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Sunday, September 27, 2020

Big Toe Joint Pain after Immobilization: Email Advice

Hello Dr. Blake,

I feel very fortunate to have found your blog. I recently suffered a Jones 
Fracture and had
 surgery to implant a titanium screw in the 5th metatarsal in early July. 
The first x-rays from the 
break also showed mild great toe arthritis (I had some pain in the toe, 
but no problems putting weight on it at all). The most recent x-rays from 
September 
show the 5th metatarsal healing well, but significant arthritis in the great 
toe, and now it 
is painful to push through (I am wearing Hoka shoes now and having an
 orthotic made). 
My podiatrist/surgeon immediately suggested a joint fusion of the great 
toe despite the 
fact that the recent surgery and non-weight bearing recovery was quite 
traumatic for me, 
and I still have movement in my toe and am in physical therapy. I would 
love any insights 
you may have as to why my toe arthritis may have worsened so much 
while in a boot, and 
most importantly, if you could suggest any doctors in the 
Seattle/Bellevue, Washington area 
who are more in-line with your way of approaching Hallux 
Limitus and Hallux Rigidus. 
Thank you so much for your time and wisdom.

Dr. Blake's comment: My job is so easy when I can sound smart using 
common sense. You
do not need a big toe joint fusion, at least for now, and hopefully not for
 a long time. Immobilization 
for whatever the reason causes joints to freeze up. Arthritic joints love motion, 
not excessive, but they love to 
move since it helps them to lubricate. Email me how you are doing in 3 months 
and attach this post 
so I can refer to it. But, what to do now?
The Hokas with their rocker sound great. The orthotic can be helpful or 
not at this stage, if not, it may be 
helpful later. Learn about dancer's padding and spica taping and experiment. 
Do not let the physio try to increase range
of motion, it tends to backfire. The goal is to reduce pain, not increase range 
of motion. You can review 
my video on self mobilization which may help. Ice 3 times a day for 10-15 
minutes to cool off the joint. 
Again, non weight bearing does not help, so gradually try to find the amount 
of day to day walking you 
can do and keep the pain down. Since I would rather you walk 10,000 
steps aday than not, this is where 
the shoes, orthotics, dancer's padding, and spica taping come into play. 
What helps when?
The PT can do iontophoresis to the joint to calm it down if you can get 
a script for it. 
I would rather you back in a walking boot for 2 months, with the emphasis 
on walking, then not walking. Give me
an update soon. I will try to find someone in Seattle. It is a great place 
with good podiatrists. Rich
Good luck!!







Severe Ankle Pain after Working Out: Email Advice pre-flying internationally

Hello, Dr. Blake -

I have been reading your blog quite a bit lately.  It’s very informative, thank you!  Unfortunately I’ve got some pretty debilitating pain in both of my feet.  I noticed the pain about 3 weeks ago.  I woke up one morning, and on my way to the bathroom I felt a pop! in my right foot and it was quite painful to walk.  I went back to bed and thought it was just a strange thing that happened.  When I got up for the day, I again felt some pain, but it went away quite quickly as I walked around the house.  I routinely do High Impact HIIT classes at home and the day before I felt this pain, I did a workout that I have done many times before but with a different pair of shoes. (Long story short, they were the only shoes I had).  

After that, I stopped any working out that required standing up, jumping or weight-bearing.  However, I did not stop walking or standing.  As time went on, my movement has been more and more restricted.  I am using crutches to get around.  I do not walk anywhere except to the bathroom, bed and kitchen.  It is awful.  I use ice, NSAIDs and rest, rest, rest.  I tried some ankle braces, but they feel too tight now.  The pain started in the inside of my foot, below the ankle.  I notice inflammation and warmth in that area after use.  

I cannot walk normally on my right foot and if I do, I feel it in my arch.  I do not even attempt a one leg lift.  The pain started in my left foot (same area, below ankle near arch) about a week and a half or 2 weeks after the right.). The pain has at some points in time migrated to other areas, such as below the arch, above the ankle bone on the inside of the leg and even an almost pinching sensation on the outside of the ankle.  I have also had pain at the top of the ankle when I step (upon waking up) and shin splints pain on the left leg, soreness in the ball of the foot and even on the heel.  At times my calves feel pretty tight, but I have stopped doing stretches because I don’t want to aggravate anything.  I am pretty sure it is PTTD, but I need to go to the doctor for a proper analysis. 
Dr. Blake's comment: It sounds like some version. Do you have a history of flat feet? Or a history of other foot problems? Can someone take a photo of both feet standing, that I will attach to this post, one from the front, the inside arch and one from the back of the heel? And, while you are at it, a good photo of the original injured ankle area? 

We are currently abroad but flying back to the US in 3 days.  Once we return, all doctor’s offices require 14 day waiting period (Coronavirus requirement) before coming in.  So I just have to be patient.  I have two young children and am a stay-at-home Mom.  I am physically fit and normally very active.  I am so incredibly frustrated that I have admittedly started crying.   I am trying to be patient.  My question is, what can I do in the next few weeks before my appointment to try to improve the situation?  How can I manage an international flight with 2 toddlers, crutches and luggage?   Is there anything I can do beyond RICE? 
Dr. Blake's comment: Yes, try to get a below knee boot for the worse side and the posterior tibial tendon dysfunction brace by aircast for the other side. You have to carry things evenly on your back with a backpack, and walk slow if you can. You could switch to hiking poles from crutches. A local pharmacy may have the boots, but maybe Amazon can rush them. 

Oh, I just bought new shoes yesterday that are softer on my feet than the ones I was wearing.  (I tried to get the Brooks Ariel that you had suggested in a separate blog, but they did not have it.  I just bought the type of shoes I was working out in before I switched.). Also, while the past few days I have noticed that the pain/swelling is occurring earlier and earlier in the day and will come back sooner, the pain has remained localized near the arch of the foot.

I went to urgent care here in Switzerland.  They said it did not appear to be a bone issue, that I would likely need an MRI for proper diagnosis.  She said it is possible there is a very small fracture, but that is all speculation.  She did say it was concerning that it was worsening.
Dr. Blake's comment: During the flight, swelling can increase your chance of blood clots. Get some 20-30 mm Hg compression hose to wear on the flight and keep your feet up and moving up and down at the ankle 20 times every hour. If you went to an urgent care, maybe call them for any other advice. Get some form of baggie, and apply ice (that the plane will have) 15 minutes every hour to hour and a half to the ankles. Maybe plan on going there one more time the day before you leave for advice. Ask the crucial question if you should fly in the first place. 

At this point I feel like I will never walk again. 😩  I am so afraid that it is degenerative and I have already done too much damage that I will not be able to reverse.  Any recommendations or even words of encouragement would be extremely helpful.
Dr. Blake's comment: It is rare to have a permanent situation days after doing high level workouts. I think you have not immobilized enough, first phase of rehab, so get to it. It is something you can control. I await the photos, etc. Rich 

Thank you so much,

Sunday, September 20, 2020

Sesamoid Injury: Email Advice

Good afternoon Dr. Blake,

I hope this email finds you and yours well. Your foot and ankle injury blog and videos have been a great resource for me as I have been dealing with a sesamoid fracture/injury since late Feb/Early March. 

Essentially, I'm not sure how I fractured my sesamoid, but I didn't have a great podiatrist at the beginning of the injury, which, coupled with the quarantine (I'm in NYC), essentially means that I lost 3 months of proper treatment right away. I had x-rays and MRI with this doctor, but everything was taken very lightly. I was told it was maybe fractured, then just an itis, with no clear plan of how to get it to heal. I had to wait til June to get an MRI (now I know I should have had one right at the beginning.) It was all downplayed a lot and I even had to ask for a boot but with no instruction of how long to wear, when to wear, include dancer's padding etc. I stayed in the boot on and off for March/April but with no dancers padding and only outside. Inside I used slippers but was sometimes barefoot. Then in May/June (what is time anymore!?) I went to an orthopedic surgeon who saw me for 15 minutes and told me to get custom insoles, which I did get and now have for sneakers. I still knew something was wrong because I still had pain walking in the sneakers and did not feel comfortable putting all the weight through the ball of my foot and it just wasn't getting better. Fast forward to July, after getting more x-rays and a CT scan with a different podiatrist, he confirmed a fracture diagnosis, put me back in the boot and now I'm using a bone stimulator. I've been in the boot since July 29th and have been using the bone stimulator since August 17. Sometimes I use it twice a day. I've attached my MRI and CT scans below (if you'd prefer access to the portal to view all the images, I can certainly provide that).
Dr. Blake's comment: So sorry for the delay, but it did not sound like you made it worse, and it is sounds like good progress now!

As I've read from so many people who have this particular injury, it is incredibly frustrating, with little understanding of it, and very prone to setbacks. Right now, I'm wondering what else I can do besides the contrast baths, taping etc. I have gone to PT but haven't gone as much since I am back in the boot and am trying not to travel extra to the city. Plus I do a lot of leg strengthening at home. Should I be refraining from walking as little as possible and pretend as if this fracture happened yesterday and not in March? 
Dr. Blake's comment: Create the 0-2 level, walking within at framework actually is better for the muscle strength, bone demineralization, sanity!! There is no guarantee of complete healing for many reasons, but 3 straight months of immobilization in the walking boot, and then another 3 months of keeping the pain between 0-2 as you wean out seems vital to alot of these injuries. Unfortunately, the initial trial of boot does not count. 

I really want it to heal, yet I feel that this is going to be another 3 months, at least. It's so sensitive and a tiny little thing seems like it causes a flare up. My legs/feet and left foot just feel off/bad from being in the boot and even up on the left foot for so long, on and off this year, and I'm honestly afraid I'm not going to remember how to be in sneakers or how to eventually transition back into wearing them.
Dr. Blake's comment: It is not a waiting game since there are some many things to do now to prepare for the weaning out of the boot period. You need to make sure that your orthotic devices and dancer's padding off weight the area (so some visits with good shoes to the podiatrist office to make sure all is well is important). You want to have perfected spica taping, and have some stiff dress shoes for the holidays so you can place in Dr. Jill's Gel Padding as protection. PT is less important now since you are back in the Immobilization Phase, but without irritating the sesamoid, you need to keep strong, flexible, and with infrequent flare ups (but they will occur even in the best situations). 

I do ride my bike sometimes (walk down the stairs in the boot, switch to sneakers with insole etc-it's a process!) but sometimes even if my steps add up to 1 mile each day, that seems to aggravate my foot. It's all very frustrating :) I really want this to fully heal as it's been many months now. If you have any additional insight on my particular case, I would be so grateful! 
Dr Blake's comment: The 4 common areas you need to deal with are: protection (just discussed with boot, orthotics with dancer's padding, dancer's padding alone, cluffy wedges, spica taping, stiff shoes, or rocker shoes like Allegria dress, or Hoka One One type), inflammation (ice and contrast bathing very important, NSAIDs and cortisone shots can slow bone healing, and PT when needed), nerve sensitivity (pain free massage 3 times daily, big toe joint gentle range of motion with your muscle strength only, occasional topical or oral nerve stabilization meds), and bone health (eating habits, low vitamin D, smoking, etc). 

Thank you so very much.

My Best,
Dr. Blake's comment: So, now to the images you so kindly sent. A question I have was there a fall or accident before your symptoms developed since they have a diagnosis of medial sesamoid chronic ligament sprain? Also, any sesamoid injury which is definitely bipartite we need to know if you have a possible turf toe injury also. This is where the ligament is sprained, and the joint can become looser, and possibly require surgery. I assume since you did not mention anything, the doctors have ruled it out, but ask them about it and also if they have done bilateral Lachman tests for joint stability. The sprain can also just cause excessive scar tissue that gets in the way. 
Possible AVN in definite bi-partite. You can fracture the junction between the 2 pieces and the treatment may be the same. 

Here less AVN looking with bone marrow. Bipartite pieces are different sizes

Here T2 MRI clearly shows no AVN!!

Turf Toe Possible Raised when Ligament Sprained


Sunday, September 13, 2020

AVN Sesamoid: Email Advice

Hi Dr. Blake,

I’m so happy to have found your blog and YouTube videos, and I hope you can provide some insight and guidance for my situation:

About me: 38 y/o female, chemistry professor by day, professional belly dancer by night and aspiring amateur Muay Thai fighter all day, every day (thai kickboxing).

History: late in 2019, I started noticing some pain in my left big toe upon extension. The pain was never severe, so I kept training. Nothing a little tape wouldn’t fix (or so I thought). Then the pandemic hit, and I started running a lot since my gym was closed. The pain got worse, I did less and less. Still, the pain was never terrible but it was persistent. I saw my podiatrist, and he diagnosed me with AVN of the fibular sesamoid by MRI in early June 2020. This was confirmed with spect CT in early July. My x rays were normal, there was no apparent fracture or degeneration. Both the MRI and CT showed some soft tissue inflammation/edema but no tears. I went in a boot for 6 weeks, and I was given a bone stim (ortho fix) that I’ve been wearing for 3 hours a day for almost 3 months. My pain was at a 0-2, so I have been attempting to gradually step up my activity, but it seems that it’s always 2 steps forward, 2 steps back. My PT primarily does manual therapy, and I’ve been doing toe yoga and trying to go for walks or short hikes (In the shoe recommended by my podiatrist - hoka Bondi 6). Anytime I do this, my foot starts to swell again and be painful. I am so frustrated.

Here is my dilemma - I also have some mild/moderate scoliosis, and the lack of activity has severely flared up my back pain - to the point that the idea of spine surgery has been floated by my sports med doctor. As a result of the crooked spine, I have degenerative disc disease (Several herniations, stenosis and facet joint arthritis) that I have been keeping in check by remaining fit and active. Resting my foot and doing seated exercises (like a stationary bike) has been hell on my back. Obviously, abnormal gait and wearing a boot didn’t exactly help my back either. I need to get back to my regular training/dancing schedule to ensure that my spine stays functional and I avoid back surgery.

What is the best course of action to return me to normal activity as soon as possible? In your experience, does this type of injury heal with conservative treatment and is the person able to return to their activity? I’ve scoured the literature, and the lack of studies is frustrating, and what little there is focuses on surgical treatment. How do people fare after surgery in your experience? I’m not keen on doing unnecessary surgery but I am trying to balance the needs of my back with the needs of my foot. Lastly, what is your opinion on the use of NSAIDS during AVN? I am concerned about the anti-angiogenic effects.

Thank you for taking the time to read this and consider my case.

Kind regards,

Dr. Blake's comment: Definitely switch out of the boot for your back and into some bike shoes with embedded cleats. This will provide evenness in function and weight between the two sides, something your back will be happy for. Your physical therapist should be able to put you on a program to keep your back loose and strong as you go through the foot rehab. When will you get another MRI? I usually wait 6 months, but in your case, every 3 months to see some light at the end of the tunnel with the AVN healing. In your whole discussion, you mentioned nothing about all the other things besides Hokas: orthotic devices, dancer's padding on the orthotic and separate, cluffy wedges, varus cants, spica taping, carbon plates with first ray cutouts, etc. Send me a photo of coronal view injured sesamoid both T1 and T2 weighting to see the AVN. And yes, no NSAIDs, but you should be doing contrast bathing for deep bone flush and circulation every evening. Rich 

Tuesday, September 8, 2020

Article on Hamstring Tightness and Plantar Fasciitis

https://journals.sagepub.com/doi/10.1177/1938640010397341

     I have to admit that when patients present with plantar fasciitis I fail to measure hamstring tightness as much as I should. This is a good reminder that plantar fasciitis been be shown to be associated with achilles tightness, with pronation, with obesity, and with tight hamstrings. It is important to stretch out the tight hamstrings when plagued with plantar fascial symptoms. 

Liz, a nurse which used to work with me, discusses 7 principles of stretching while stretching the lower hamstrings. 

Sunday, September 6, 2020

It is Just the Wrong Timing of Events: Athletic and Other Injury Rehabilitation

     I am saddened when patients prolong their injuries with the Wrong Timing of their Treatments. Many times it is only because the definitive diagnosis has yet to be made. Many times it is because the health provider has too short of range of options to offer (as I do sometimes). Many times it is because the patient is impatient for a cure, or the subtleties of any treatment regimen is not followed or fully explained (and thus the patient keeps irritating things). And thus there are so many variables, so many different provider that will practice their treatment protocols, that I have found following the 0-2 pain level in all treatment phases must be followed. I know only some good physical therapists that can make you hurt and still get you better. I know that when surgery is required (1-2% of all athletic injuries) you will have more pain for awhile. But, in general, after you get the proper diagnosis, you should get better and better on a month basis (so September should be better than August, and October better than September, etc). 
     So, you develop pain with or without an injury. If the pain is between 0-2, and you can do full activities, you can probably wait a month before you see someone (and maybe the pain will go away by then). Of course, when you do see someone, you expect their diagnosis to be correct (which it normally is by the way), and month by month you get better and better (I assume 3 months on average to greatly improve if the injury requires a doctor visit). It is important in my mind to drive the pain down to 0-2 as quickly as possible (a week for sure), and then keep it there. This could initially be done by stopping an activity, put in a cast, and/or up on crutches. This is how you know you have the right diagnosis and treatment plan. You should be able to increase function, with no increase in pain, month by month. Of course, if your diagnosis requires a cast or boot or surgery, you may not be able to start that progression to full function for several months. In these cases, the diagnosis is definitive from the start (verified by xray or MRI or ultrasound).
     So, that is the Right Timing of Events: Injury or Pain Development, Proper Diagnosis and Treatment, Pain Quickly Down to 0-2, and Pain Kept There as Full Function Returns. Sounds simple, but it gets messed up all the time due to the limitations on medicine listed above. And, we can add insurance issues that block both diagnosis (say inability to get MRI) and treatment (do not cover the expensive bone stimulator you need). The patient is carefully moved through the phases of rehabilitation (immobilization, re-strengthening, and return to activity) and all goes well. 
     I will give you 2 recent examples of the Wrong Timing of Events. The first was a patient that partially tore her achilles, pain level 6-7, limping. She went to the local hospital clinic, and received 3 stem cell injections one month apart as her only treatment. No cast. No driving the pain to 0-2. And, no better, so 5 months later comes to me for a second opinion. This is one of the top hospitals in the country, or so they advertise.  The second was a patient whose plantar fasciitis was improving with orthotics, taping, icing and stretching, but when she had a flare from running too much on the weekend, when the pain got to 5-6 from the 0-2, all the doctor did was put some more padding on her orthotic devices and give her a Rx for PT. This does not sound bad, but she had never had this much pain, and it took 3 weeks to see the PT for the first session (which is typically just information gathering). So, one month went by, the heel padding had made her worse, the PT really not started, and her pain from limping had increased to 6-7 levels. The doctor had a second chance to right the ship, but again the orthotics were adjusted, and taping was applied which did not help. She clearly had a severe flare of her plantar fasciitis or a new injury. After seeking a second opinion, due to the level of pain, an MRI revealed a calcaneal stress fracture, and definitive treatment started. So, when the pain you are treating gets worse, ask yourself if you still believe in your working diagnosis first, and ask how can I reduce this patients pain to 0-2. 

Friday, September 4, 2020

Bi-Partite vs Fracture in the Sesamoid Bones

Hey, I came across your site yesterday while doing some research. I have been dealing with some pain on the side of my left big toe joint since December of last year. I initially went to a local orthopedic where they x-ray both feet and they said I have bipartite sesamoid on both feet. They didn't really have any answers as to why I am experiencing pain though. I am able to run fine but and the pain is more of an annoyance than a debilitating pain. I can run for 3 hours or even do hike/runs for 6 hours and the pain doesn't get any worse. I would say the pain level is between 4-6.
Dr. Blake's comment: To most of my patients, pain levels over 2 and they are going to the doctor, and over 5 they are not running at all. 

Just walking around the pain is at a 1-2.

I recently went to a podiatrist foot and ankle specialist and he immediately said I in fact have a fractured sesamoid on my left but the right is a bipartite sesamoid.
Dr. Blake's comment: Only an MRI is conclusive, but to me they both look bi- and tri-partite with smooth borders. Sesamoids that are in multiple pieces congenitally can get irritated, even the junction between the bone fragments sprained or fractured. If you are not getting an MRI, you have to go by the amount of swelling, the level of pain, and use comparison xrays 3 months apart or so that will show a change. A broken bone will change and the xrays after 3 months will show that difference. Month to month changes will be less definitive. Unfortunately, when I have a decision between fracture and bipartite, and I can not get a definitive MRI, I treat it as a fracture with a cam walker for 3 months and I definitely do not allow my patients to go over pain level 2. 







He said I could try some custom orthotics or have surgery to remove it and that would fix the issue. Attached are images of the x-rays.
Dr. Blake's comment: To do surgery on a probable in your case non-fractured sesamoid is pretty absurd. So, custom orthotics (which should be only one of 10 things you are doing for your sesamoid to drive the pain now and let this heal: removable boot, hoka one one rocker shoes, spica taping, dancer's padding, cluffy wedges, activity modification, icing, contrast bathing, bone stimulator, and some PT to get their advice). 

If I get the surgery will I be able to run again? I am a competitive trail and ultra runner and I also race mountain bikes.
Dr. Blake's comment: Typically, unless you are the 1 in 10 that gets some complication, or has other unknown factors at play, you can run again, but the sesamoid bone will have to always be protected. Always. And this is why patients fight getting the right diagnosis and right treatment no matter how long it takes. Good luck Rich 

thanks