Fat Pad Atrophy: Email discussion

This patient has fat pad atrophy post cortisone shot one heel and sesamoid area other foot. Here is a discussion we recently had regarding a procedure to move the fat pad placement and inject stem cells to encourage fat regrowth. The doctors are up in Pittsburg, Pennsylvania. I have reviewed the MRI for her noting tremendous scarring of the fat pad at the heel called panniculitis. 


Hi Dr Blake,

I wanted to get your opinion on this procedure. I have lost fat on the lateral side of my left heel as well as under my big toe (same foot) due to a cortisone injection for plantar fasciitis and sesamoiditis. Unfortunately, I haven't found any shoes that help or inserts, taping, etc. I've been doing a lot of research and found 2 doctors performing the Foot Fat Grafting. They're married, the wife is a podiatrist and the husband is a plastic surgeon. It seems like they've had good results for far in their pilot and research study.

What are your thoughts, do you think it's worth trying? I'm only 28 years old and the pain is unbearable. I just want my freedom back.

http://footfatgrafting.com/index.html

https://www.ncbi.nlm.nih.gov/pubmed/27391833

https://www.podiatrytoday.com/can-autologous-fat-grafting-help-address-fat-pad-atrophy-patients-diabetes

Thank you!

Dr Blake's comment:

      I reviewed and found the articles interesting and hopeful. They would, of course, recommend it if you went there. You would need a doc near you to followup, and hopefully, someone independent to think your pain is from the fat pad atrophy also. But, it sure makes sense. Rich

Thanks, Dr Blake. I've had one doctor say it'd atrophy but then others haven't. It's hard because I hear so many opinions, a lot of "plantar fasciitis" but I have the scarring in my heel fat pad that is shown on the MRI. They will do ultrasound prior to the procedure to confirm the thickness 

Dr Blake's comment: 
     I read their reviews. Also, see if you can talk to one of their patients. 

I spoke to one of the patients yesterday and it sounded promising, she only had it done 3 months this ago so hard to say if the fat stays and if the stem cells from the fat help with new growth of the fat pad

Dr Blake's comment:
     I was thinking the same, but as long as we get good results probably does not matter!

They are doing a volunteer study for the heel which I'm going to apply for so it's free. Worth a shot. I'll keep you posted in case it might help others. 

Tuesday's Question of the Week: Multiple Pain Syndromes: Email Advice

Dear Dr. Blake, 

I have been following your blog for two years now.  I credit your blog for keeping me walking. The tips and advice I have read have helped me along this far.

I am a 41 year old very healthy female.  Until November of 2009 I was a runner, recreational athlete, and yoga instructor.  I woke up one day in November and noticed my knees were aching.  I had replaced running with using an elliptical trainer due to separating my shoulder 9 months earlier.  I thought maybe the elliptical was causing an imbalance, so I beefed up my hip strengthening at the gym.  My knees continued to hurt.  I saw an orthopaedic surgeon. I had an  Mri of both knees ( 3 times), went to physical therapy.  Physical therapy made things worse.  I developed quad tendonitis.  I could not bend my knees.  Sitting with bent knees was excruciating .  My knees burned and would get very hot and red.  I found a new doctor.  Then another doctor and a chiropractor.  Had RA labs drawn ( 3 times) .  All negative.  Found a biomechanics expert.  Started working with him exclusively. I made a little bit of progress. 

Two years later my left foot started to hurt and my entire lower leg. Then both feet and lower legs started to hurt.  Peroneals, post tib, calves, the ball of my foot. I could no longer stand barefoot ever. I wear shoes in the shower. I started going to podiatrists after ten days of unexplained pain.  I went to five different doctors in my area.  All found nothing.  All insisted I did not need orthotics. One went so far as to say he wished he had my feet. He said he thought I had fibro. He said orthotics are golden arches and to not to come back unless I broke my foot.   I had previously visited a physiatrist at University of Florida who ruled out Fibromyalgia. 

Dr Blake's comment: If you have pain in your foot, some form of orthotic device can help. There is a infinite range of devices to work with and all the variations of support and cushion and off weight bearing. 

I found your blog.  You advised a reader to look into Barry University.  I found a doctor a few hours from where I live.  The minute they looked at my feet I knew something was wrong.  They could not believe the atrophy of the balls of my feet for my age. They recommended orthotics.  Another option was sculptra injections in the balls of my feet.  My first pair of orthotics were made of hard plastic and the heel cup was too small.  I walked around on those orthotics for 3 months, then my heel fat pads started to thin, but my knees started to get better!   Orthotics were sent back and I was referred to another doctor to start sculptra injections.  New doctor made softer orthotics and injected sculptra.  The sculptra helps a lot.  It did take about 18months and several rounds to get to this level of comfort.  Sculptra is very expensive and does not last more than 6-7 months. The balls of my feet still get hot every night and sore.  I still have to where soft orthotics and soft tennis shoes.  I no longer hard limp all day which is a miracle. My knees no loner hurt every day.  Just every now and then. 

Dr Blake's comment: I am so proud of you for not giving up. If your doctor can send me a cast of your foot, I will make a Hannaford for you. But, I need a doctor/pedorthist to dispense/adjust. Hannafords would be the best design for your feet. 

http://www.manhattanfootcare.com/2013/03/sculptra-derma-fillers-for-treatment-of-foot-conditions/

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-31.html

My heel pads have started to thin again. I can feel the bones easily when I palpate my heels.  It hurts along the outer rim and along the back of heels.  It feels like I always have a blister when I do not have one. Hurts a lot.  Gets red and hot every night.  I use ice packs a few times a day, every day. I have to sleep with my heels off of the bed, because the pressure hurts.

Dr Blake's comment: Here is the links to two products you should buy.

https://www.mooremedical.com/index.cfm?/Achilles-Heel-Pad%E2%84%A2/&PG=CTL&CS=HOM&FN=ProductDetail&PID=166&spx=1

http://www.alimed.com/stay-on-heel-protector.html

 The orthotics I am wearing are slow recovery poron with spenco on top.  This worked for about a year. I have currently stuck a thin gel sheet over the heel portion.  Not perfect but helps. Thinking of buying J gel.  In October the spenco was replaced but not the slow recovery poron.  Spenco bottomed out in a few weeks.  Heels hurt.  the physician I currently see always keeps my orthotics for 4-6 months before I get them back. I never leave my current pair .  The adjustments have to be made when I am in the office.  I have been waiting for my new pair since October.  When they do come back the lab has usually botched them.  I have become my own pedorthist.    I have a dremel tool.  I make my own met pads . I add cushioning to my orthotics.  I wear my orthotics at all times,  except in the shower. 

Dr Blake's comment: Sounds like you deserve at least a honorary Podiatry degree. This is why I make my own orthotics. If only my patients really understood my dedication. Partially LOL!!!

I  need orthotics that will help my very boney feet to stop hurting so much.  I think that the right orthotics will keep my feet protected and comfortable and keep my knees happy.I worry that if my feet are this bad now, what will happen in the future?  I can come to California if needed to see you.  My exercise physiologist said I have 20 year old bones and 80 year old fat pads.  It would be wonderful to  get my life back.   So many doctors have turned me away.  I want to know if you believe you can help me? 

Thank you, 

Dr Blake's comment: I have since communicated with the patient and sending her a size 10 (her size) Hannaford. The wonderful part of a Hannaford is what you get back from the lab is just a little more than an insert with your foot length and width. The Hannaford is multi layers of memory foam and you do the molding during your first 30 hours of wear. They feel like walking on a cloud, but need big enough athletic shoes to fit them. If you are looking into Hannafords, I am happy to work with doctors and labs to learn how to make them. Read all the posts previously on Hannaford orthotic devices. 

http://www.drblakeshealingsole.com/2013/01/grinding-hannaford-orthotic-you-tube.html

Juvaderm: A Fat Pad Possible Replacement? The Jury is still out.

Tissue Filler Can Delay or Prevent Hammertoe Surgery: NY Podiatrist


When Diana Smirkle had painful corns which conservative treatment did not work, she turned to Dr. Johanna Youner in Manhattan for one of the latest techniques in foot pain relief. "It's an off-label use of filler that has been FDA-approved for areas on the face, the nose, and the labial folds for years, and we found it safe and effective in the feet," Dr. Youner says.

Dr. Johanna Youner

The filler, Juvederm is injected beneath the corn and fills up surrounding tissue that has been lost through years of wear and tear. The filler not only evens out and shrinks the corn, it triggers the body to replace its own worn out tissue. "Using filler we can either delay surgery or halt it all together," Dr. Youner says.

Source: Amy Leone, WUSA-9 [12/20/11]

http://www.juvederm.com/views/what-is-juvederm/?cid=ppc_gg_juvederm

http://www.zeel.com/t/Juvederm/review?utm_source=google&utm_medium=cpc&utm_campaign=Non-Invasive_Search&gclid=COb6pKfZlK0CFQhbhwod0VOdlw



http://www.yourplasticsurgeryguide.com/injectables-and-fillers/juvederm.htm