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Sunday, November 29, 2020

Video Chat to Patient with Avascular Necrosis of Lateral Sesamoid Discussing Surgical Success

Video Chat to Patient with Sesamoid AVN and Contemplating Surgical Removal of Damaged Sesamoid

Saturday, November 28, 2020

What does Sesamoid Avascular Necrosis (osteonecrosis) Look Like?

Bone Fragmentation is Noted in AVN (here of the lateral or fibular sesamoid

This view showed the tremendous inflammation between sesamoid and metatarsal (this is actually why the patient hurts)

Another view of the fragmentation on CT Scan (these pieces will never come together)

The view is T1 (meaning healthy bone should be white) of the bottom of the foot

This view is T2 (normal bones can look like this) but the T1 and T2 should be different. You can tell the lateral sesamoid is both darker than the medial sesamoid and the white within is just the inflammation seen between the fragments.

So, it you just looked at T2 here, you would be misled as the sesamoid are darker, and there is tremendous inflammation within the joint.

This is crucial to making the diagnosis of AVN with the lateral sesamoid dark on the T2 above and T1 here. A fractured sesamoid can be dark on T1, but should be very bright with inflammation noting healing potential on T2. 

I discussed with the patient, who has had 2 years of pain, that AVN has occurred and removal of the lateral sesamoid is recommended. However, if he wants to try one more year of conservative treatment, even when the fragments will remain separate (some of these just do not hurt), then daily Exogen bone stimulation, contrast bathing twice daily, and some regimen of acupuncture, could be tried. 

Wednesday, November 25, 2020

Video Greeting from Dr. Blake and Happy Thanksgiving

Gout love Ice Better than other Inflammatory Problems!!

The following article presented a discussion on ice versus heat. It seems that if you are having a gout attack, ice packs for 10-15 minutes prevail. Some of the other forms of inflammation actually prefer heat like in wear and tear arthritis. I will have to rethink my recommendation of "When In Doubt, Always Ice!" I still feel the patient must experiment to see what makes them feel better. Rich 

Schlesinger N, Response to application of ice may help differentiate gouty arthritis and other inflammatory arthritides. J Clin Rheumatol. 2006 Dec;12(6):275-6

Monday, November 16, 2020

Hallux LImitus: Can I Avoid Orthotics?: Email Advice

Hello Dr. Blake, 
I came across your article  “ Treating a runner with Hallux Limitus who does not want to stop running.” while searching online for advice to keep running after being diagnosed with Hallux Limitus with bone spurs. 
Is it possible to keep running with this diagnosis without orthotics?     I run in Brooks Ghost and put in about 15 miles/ week. Can I run in my Brooks with the medium gel toe separator and avoid additional injury to the joint ? 

Any advice is greatly appreciated. 


Dr. Blake's Response:

Hallux limitus is a slow gradual progressive degenerative process when there are spurs. I have had runners for 30 plus years continue running, but there is no magic cure. The goals are to protect the joint with decreasing stress somehow, never run with pain over 2, and especially no limping. Running itself is very natural for the body building strength in muscles and bone, and has a huge emotional aspect. It is part of any athletic participation program, and I think vital to people’s health. 
    The goal in the short term is to continue running your 15 miles per week, while you build a program to keep the pain level between 0-2. Orthotics themselves can both hurt and help, so typically not my #1treatment unless you are a moderate to severe pronator. Pronation jams the big toe joint into the ground increasing the stress. The orthotics have to be full length and require expert attention since the rigidity under the big toe joint in a full length orthotic device may be too much pressure to the joint and have to be modified.
    So, in achieving this 0-2 pain level, without going over the physics of each one, include the following which predictably decrease stress on the big toe joint: spica taping, dancer’s padding, hoka running shoes with rocker bottoms, cluffy wedges, arch supports, Morton’s extensions, shoes with great forefoot cushion like the Ghost, etc. 
    My blog talks about this individual treatment options. I hope this makes sense. Rich 

Saturday, November 14, 2020

Sesamoid Break with Pain Out of Control: Email Advice

Hello Dr. Blake-

Looking for an opinion and I have hit a wall I feel like. I have 4 year old twins in this past June they ran over my feet while riding in their power wheels (accidentally) causing my Sesamoid bone to break.

 I had xrays to confirm it (Drs were able to confirm it was a break by comparing previous xrays two years ago showing the bone was not broken). I was immediately put into an air boot and for the first two months followed with xrays each time showing no healing. I then was sent to an orthopedic who recommended foot orthotics however after going from the boot to the sneaker with orthotics the foot got worse and my tendon between the big toe and the toe next to it became irritated.

 I was then sent to a podiatrist who put me back in the boot and had me tape the big toe 24/7 and xrayed me each month through September, still no signs of healing. In September he gave my a cortisone injection which was horrendous but after two weeks it did calm the area down but that only last until about two weeks ago.

 I saw him at the end of October and he has me taping 24/7 the toe next to the big toe and staying in the boot fulltime other than to sleep. Now my entire foot is swollen, I have pain not only where the Sesamoid break is but now across my toes, top of my foot, and it wraps around my ankle to the achilles and back to the inside and underneath the arch of my foot. I have swelling and bruising in all of those areas and have also started to bruise just above my joint where the foot meets the leg (lower shin area).

 The pain in my ankle and achilles is almost unbearable in and out of the boot. My podiatrist has requested me to have an mri but hasn't scheduled it yet and I don't go back for xrays again until next week. Since June I have had it elevated every night and use ice packs. I can’t take any anti-inflammatory medications because I have an allergy to nsaids and ibuprofen which has made it difficult to control the swelling and pain. The podiatrist did try me on prednisone before the cortisone shot but it did not work and gave me arrhythmia so he discontinued that.

 I am a 35 year old Mom of 3 all under the age of 10. I am extremely frustrated but also worried that we are missing something. Does it normally take this long to heal and also can other ailments occur from the Sesamoid taking so long to heal? How concerned should I be regarding the new areas of extreme pain and swelling? I feel like my doctors down play it and I just don’t want to keep getting worse. Is there maybe some other diagnoses I should suggest being checked for now? 

Maybe someone not from my area like yourself may have other suggestions that I could inquire with my doctor about when I go back this month? I have included pictures. The first three photos were from Friday and the last one with painted toenails is from tonight. The swelling is all over the place and up and down consistently since June. I am not a diabetic, I am not severely obese (5”7 160lbs). My only medical history is allergies to medications, graves disease that I take thyroid medication for, and I had a hysterectomy after my twins 2 years ago and take estrogen every day as a replacement. Thank you in advance.

Dr. Blake's response: Thank you so very much for your email. Initially, you were just treating a broken sesamoid which is in some form of healing or non-healing, but that is not what you should really work on now. You have developed perhaps a nerve hypersensitivity from the chronic pain and prolonged immobilization. Go to the doctors, and say CRPS has been suggested as your pain is out of control. The treatment for this should be now, so I would forget the broken down until this is addressed. The mottled skin in the photos could be a sign of CRPS which stays for Complex Regional Pain Syndrome. You may need a sympathetic block in your back. I developed CRPS personally after a herniated disc in my back, and I was literally rushed to get the injection. You need to throw this word around until someone takes you seriously. Typically you may have to go to the ER to start the process, but any doctor who agrees with me can get you going. If it is not, great!! If it is, the sooner you get treatment the better. Rich