance. Medicare Advantage plans also often offer extra podiatry services, such as routine foot care exams.
In summary, Medicare will cover podiatry services as long as they can be deemed medically necessary. If you’re unsure about whether your specific service will be covered, ask your podiatrist.




Monday, June 3, 2019

Big Toe Joint Pain: Diagnostic and Treatment Dilemma

Hi, Dr. Blake, 

I came across your blog and immediately felt the urge to ask you for your opinion on my foot condition. 

I am 38 years old woman and have been dealing with pain under the ball of the foot for a year. At first it was on the side of the ball which lead the orthopedist to think it was due to hallux valgus. 
But the joint was also swollen, so I did an MRI which showed a suspected "fracture" on the medial sesamoid bone, which could be a state after trauma.
Dr. Blake's comment: The one MRI view you sent me looked normal. What was the report? 
I got custom made orthotics (5 variations) and ate a box of Arcoxia, but after several weeks the pain was only worse. I do not have pain if I touch or press on the ball, but when I walk, the whole area is kind of sore. I walk on the outside of the foot, which I think makes it even worse - also the soft tissues around the ball are kind of stiff, I have to massage them. Some days it better, some its worse. 
Dr. Blake's comment: Start doing ice pack 10-15 minutes twice daily, and contrast bathing starting at one minute heat one minute ice for 20 minutes each evening. Non painful massage is wonderful 2-3 minutes and 2-3 times a day. Are the orthotics off weighting the area of the ball of the foot enough? 

I try not to walk a lot, since the condition gets worse after several minutes of walking. I can't do hiking or running anymore. I ride a bike, do Pilates (but no planks!), I also go swimming, but there is also pressure on the foot when swimming, so its not perfect. 
Dr. Blake's comment: this is great while you wait for healing to cross train. 

I made another MRI in January 2019: 
"In the distal part of the medial sesamoid bone transverse is a moderate hyperintense line. The bone structure of the distal pole of the sublingual bone is somewhat non-homogeneous, somewhere hyperintensive ________ (there is a word missing in a report). The proximal part of the sesamoid bone has normal signals also on the contact surface. It could be a bipartite sesamoide bone with degenerative 
changes in the distal core, less likely for a condition after an old injury."

Dr. Blake's comment: Try to send more images. You can send 8-9 that shows sesamoid bones for the 3 MRI directions.

The doctor said that MRI is not very clear, and it clinically looks like sesamoiditis, but that it's strange that it doesn't hurt when he presses on the area. He suggested PRP (platelet rich plasma).  Do you have any experience with it curing sesamoiditis?
Dr. Blake's comment: No, has promise for tendons and fascia. You do not know what is wrong yet. It would be very experimental and guess work at this point. 

I also tried taping the foot which helps a bit, physiotherapist did a laser, which kind of helped, but he said it's no use coming back, since it will be always be worse when I walk again. He suggested MBT shoes. 
Dr. Blake's comment: Start doing the normal stuff for sesamoids right now: Hoka Shoes with the rocker, cluffy wedges, dancer's padding, some arch support, spica taping. Do them all and limit walking this month June to day to day what you have to so. Work on the inflammation with ice, contrasts, arnica lotion. See if you can not turn this around. 

I visited 3 doctors and one of them said there's nothing you can do besides custom orthotics and 2 of them (which were private) said, they would try with PRP. A trauma doctor gave me a cortisone injection which didn't help at all. 
Dr. Blake's comment: stay away from cortisone if we do not know what is wrong yet. What lead up to this pain developing? Were you walking too much? Did you bang it? Are you a terrible pronator? 

I am very confused since I don't even know what is wrong and I am reading all about the different diagnosis over the web and different treatments, but my doctors don't seem to know anything about this possibilities. I was never offered a walking boot or suggested a period of immobilization. I asked about the option of doing some additional research, but he said he could do a scintiography, but it would only show if there is any inflammation, but would not show the cause. 
Dr. Blake's comment: I actually think the scinitiography would be great to see if the bone lights up. Definitely, walking in a removable boot (you can purchase the Anklizer type) at least to help you do more walking every day would be great. You have to place dancer's pads some times. Even if you wore only for the 4 hours per day that you are on your feet that would be helpful. If you feel off balance, get an Even Up for the other shoe. 

I'm also reading about contrast baths, HBO program, shock treatment therapy, Exogen bone stimulator (which I mentioned to my orthopedist, but he said, "you can't stimulate if there is nothing broken ...")
 ... but I am no doctor and I really don't know if any of these treatments would be good for me.  Non of the doctors I have visited haven't advised me anything of it. Custom orthotics, PRP and finally operation if all fails, that is all.
Dr. Blake's comment: Contrast bathes, usually one minute hot and one minute cold for 20 minutes in the evening is good to reduce swelling, while ice just controls it. 

Can you give me some advise? What is my problem, fracture, degeneration ...fragmentation ...?
Could I have AVN?
Dr. Blake's comment: need more images for sure. In general, when the sesamoid is injured, it is really sore on light palpation, so we have to make sure you even have a sesamoid injury in the first place. 

A big thank you in advance, I can't wait to read your opinion.
Regards, 

And when I did not answer (as I am taking a lot of vacations this year):



Hi, dr. Blake, 

I was just wondering if you got my email? I really could use an advice from someone experienced as you in this area. 
Since the condition hasn't got any better, I received a PRP injection last week. I asked the doctor about non-weight bearing and if I should use a walking boot and he said there is no need to. I am so confused, because I read on your blog that all other patient are supposed to not bare weight during a period of time. 
Dr. Blake's comment: The goal is to do what you can to control the pain to 0-2 levels. Typically, only really acute injuries need non weight bearing. Normally, I love the removable boots, anti-inflammatory measures, and activity modification to protect the area while the diagnosis is being made. 

After 6 days the area is swollen and sore, yesterday I even stepped a bit too hard on that area and experienced sharp pain (I am trying to not step on it at all, having custom made orthotics and dancers pads  and walking on the outside of the foot) and now it even more sore. 
Dr. Blake's comment: Non weight bearing typically makes the swelling worse, so protected weight bearing is better with the boot. Any step you take pushes fluid out of the foot. Occasional sharp pains are okay, as long as they only hurt temporarily. 
Do I ice it or do contrast baths or not? I am supposed to have another shot in a week, but I am not really sure if I should do it, since there is no improvement yet. 
Dr. Blake's comment: See above comments on ice and contrasts, get the boot ($60 on amazon), get the scintiography if you can, send me more images. Do non painful massage several times a day. Send me a photo of the top and bottom of both feet now. 

I would be very happy for your opinion.
Thank you

Saturday, June 1, 2019

Chronic Metatarsal Pain: Email Advice

hello dr Blake,
I am writing all the way from Italy and was wondering whether you could be so kind as to help shed some light on a foot problem I've been struggling with for the past 5 years. I hope you enjoy puzzles! I'm 33 years old, male, 6' 4'', 165 pounds. 

5 years ago I suffered a minor injury which caused capsulitis on my 1st MTP joint (right foot). Eventually the capsulitis resolved, but at the same time I gradually started to experience additional discomfort on the same foot for reasons which in hindsight seem to be attributable to increased weight/pressure on the affected foot when walking. For example, the metatarsal pad of the orthotics I had been prescribed to treat the capsulitis after a few months started to be painful (whereas with my left foot I could barely feel it), and after I switched to a pair without the met pads (April 2016), the discomfort shifted to other areas of my forefoot (sometimes lateral, sometimes medial, and always when pushing off). Sometimes I had the unpleasant sensation of 'feeling' my metatarsals when walking. Fed up with the orthotics, I tried to go back to walking without them as I had always done for 30 years. After a few days of walking pain-free I thought the condition had finally resolved and everything was back to normal, but shortly after the old symptoms came back. 
     So I went to see a podiatrist (January 2018), who said that my discomfort was due to unilateral over pronation and that I needed semi-rigid orthotics. The new orthotics worked very well for a couple of days, but then again symptoms-wise I was back to square one, with modest improvement. The podiatrist then made me a rigid pair of orthotics, but again, very little changed. Since he couldn't see any structural faults he came to the conclusion that the problem was muscle-related, more specifically my right calf was weak. This was maybe due to the original injury, since the capsulitis made it painful to push off as usual and so probably I started to use my calf muscles less and less. Nowadays I can rise on my toes on a single leg but I find it much easier with the other limb. I signed up at the gym, carried out a 4-month program with a fitness instructor (nothing specific for my problem though), experienced some improvements but very discontinuous, and finally went to see a physiotherapist (March 2019).
     The PT noticed a number of compensation patterns on the affected side, mainly internal rotation of the leg, pelvic tilt, an overactive tibialis anterior, and something about my latissimus dorsi which on that side was working harder than normal to maintain balance. I did 5 sessions where they manipulated mainly my pelvis and trunk, the reasoning was that all of those imbalances were affecting my foot, and not vice versa. On some days I noticed a definite improvement, but again, a bit discontinuous, so eventually they referred me to a podiatrist they knew in order to rule out intrinsic foot problems (April 2019, i.e. this week). 
Dr. Blake's comment: First of all, I am sorry I am late answering. You are not overweight and I am not sure that their is any association with the original capsulitis. All of your symptoms could be related to your unilateral pronation. If you look at your two orthotics, are they asymmetrical, with more support to the unilateral pronation side. 
     The podiatrist noticed a number of things apart from the unilateral over
pronation (ligamentous laxity, not much forefoot fat pad, big toe tends to make little contact), but the main thing seemed to be that the affected leg is 0.4" longer).  Thus, I would need a new pair of orthotics that took all of these things into account. I have no qualms about that, and I am willing to believe that 0.4" could go a long way to adding weight on my leg and foot and contributing to the problem. The affected leg is probably a bit longer, my fitness instructor once filmed me while walking on a treadmill and it clearly showed that the affected leg tended to circumduct (is that a verb?), and the anatomical leg length discrepancy may be compounded by a functional one.
Dr. Blake's comment: Yes, the long leg tends to be the more pronated, and 11 mm is a lot. I tend to try to separate the orthotic therapy and the lift therapy. So, I would gradually over one month build you up under the short side. When the patient is more pronated on the long side, correcting that aspect will make that side even higher, so you may need up to 1/2 inch. 

     I am willing to accept all of this. What I really can't wrap my mind around (and this is my main question) is this: if it really is a matter of bearing too much weight on the affected foot then why did it become symptomatic only in recent years, after the original injury? If the leg length discrepancy is truly anatomical, shouldn't I have had similar problems before the injury as well? The injury itself was no big deal, I hit a curb with my big toe but no fractures, just the capsulitis. Until 5 years ago I had never had the slightest problem. Could compensatory postural adjustments or lower leg muscle weakening post-injury have played a role in adding further weight to the affected side?
Dr. Blake's comment: Yes, for sure, an injury can cause other stresses to manifest for the first time. I am never sure if it is due to the deconditioning from the injury, or the compensations from the injury, but it happens all the time. I joke to my patients that at least it will stop after the third area begins to hurt (sometimes they get my humor). The long leg does put more stress on that foot for sure, and if you add the tightness that develops in the achilles with injuries, the stress to the injured foot can be quite bad. 

I'm adding a few bits of info which might help:
  • I tend to feel much less discomfort when walking barefoot (Dr. Blake's comment: for sure, shoes for sure add stress across the metatarsals as we try to bend at push off. Only stress fractures and other bruises hurt worse barefoot. This of course could be a clue for you to try very flexible shoes in the forefoot)
  • x-rays and MRI have always come out 'clean' (Dr. Blake's comment: Negative MRIs to me mean nerve injury first until ruled out. Nerve injuries show negative MRIs. Have you had any nerve symptoms like numbness, sharp, tingling, buzzing, electric, etc. It is also a good sign for the future as you do not have early onset arthritis).
  • pedograph analysis showed more pressure on the affected foot when walking, thought barefoot they were even (Dr. Blake's comment: Many times the difference only shows up running as are bodies have a harder time distributing the weight evenly.)
  • I tend to think that I am bearing more weight on the affected foot, but there are no signs of that on my skin (there is a slight degree of 'hallux valgus' though, could that be a sign?) Dr. Blake's comment: Yes, unilateral bunion formation or hammertoe formation is a sign of more stress.
  • as I mentioned before the discomfort I have on my forefoot is quite changeable, most times it's on the head of my 5th metatarsal, sometimes it's bit generalized, other times I don't feel anything on the 5th metatarsal and it's more on the big toe. In any case, it's always during push off. Dr. Blake's comment: The variability is more a stress syndrome than an injury. Change the mechanics, get stronger with single leg balancing and metatarsal doming, and stretch the achilles tendons several times a day. 
  • judging from what I see and from the pedograph analysis the arch of the foot seems fairly normal
I would be really grateful if you could share some thoughts on all of this, I've been through so much and am getting a bit depressed

thank you
Dr. Blake's comment: I hope you are feeling better. Get more flexible, get stronger, get at least 1/4 inch full length lifts and see if you are better with these changes. Rich 

The patient then answered:

hello dr Blake,
thank you very much for answering. I am writing a follow-up email to let you know how I am doing. If you feel to add any ideas or suggestions that I could pass on to the professionals that are looking after me (also in terms of diagnostic tests) I would be even more thankful (I have made a small donation to your blog as a token of gratitude). I don't want to take advantage of your kindness so if I don't receive further communications I will fully understand.
Over the last month and a half I have been wearing the new pair of orthotics (they have a 5 mm heel lift on the shorter leg, so the lift is not full length), my gait has improved as now I find it easier to push-off (last pair of orthotics were rigid and with little padding), while symptoms have also improved a bit but have not resolved. I am still doing physical therapy and next Wednesday I have a check-up with my podiatrist so I hope to clear things up a bit, but in the meantime I have been doing some research on a number of topics and I have come up with some new elements that may be worth mentioning. As my foot is apparently subjected to increased stress, I'm trying to understand what is causing it.
Dr. Blake's comment: Explain to the podiatrist to perhaps experiment with another orthotic device for the short side without the lift attached and with 2 (1/8th inch) full length spenco or other soft material as lifts one full length and one cut at the toes (sulcus length). That will add cushion but not pitch you forward as much onto the metatarsals. If you use soft material as lifts, you typically can go up a mm or 2 due to the compression. 
One of the working hypotheses is that it may be bearing more weight for some reason, but I've noticed this is something that hardly ever pops up in podiatry or PT. I have read several textbooks and at the most they talk about asymmetrical weight distribution foot-wise (i.e. more lateral or medial) and not body-wise (i.e. right leg/left leg).
Dr. Blake's comment: One method of getting some idea of the right to left weight bearing is looking at old inserts, ones that you have worn awhile, to see if one side is broken down more. The other common method is to stand evenly on two bathroom scales that you know are equally calibrated. Try to stand with equal weight in your mind, and have someone else take the measurements of left and right side. As soon as you look down to read the scales, you throw off this technique. It is only one tool, other than more sophisticated force plates/mats, but seems to be helpful. 
 I am wondering whether muscular imbalances in terms of tightness/weakness between the two halves of the body might play a role in how weight is distributed or force is transmitted to the lower extremities but I haven't been able to find any bibliography on the matter. Also studies on LLD and body weight distribution seem conflicting as to which leg bears more weight, so it's all a bit confusing to me. I did another pedobarographic analysis last month which apparently ruled out this asymmetrical weight-bearing hypothesis, as it showed that mean pressure was actually higher on the healthy foot when walking barefoot, but I don't know if such a test is supposed to be conclusive on this matter.
Dr. Blake's comment: I am not aware of any research on this matter, so I apologize. When a patient is bearing more weight on one side because of short leg syndrome, scoliosis, tight hamstrings or calves, weak muscles, etc they create postural instability as they try to compensate. This postural instability can lead to the measurements varying from step to step, with one side greater with one step, and the other side greater with the next step. Or, something like this. The force plate analysis as an office tool makes it difficult unless you do the test multiple times, and a definite pattern emerges. Most researchers feel you must walk over the force plate 10 or more times even to begin to practice the landing. This is actually why in a busy office I have not purchased these, but I understand their help in many situations. 

You mentioned in your reply to check for neurological signs, and this is something I didn't include in my first email. I do think there is something going on in that regard as well. One sign involves the dorsal aspect of the big toe, so I don't know if it's related to the general problem (forefoot plantar discomfort) but nonetheless it's worth mentioning. Sometimes I feel a mild burning sensation coursing along the big toe which is (sometimes, not every time) elicited if I move my leg after a period of inactivity when seated or lying down, and on sitting down after a walk.
Dr. Blake's comment: This is classic L4 nerve root irritation.

Or, also, when I'm doing sit-ups with my leg fully extended. What makes me think it's neurological is the fact that this burning sensation is sometimes elicited by stimulating the anal area (e.g. when I wipe after going to the bathroom), a very distant area that is directly connected to the foot only by means of nerves. I know that the deep peroneal nerve innervates the first web space and that it can get irritated when sitting with your legs crossed (something I used to do), but that doesn't match 100% my symptom in terms of location, as it's more dorsal 1st toe rather than 1st web space, and the peroneal/sciatic nerve is more 'buttock' than 'anus'. This burning sensation started post-injury, and I definitely remember that a few years ago sometimes I felt it coursing down my medial calf, on the side. Might it be that some nerve got irritated/damaged with the injury (big toe stubbed against a sidewalk) or consequent capsulitis? I know also that overpronation can cause tarsal tunnel syndrome but in that case symptoms involve the arch/ankle (not my case).
Dr. Blake's comment: This is up to a neurologist to put together, but sounds very neurological. The dorsal of the foot is irritated by tying your shoes too tight or above the knee problem like tight hamstrings, piriformis, or low back, not the tarsal tunnel. 
On the other hand though it's puzzling because other than the burning feeling I've never experienced the classic neurological telltale signs, i.e. tingling/numbness/electrical sensation, and it's something which is elicited with specific motions, and never at rest or at night.

All of this dorsal-big-toe-burning-symptom, though, as I said may not have much to do with the general problem, but I have come to think that there might a neurological component in the plantar aspect as well. Might it be that some plantar nerves are being compressed/being put under stress for some reason, and that weight-bearing pressure is 'felt' much more than usual? On the other hand, as I said before, the telltale signs of neuropathy are absent, and even on forceful palpation the sensitivity of my foot appears normal, so to my layman eyes it appears more a matter of stressed soft tissue than nerves.
Dr. Blake's comment: You have some minor nerve problem, and nerve problems cause a hyper-sensitivity that can make something hurt more at the foot. This is called "Double Crush". Definitely worth to check out, and right now deal with them separately. I hope I have helped and thank you for the donation. Rich

Again, thank you very much for your reply and for any further help you can provide


Antonio