Total Pageviews



Thursday, March 21, 2019

More on Minimalistic Shoes: Great Video

     I love shoes period. I think shoes protect our feet and give us support and cushion when we need it. And, as a podiatrist, I treat injuries or patients who are biomechanically stressed. By that I mean, some patients (whether they are runners, hikers, cyclists, etc) need a correction in their gait or structure, just to be aligned right to avoid injury. The video above is very well done and fun to watch. My problem is that their thinking is too narrow. They should come out and say that some people may get injured going without cushion and without support, and that those patients should be able to wear shoegear that corrects. It is up to the health care provider, athlete, and shoe stores to figure out what they need. I certainly could not walk as much if I did not have cushion and support. Some people do just fine with a minimalistic approach. But, my waiting room is filled with patients who can not walk without aids, and cushioned shoes, and who may be trying to slow down their knee arthritis from needing a replacement. I think a healthy runner should have traditional, maximalistic and minimalistic shoes in their closet. Alternating is very very healthy. Staying in the same enviroment is unhealthy. We all have to learn from each other. Everyone should do more strengthening and flexibility work. Everyone should do various forms of exercises. Everyone should try to find out how to do these things safely and with no pain. I have no idea why 30 years of sports medicine knowledge is being completely thrown away for the potential gains from minimalistic shoegear. Rich

Wednesday, March 20, 2019

Big Toe Joint Arthritis: Email Advice

Hi Dr. Blake, 
I recently found your videos on YouTube.

I was wondering if you do any Skype evaluations. 
Dr. Blake's comment: I am sorry, right now I do not. I will in the future however. 

I have a problem with my right big toe lacking full ROM. I jammed it really hard about 7 years ago going from a headstand into chaturanga (low push up position) intentionally in a yoga class.

I guess I did not have my right foot flexed enough. It really hurt my big toe which felt sore to walk on for several weeks. It never had full ROM after that when I flexed my foot. But I kept working that range of motion until my toe would not bend anymore thinking I needed to work the ROM so I would not lose it.

Six months ago I went to a physical therapist and asked him to work on my big toe. He held my big toe and extended it and moved it around. He said he felt increased ROM when he was moving my big toe but I did not feel anything. However after I left my foot really hurt around my 4th metatarsal which turns out had a stress fracture that I discovered after I finally went to a podiatrist for an x-ray. 
This really made me pay a lot of attention to my foot. I attached the x-rays. It looks to me like the sesamoid bones are out of alignment. But I am not sure - the podiatrist did not say anything about that.

This x-ray shows lateral compartment arthritis in the big toe joint

Do you do Skype consultations? Does it look like the sesamoid bone is out of place and if so is there a way to heal that without surgery?
My posterior right arch collapses a bit when weight bearing.

I live in Asheville, NC and do not really know of anyone who is really good at helping me from a holistic point of view.
Dr. Blake's comment: Look at the AAPSM directory list. This is the sports medicine aspect of podiatry. See who is near you in North Carolina. I think your treatment is for Hallux Rigidus, or just arthritis of the big toe joint. Rich

I would appreciate any advice. I really want to address this problem and find a good solution. I am willing to do the work to make changes.

Thank you. 

Monday, March 18, 2019

For Podiatrists: The Significance of Heel Bisections

This is the second of many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

     For me, I need to be able to draw a line on the back of the heel that represents the bisection of the heel. I am sure my measurement is only accurate within a few degrees. I am trying to have a line represent an entire heel bone and I try to do this the best as I can. I should be able to draw the same line with the patient prone or standing. It is one of the basic skills taught podiatrists. 
I use the heel bisection to see how my orthotic devices are helping, or if more correction is needed. 

The ruler is just a reference line as the orthotic device on the right foot straightens up the everted heel below

This right foot is everted to the ground . I use a bisection line that I was taught in Podiatry School, to represent whether the heel bone is everted to the ground, vertical, or inverted to the ground. Then I can check (be honest) if my orthotic device is helping make the foot more stable. You should first look at the back of the heel and decide if it is everted, vertical or inverted. Then draw your line and see if you captured this heel position. If you are performing this at orthotic dispense, then this should correlate to what you see in gait. Or, you just keep learning.

Here a goniometer is being used to measure the degrees at the heel.

Of course, when we are designing orthotic devices, we try to make everted heels generally less everted, vertical heels inverted when the foot is pronated, and inverted heels generally less inverted unless there is significant rearfoot varus conditions. 

Saturday, March 16, 2019

Hallux Limitus: Email Advice

Hi Dr. Blake -

I stumbled onto your blog while searching for information on hallux limitus, which has been suggested to be by a podiatrist and PT. I'm a 33 year old man, in general good health and consider myself to be an active person.
Here's a brief background around the hallux limitus:
  1. I started walking about 10k steps per day in October 2017. (Roughly double what I was doing before Dr. Blake's comment: That total is one of my mantras for life. 
  2. In January 2018 (4 months later), I began a transition to moccasin-style (SoftStar) shoes with CorrectToes silicone toe spacers.
    • Both of these were in hopes of improving knee and hip pain that doesn't allow me to run and shows up while hiking long distances, but that wasn't a problem during everyday walking.
    • About 10 years ago, a PT told me I had "runners knee", "patellofemoral syndrome" or "IT band syndrome" causing pain in my right knee that required me to stop a training program for a marathon. This diagnosis was when I got interested in minimalist shoes and other 'alternative' approaches, and why I began this transition in January 2018.
  3. In March 2018 (about 2 months into the footwear transition) - during one of my walks I had a sharp pain develop quickly (over the span of probably one minute) in my right big toe. It was bad enough that I had to stop walking and get a ride home.
    • That evening I noticed some bruising that wrapped basically from the underside of the proximal phalanx to the right side of the IP joint on my right big toe. Not sure exactly how to explain this, but it looked like bruising that originated from inside the toe somehow - i.e., not from some kind of trauma. Dr. Blake's comment: I do not know how much you pronate, which could be the issue, or just the correct toes pulling on the ligaments too much with that amount of walking. I tend to use correct toes just around the house, at least for several months until you get used to them. They are powerful tools, but of course you probably had no guidance. 
  4. My physician ordered x-rays - which he said just showed soft tissue swelling under the joint but nothing specific. Dr. Blake's comment: Good start. 
  5. In April 2018 - A podiatrist examined me and suggested I had Hallux Limitus. Dr. Blake's comment: Is it functional or structural, or a combination of both. What were the degrees that they measured? Normal big toe dorsiflexion (upward bend) is 75 to 90 degrees and Hallux Limitus is between 30-60. 
    • His recommendations were: orthotic inserts, shoes with a 1/2 to 1 inch heel, and shoes with a rigid midsole. Dr. Blake's comment: With hallux limitus, all three of those things can help or hurt based on several factors. If you get them, and they bother you disregard. Try everything together, and also separate to see what the effect is on the big toe. 
    • I ended up using Vasyli Dananberg First Ray Orthotics, which claim to help with hallux limitus by having a 1st MPJ cutout. Dr. Blake's comment: These are to increase the motion in the big toe joint, so why a rigid shoe? Of course there are times to limit the motion, and times to free up the motion. Do the self mobilization video a couple of times a day to see if that helps.
    • And I moved to walking primarily in hiking boots which met the podiatrist's suggestions.
    • The footwear and orthotics didn't really help - and I developed gait compensations around the toe pain that caused me to develop some hip and knee pain just from everyday walking. Dr. Blake's comment: It can just be the timing of the treatments. If the joint is sore, the treatments may best be spica taping, no orthotics to increase motion, and stiff shoes. You can also get Hoka One One shoes for a while to limit the toe motion but allow walking. 
    • In June 2018 - I saw a PT to help me with some stretching and exercises.
    • This seemed to help a bit, though I couldn't resume my 10k steps walking program. Dr. Blake's comment: Do you think it is weight bearing pressure causing the pain (then dancer's padding is apropriate) or the bend of the big toe joint (then spica taping, rigid shoes like Hoka One One). Both seem would be made worse with an elevated heel unless it supinates you so your weight is more lateral near the 4th or 5th toes. 
    • I kind of gave up at this point in frustration.In August, I realized I had taken a couple long hikes with no pain or toe problems - so I cautiously started my 10k daily steps program again.Over the 5 months since then, I've continued the walking. I have had some pain, but never to the point where I had to stop walking. And I could manage things with achilles tendon stretching, dorsiflexion exercises, and general funny business with ankle movements.But now in the last couple weeks, the big toe pain has come back big time and I've had to stop my walking program.Dr Blake's comment:  I am glad you mentioned achilles flexibility, since tight achilles puts extra load on the metatarsals and is helped with stretching. Joint pain can come and go. Now is the time to see if Hoka One One, spica taping, dancer's padding, and ice 10 minutes three times a day will help. Do you have a walking boot to maximally rest it? 

I have a couple goals:
  • Keep up my walking.
  • (Stretch goal) Start running again.
  • Importantly: Don't harm my joints in a way that will be debilitating later.

I'm open to a variety of interventions to reach these goals - but in general, I would prefer things that involve strength, flexibility or gait improvements rather than footwear, orthotic or surgical solutions.

Your blog and youtube page seem to have a lot of really good information about hallux limitus - so I figured I would reach out and see if you have some suggestions for me.

I also see that you're in San Francisco - I live in Oakland and I would be interested in scheduling a visit if you thought that could be productive.

Thanks so much - for your excellent information online, and for reading this (Dr. Blake's comment: only read to this comment, no farther!!LOL) far!


And the Patient Responds:
Thank you for the great responses. To answer the questions you asked on the blog:

 Is it functional or structural, or a combination of both. What were the degrees that they measured? Normal big toe dorsiflexion (upward bend) is 75 to 90 degrees and Hallux Limitus is between 30-60. 

Neither my podiatrist or PT mentioned checking for this. They also did not take explicit measurements of the dorsiflexion, just a general examination. Is there a method to examine and get clear answers to both which type and what the degrees of dorsiflexion are?
Dr. Blake's comment: The first video above shows how to measure joint motion, and the link below shows Dr. Sander's video on functional hallux limitus.

 [Regarding Vasyli Dananberg First Ray Orthotics] These are to increase the motion in the big toe joint, so why a rigid shoe? Of course there are times to limit the motion, and times to free up the motion. Do the self mobilization video a couple of times a day to see if that helps.

I selected these orthotics after some research online. I don't think I fully understood there was a difference between functional and structural hallux limitus. So if I'm thinking about shoe/orthotic pairings - would you suggest that I stick with standard orthotics on a rigid shoe, and the cutout orthotics with a more flexible shoe? And just test how things feel with one or the other.
Dr Blake's comment: That may be best, but right now go with feel. It may be the opposite for you, in flexible shoes you need more orthotic restriction, and with rigid shoes you need more orthotic motion. 

 Do you think it is weight bearing pressure causing the pain (then dancer's padding is appropriate) or the bend of the big toe joint (then spica taping, rigid shoes like Hoka One One). Both seemingly would be made worse with an elevated heel unless it supinates you so your weight is more lateral near the 4th or 5th toes. 

Hard to say if it's weight bearing pressure or from bending the joint. If I had to get specific on the pain location, I'd say it's on the underside of the right big toe between the MPJ and the IPJ. And when it gets bad, the joint (I think the IPJ) tends to click or pop for awhile until it heals up.

 I am glad you mentioned achilles flexibility, since tight achilles puts extra load on the metatarsals and is helped with stretching. Joint pain can come and go. Now is the time to see if Hoka One One, spica taping, dancer's padding, and ice 10 minutes three times a day will help. Do you have a walking boot to maximally rest it? 

Much appreciated, I'll try these things. How much risk is there of permanent damage if I continue to walk when the pain is intermittent and not debilitating? Dr. Blake's comment: None, if you have a degenerative process, it will slowly get worse, and you must try to manage the symptoms with as active life as you can. If this is not a degenerative process, that type of pain is not damaging only a nuisance (definitely frustrating). Good luck Rich

Thanks again.

Friday, March 15, 2019

For Podiatrists: Biomechanical Discussion Points #1

This is the first of hopefully many blog posts under the label of Bio-mechanical Discussion Points that has been sparked by the wonderful books from Dr. Kevin Kirby. 

Bio-mechanical Point #1: In what position of the heel are the patients most stable: is it heel vertical, heel inverted, or heel everted?  

     The best heel position for stability depends on several factors. One concept was first introduced by the ballet world in the 1700's that the most stable position of the heel is when it is stacked directly under the talus, and the talus is stacked directly under the tibia. I have always found that patients, and especially dancers (who are very attuned to their bodies), can feel this inherent stability. This has been termed the neutral position of the subtalar joint (neither inverted or everted) from that position, much as the neutral position for stability of the ankle joint is where the tibia is at a right angle to the foot (in which the ankle is neither dorsiflexed or plantar flexed from that position). 
     That stable subtalar joint neutral position is inverted to the ground when we have tibial varum and other forms of rear foot varus. That stable subtalar joint neutral position is everted to the ground when we have tibial valgum or other forms of rear foot valgus to treat. Therefore one person can be in their most stable heel position to the ground 5 degrees inverted and another person 5 degrees everted. The most common will be tibial or rear foot varus that will set the ideal heel position to the ground somewhat inverted. Too often orthotics are set at vertical for these patients meaning that the orthotic holds them pronated or everted from their most stable position, which means makes them more unstable. If we measure these positions, or at least recognize these deformities by observing the patient in angle and base of gait, we can be more thoughtful in prescribing an orthotic device's heel position. 
     When does this thought process get thrown out the window? All the time. Patients present with certain needs that may have higher priority than simple Root Bio mechanics (not that there is anything simple about Root Bio mechanics). This need may be permanent or temporary, but must be addressed. What are some examples? A patient presents with terrible pronation due to a high degree of tibial varum (bowlegged) mechanics, but they have had 3 ankle sprains and are trying to avoid ankle reconstruction. Root Bio mechanics would have them Inverted due to a high rear foot varus, but their injury with lateral instability requires a vertical heel pour or even slightly everted if they have the range of motion. The goal of the orthotic device, which may change down the line, is for elimination of the supination forces, not correcting the abnormal pronation. This is so common in a sports practice. 
     Another example which is very common in my practice, almost daily, concerns lateral wedging for medial meniscal at the knee problems. If you pronate the foot for a period of time, and open up the medial knee joint line, you can let an injured meniscus have time to heal. You are not concerned about the ideal heel position for stability, but only to generate enough pronatory force to off weight the medial compartment of the knee. This can be extremely important in documented medial knee compartment issues 50% of the time. The other 50% actually want more stability, and you may be inverting the heel to give them that. Inverting the heel 3-5 degrees in general, stabilizes the medial knee compartment, places more weight on the medial knee compartment, helping so many soft tissue medial knee torque or instability problems. 
     I hope to keep the thinking going. Thanks for reading. Rich

Monday, March 11, 2019

Chronic Pain: Curable App with Graph

I would love to have any patient with chronic pain from all different sources download Curable App and see how it works for one month. I am so hopeful it can help reduce your pain. 
This wonderful chart is reprinted courtesy of Curable App. 

Saturday, March 9, 2019

Use Code to help Dr. Blake's Travels. Why not?

Hi Richard,

Have a great trip! Why not make it even better by earning a reward for you and your friends?
All your friends have to do is book using your referral link. When they get back from their trip, they’ll get a US$25 reward, and you’ll get US$25, too!

To All my Blog Friends, if you travel, you know is a great site. If you use the code above, both you and I get $25 each. Good deal right? Thank you in advance. I love Rich

Start Standing: A help for Back Pain

We all know we must stand more to help our bodies, especially the low back. I hope this website helps in your journey toward better health. Rich

Sesamoid Fracture Treatment: A hope to avoid Surgery

Hello Dr.Blake!

I am happy I found your blog post about fracture seasmoids. I’m hoping to get some advice or maybe just some encouragement!

So here goes! I am pretty active and enjoying hiking, running and workout classes. I suffered from turf toe back in 2016...after therapy and taping it got better. A few months later similar pain returned and it was diagnosed as sesamoiditis. Last year we found I had a complete fracture of my medial seasmoid. I was put in a walking boot for 6 weeks and the pain went away but fracture didn’t heal. The podiatrist told me to leave it alone if it didn’t hurt. Fast forward to a few weeks ago when I finally got a second opinion and I am now non weight bearing and using a bone stimulator twice a day. My biggest question is this, do you really think that after a year this fracture could heal without surgery? I’m pretty skeptical.
Dr. Blake's comment: Depends on the gapping or the fragments, the amount of avascular necrosis that has sent in, the biomechanics of your foot and activities placing stress or little stress on the fracture area, the overall fragmentation, the bone density and Vitamin D levels, eating habits, etc. You want to do the contrast bathing as a deep flush. A CT scan would give us the best imaging at this point.
     I have many patients that the sesamoid does not look great on any imaging, but do fine, and as long as we can keep the pain between 0-2, and they are happy with activity levels, I just follow them.

The pain wasnt unbearable I just wanted the second opinion because I am 32 and work a pretty physical job (PT assistant in an inpatient setting) so on my feet many hours a day.  I also enjoy running and hiking. Those are things I wasn’t able to do the past year so I have substituted with using a stationary bike and weight lifting. I have been using a dancer pad and started wearing hokas which I love but the pain still lingered. I feel like I’m too young to just give up but I am really hesitant to get surgery for this. My podiatrist said if this doesn’t heal she would like to do a bone graft and use it to pack in between the non healing fracture. It seems like more trauma to my foot than I’d like to deal with. I know I should be more positive because maybe this can heal with NWB and bone stimulation but again I’m skeptical. I should also mention I started taking a vitamin supplement to help bone healing.

I’m sorry for the long email I just thought you should have all the info.
Dr. Blake's comment: Unfortunately, I have had no experience the results of bone grafting. If you find any articles, please send my way. I just want to know if you have surgery, they are just not experimenting with you. I am not a surgeon, so I have to leave final decisions to surgeons, but send me one or two images of the fracture from a CT scan and I will give you some thoughts. Have your Vitamin D level measured. Go 6 months on this course, although at some time you will have to switch from NWB to a weight bearing boot for 4 weeks and then back into your Hokas. The bone stimulation should be 9 months period. Hope this helps. Rich

Thank you in advance for even reading this and thank you for what you do!

Wednesday, March 6, 2019

Nerve Pain after Long Distance Bike Ride

Hello Dr Blake,

I found your email address after reading your blog and an article written by you in "Podiatry Today" on Morton's neuroma. I am writing to you from Australia seeking your medical opinion after seeing many specialists in Australia on my foot issue, with no real success. First a little background on my issue.

My problem started back in September 2018 whilst working overseas. I first hurt my right foot after training for a long distance bicycle ride. The initial symptoms were tightness in my calf, sole of foot and some heel pain. The heel pain would be shooting pain on the inside of heel whenever my foot was dorsiflexed. Over the following three weeks, whilst standing in my job, my condition worsened with the onset of pins/needles throughout the sole of my foot. At the end of a typical work shift my whole right foot would be completely numb and tingling. The GP's that I first saw thought it was plantar fasciitis and prescribed me anti- inflammatories which provided some relief.  I also saw a podiatrist who moulded me a set of orthotics with little improvement noticed.  After three weeks I returned to Australia in October and sought further investigation.
Dr. Blake's comment: There are 3 sources of pain: mechanical, inflammatory, and neurological. The cause of your pain was mechanical (the long distance bike ride), but the symptoms are all neurological. This is like overstretching the calf, and pulling too long on the sciatica nerve, and having the calf pain intensify. You have to treat this neurologically at first with treatments that help nerves. then work on the mechanics, and any inflammation that has set into the tissues.

Since I have been back in Australia I have seen the following specialists:
  • Neurologist (Nov) - performed a nerve conduction test, which was inconclusive, apparently quite often this happens with people over the age of 40.  Had an MRI (report attached below) which showed a thickening of the medial planter nerve throughout the mid-foot course involving up to 8 cm in length.  The Neurologist concluded that I had Tarsal Tunnel syndrome, informed me that surgery was my only option and referred me to an Orthopaedic surgeon.
          Dr. Blake's comment: Yes, there is 1-5% of almost any injury that has a surgical solution, but
          that is not where you start. Hopefully, you never have to go down that route.
  • Orthopaedic Foot Surgeon (Nov) - the orthopaedic surgeon said that I did not have tarsal tunnel syndrome as the thickened nerve was not in the tunnel.  He was reluctant to operate and advised me to take three months of rest and see if my condition improves.
  • Podiatrist (Dec) - visited a podiatrist who concluded that I may have medial calcaneal nerve entrapment and/or Baxter's nerve entrapment.  Advised me to keep wearing my orthotics.
  • Orthopaedic Foot Surgeon (Feb) - condition had improved after three months of rest, but still only limited function. Surgeon would not operate and referred me to a Anaesthetist/Pain Specialist.
       Dr. Blake's comment: When you irritate nerves, they can take a long time to relax, so most of this
       advice is good. It is using only rest as the number one treatment for nerve pain, but not bad
       advice. Glad that they sent you to a nerve guy (called pain specialists).
I am now awaiting an appointment with the Pain Specialist on March 27th.  My current symptoms are the following:
  • Can walk okay, but after one mile or so start to experience pain in the sole of my foot 4/10 (feels like a stone in my shoe). The pain extends from where the heel ends, along the mid-foot section. Dr. Blake' comment: Do not push through this pain. Do you guys have Uber down there?
  • Tightness in calf has disappeared. Dr. Blake's comment: Great, that means some of the neural tension is improving. Has the heel also resolved?
  • Cannot walk down stairs properly as the dorsiflexion of my right foot causes a shooting pain on the inside of my heel. Dr. Blake's comment: Just answered the above question. Remember the sciatic nerve, branches of the big nerve are irritated on you, is pulled too much right now with ankle dorsiflexion, straightening the knee, and bending over at the waist. Try to go downstairs leading with the bad side, and then lowering the good side to the same level. That is usually the best. Down with the bad, up with the good is the mantra.
  • Flat surfaces are okay for a mile or so, but inclines uphill or downhill really take a toll on my foot quite quickly. Dr. Blake's comment: Stay on flats right now as the neural tension resolves. It is never a fast process. Sorry.
  • Sometimes when I stand in one spot for an extended period my foot turns red.  Podiatrist was initially concerned that I may have the beginning of CRPS and encouraged me to keep walking. Dr. Blake's comment: This is called vasomotor insufficiency where the skin and soft tissue are influenced with nerve spasticity. This is part of the neural tension also. Nerves love motion, and not prolonged stretching. They do not like certain positions, so keep moving is a good thing, or at least finding comfortable sitting or laying positions when you can not move.
  • Still wearing orthotics which help a little.
  • Currently on Lyrica 150mg to ease pain on the days I walk more. Dr. Blake's comment: Typically I wonderful nerve treatment if you can tolerate.
Am I a candidate for Radio Frequency Ablation, cortisone injections, or alcohol injections?
Dr. Blake's comment: Unless someone can tell you that a neuroma, or entrapped nerve, is a constant trigger for the pain, it is best to not risk irritating it for now. As your symptoms get better, and one spot on a nerve remains super sensitive, then some discussion is in order. I doubt you will need these, but I am of course not sure. I would not do anything invasive to speed up the treatment. With nerves, that course of action tends to irritate more than help.
  Is there any value in having a diagnostic injection around the medial calcaneal nerve or Baxter's nerve to see if the shooting inside heel pain is relieved when foot dorsiflexed?
Dr. Blake's comment: Local anesthetic on an inflamed nerve could help, and you may need to do several over 3-4 weeks. That being said, it goes against my better judgement. Do this for me. Have you knee straight and then dorsiflex the foot, you should get nerve pain. Now, bend the knee to ninety degrees and then dorsiflex the foot. If there is no pain now with that change in position, it is most likely an irritated nerve, not an entrapped nerve (which should hurt both ways). It is another finding and for sure not conclusive. What I have not had you say is that the MRI showed a possible nerve entrapment in the heel with intense swelling, etc. I have also not heard you say anything about a low back MRI since this can be all coming from your back.

 Could I have a nerve entrapment that might be relieved with Radio Frequency Ablation?
Dr. Blake's comment: This is not a procedure I have any experience in. Start doing traditional treatments: neural flossing, Neuro-Eze or like products, get the Lyrica dose up to normal amount, add Cymbalta if you can tolerate, avoid positions that irritate the sciatic nerve, see a physical therapist skilled in nerve problems, try topical compounding meds that have Ketamine, get your low back pain eval, look into foods that irritate the nervous system, and get supplements that calm it down. Most of this is in my blog also. I hope I have been somewhat helpful. Rich
Be kind to yourself, and do not rush into treatments, meditate daily, acupuncture can be of great help.

I have researched a lot online and there is very little information about enlarged nerves, besides Morton's Neuroma.  I really don't wan't to be on painkillers the rest of my life and refuse to believe that this is the end of the road for me.  I recognise that I may never get full function back, but am searching for a procedure that could improve my condition a little. In Australia there does not seem to be any podiatrist surgeons that specialise in my condition, or at least I don't know who they are.  The Pain Specialist is currently my next avenue for help.  Any feedback you could provide would be greatly appreciated.


The Patient then responded:

Hi Dr Blake,

Hello from Down Under. Thank you so much for your quick and detailed reply.  I have already actioned a number of your suggestions, like taking supplements to calm down the nerve (Vitamin B12) and ordering Neuro-Eze to apply to the sole of my foot.  I will also explore acupuncture and physical therapy.

To answer some of your questions:

  • Heel Pain - For over a month now I have been going down the stairs by leading with the bad side and lowering the good side second, just like you suggested.  Then today I decided to try and walk down the stairs normally, so I could report back to you on my progress.  Good news, I managed to walk down the stairs with only minor discomfort which was a big improvement from a month ago. Still have tenderness around the inside of heel and the arch of foot though.
  • Dorsiflexion Test - I performed the straight leg and bent knee dorsiflexion test like you suggested.  In the straight leg position I felt no pain, however I have lost about 20% range of motion when compared to the other foot. I'm pretty confident that if someone pushed on my foot it would have elicited some pain as it did before. Dorsiflexion in the bent knee position hurt.  Is nerve entrapment still a possibility? Dr. Blake's comment: Yes.
  • Explore lower back possibility - When I see my specialist next week I will ask him for some imaging on my lower back, as you indicated it may be the source of the pain.

What I didn't mention in my first email was some other symptoms that presented when I first hurt my foot 5 months ago after the bike ride. The tightness in the calf was predominantly in the top outer side portion, combined with big toe tingling and sensitivity.  In fact, whenever I experienced the shooting pains through the sole of my foot, the big toe would end up throbbing.  After researching quite a lot I believe my initial injury may have been a sprain of the Flexor Hallicus Longus muscle, apparently a common injury amongst ballet dancers and bike riders. If the FHL was inflamed throughout the foot, could this have led to the medial plantar nerve enlargement ? Dr. Blake's comment: For sure, and that should be calming down. 

Thank you again and look forward to your reply.

P.S. We do have Uber down here! 

Every Single Street: Rickey Gates Runs San Francisco

Rickey Gates runs Every Single Street in San Francisco, very motivational, we can do perhaps smaller projects, but as mindful.

Friday, March 1, 2019

Sesamoiditis turning into Fracture: Email advice

Good evening Dr. Blake,

I am currently a student at a university. I suffered sesamoiditis in February of 2018. I visited the doctor and they took an MRI and Xray, and he said it was sesamoiditis. They gave a steel toe plate to insert in my shoe so I don't bend my toe too much and it did help for a little bit. A couple of months went by and I got used to the pain.
Dr. Blake's comment: I hope you understand that we must get the pain to 0-2, not just be helped, or you will not heal potentially. This is especially true with sesamoids that are slow healers in the first place.

I did try to ice as much as I can and the pain went away. I am a pretty active person, and just couldn't sit out during the summer while I trained. I didn't think much of the injury since it was a busy summer for me and didn't know that it is that big of an injury. I trained and ran with it and played basketball with it all of 2018. I adjusted my gait so I don't put pressure on it and that lead to other problems such as calf tightness and knee pain and hip pain.
Dr. Blake's comment: Thanks for being honest. I know we all try to just live with it with the eternal hope that it will eventually get better. At your age, I would have been doing the same thing, so no guilt allowed.

I stopped playing around a couple of months ago since I knew it wasn't really healing so I didn't want to risk it (Which I already did by running on it that whole summer.) I visited the doctor on 1/30/2019 and he took an X-ray where it was found that I completely broke it. The doctor said I have to get a procedure to take out the bone ASAP and referred me to a surgeon. I talked to the surgeon and he basically just told me about the recovery time and things of such and I told him that I read some people never return to 100% and he agreed and told me to just sleep on the option of surgery. He also said it has no chance of healing since there is no blood supply to this area. It doesn't look like it is a huge break, but is there a chance of it healing without surgery and could it union? I attached the X-ray picture to this email. I came across your blog because I was desperate and it has been so helpful. Please get back to me. 

Thank you so much

Even though this is alittle blurry one can see the obvious crack with jagged edges

Dr. Blake's comment: Okay, you got yourself in a bind. Please understand that there is no gap between the fragments, so the bone contact is good for healing. Yes, these heal slowly so the rest of this year will be dealing with your sesamoid in one way or the other. I am sorry when some of my patients need surgery after a long battle, but since the majority heal fine, the battle is always worth it. Plus, even if you need surgery, you will have the orthotics and dancer's padding that will protect the other sesamoid in high impact sports your whole life.
     So, you have to create the 0-2 pain level, get a bone stimulator, start doing daily contrast bathing for swelling reduction which improves circulation, get a Vit D test to make sure you are fine there to heal a fracture, eat healing, cross train with biking, swimming, flat footed eliptical, get Dr. Jill's dancer's padding at 1/8th inch and 1/4 inch for various shoes, get good custom orthotics to take pressure off the sesamoid, and learn spica taping and cluffy wedges and see if important for you. Some of my patients love some of the Hoka One One shoes, but that depends if the roll is in the right place. Zero drop shoes are better in general than traditional shoes. I hope this points you in the right direction. Rich