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Saturday, August 24, 2019

Blog Contact Question #4: 2nd MPJ Capsulitis

Dear Dr Blake,

I found your podiatry blog, and was hoping to be able to ask you a question. I also tried to make an in-person appointment (I'm also in the SF area) but was told your appointment slots were booked for the next two weeks and then you're on vacation until October. I'm looking for a second opinion - I was diagnosed with 2nd mtp capsulitis in February, after a 4 mile hike where my (left) foot started hurting and by the time I got home it was very swollen and painful. Ball of the foot, felt like around under the 2nd toe but it's a bit hard to tell exactly. Was taped up and eventually put in a walking boot for 10 weeks. Got an x-ray to rule out stress fracture, which was clear. During that time, I started to get pain in around the same area on the other (right) foot, but slower onset/less severe. Was fitted with better shoes and custom orthotics (apparently have very high arches). All of these things helped, especially the boot, but the improvement post-boot was very very slow and not much improvement at all on the right side. My podiatrist is confused that it wasn't improving as quickly as he expected. 

I pushed for an MRI, last month, and the MRI report came back saying only a stress fracture of the left tibial sesamoid - but there's no pain there. Absolutely none, not even if you poke at it. (If it had said fibular, I would be less confused, that's kind of close to where the pain is on the left and almost exactly where it is on the right.) My podiatrist thinks it was just an oversensitive MRI and I should ignore it, but I want to get another opinion on:

1) is there or is there not a stress fracture (so I know if I can safely ignore it), 
2) confirm if it's actually 2nd mtp capsulitis, or sesamoiditis, or something else, and 
3) if there's anything I should be doing to speed up healing based on what you think it is.

I am happy to send along the MRI images if you'd like; I notice a mention of some WeTransfer protocol on your blog that I'm sure I can figure out. I would be happy to make a donation or whatever else for your time; your blog is truly a public service.


Dr. Blake's comment: I am so sorry I am not available for much of the next 2 months. Try the WeTransfer or drop by the office with the CD before this Thurs at 5. What is striking in your description above is that you are not using Budin Splints or taping. These are a must for 2nd MPJ capsulitis. High arch feet also have more pressure on the metatarsal heads and the orthotics may just be making this worse. The direct treatment is accommodative padding with some simple metatarsal support. You can see my partner to begin this type of treatment Dr. Jane Denton in my absence. The video below talks about the taping, but see the blog for references for budin splints. You should be icing twice a day for 5 minutes minimally, and try the new Hoka Shoe with carbon plate to see if it helps. You can also try the normal athletic Hokas. Rich

Accessory Navicular: Email Advice

Dr. Blake,

I happened upon your blog and found some very useful information about Accessory Navicular.  I have a unique case according to my podiatrist and wanted to share and get your opinion. 

I am a 40 year old teacher.  I only discovered anything about accessory navicular around 3 years ago.  I have always had intense pain tolerance and can remember in college after waiting tables I would curl my feet and walk on just the outside heels and toes to relieve the pain. 

I have Accessory Navicular in both feet.  It was never discovered as a child or young adult.  I played athletics and did pointe ballet for many years.  The problem increased as I got older until the pain was constant and it did not matter what I did to alleviate the pain , stretching, ice, rest it was always there. 

3 years ago I made the decision to go to the podiatrist and they made this discovery I was quickly fitted with a Richie Orthotic on both feet.   It immediately changed my pain level.  Was it still painful yes but I could now walk again and for long distances and could stand for long amounts of time again, it was wonderful. 
Dr. Blake's comment: This is a ankle foot orthotic device.

Recently I have had a change in pain in association with the Accessory Navicular on both feet.  It has come back and it is intense.  It seems as though my Richie braces while still providing some support are now not doing all it was doing even 6 months ago. 

I have been told I am a candidate for the surgery but it puts me out for quite a while and with having this condition in both feet the concern is favoring the non surgery foot and intensifying the already agitated condition.  

Do you have any suggestions?
Dr. Blake's comment: Sometimes you just have to rest the area for a while to get it to calm down again, while you are gradually strengthening the posterior tibial tendon. Flareups should not be construed as reasons to do surgery. See the videos below on a gradual posterior tibial strengthening program (6 months) and the taping technique (also 6 months). Icing 3 times a day to decrease the overall inflammation for 10 minutes a session. Below the knee boot for 4 hours per day to rest the area per foot, alternating back and forth. You have to have a EvenUp on the other side to balance. You should know if this is starting to calm it down over the next month while you continue to be the teacher of the year!!. I hope this helps you start going in the right direction. Rich

Thank you for your time and consideration


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


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. 

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.

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: 
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.

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.


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