Dancer's Padding: How To Video

https://youtu.be/GG-mSjtSwj8

     Dancer's padding was introduced by the French studying ballet injuries in the 1700s. It has a modern term of "Reverse Morton's Extensions". The current supplier for my patients is Amazon, and I can only find the 1/4 inch which you will have to thin out. 

https://www.amazon.com/Felt-Adhesive-Orthopedic-Aetna-Corporation/dp/B071KTF794/ref=sr_1_14?crid=2AO6K692L8XR&keywords=self+adhesive+felt+roll+medical+use+1%2F8&qid=1664597257&qu=eyJxc2MiOiIwLjAwIiwicXNhIjoiMC4wMCIsInFzcCI6IjAuMDAifQ%3D%3D&sprefix=adhesive+felt+roll%2Caps%2C179&sr=8-14

     I use this material constantly in my Podiatry practice, and give supplies to my patients. Any problem with the big toe joint, and some cases of plantar fasciitis, and arch pain, you want to see if this padding helps the symptoms. 

This is demonstrating the Dr Jills Dancer's Padding with Adhesive Gel

Sesamoid Pain and Trying to Avoid Surgery: Email Advice

Dear Dr. Blake, 

I work in the US but my home is Brazil. 

I just came back from vacation in Brazil with disturbing news: the podiatrist there told me I need to get surgery on my right foot, as my two sesamoids in my right foot are compromised. One of them is split in the middle and the other one is worse, fragmented (see below). 

After looking for doctors over the Internet I came across your name and website. I have also noticed that you are able to treat patients with less invasive treatments, avoiding surgery. The prospect of a surgery is really difficult for me for different reasons: (i) my family does not reside in the US, so it would be difficult to recover and work at the same time; (ii) my work involves a lot of travelling; (iii) any invasive approach scares me.

If you believe there are any chances of curing my condition without surgery, I would like to talk to you. Could you please look at the CT scan results below? I would truly be grateful for any inputs and/or ideas you might have. 

After researching online I found that a vitamin D level exam and a bone density level exam should ideally have been carried. Neither of them were requested to me. 

Below please find the CT scan results (translated by myself from Portuguese). The exam was undertaken at Albert Einstein Hospital (considered the best hospital in the southern hemisphere)  

 
A study carried out using the fast spin-echo technique, in heavy multiplanar cuts in T1 and T2, pre and post-paramagnetic contrast, showed:

·         Attitude in hallux valgus.

·         Lateral sesamoid with fragmented appearance, with irregularities and bone sclerosis.

·         Medial hallux sesamoid with bipartite morphology with bone marrow edema suggestive of overload.

·         Other bone structures with normal spinal morphology and sign.

·         Minimal metatarsophalangeal joint effusion of the hallux.

·         Lack of significant joint effusion in the other joints.

·         Tendons without significant changes.

·         Fluid distention of the intermetatarsal bursae between the 2nd and 3rd spaces.

·         Obliteration of the plantar adipose cushion underlying the heads of the first, second and fifth metatarsals, indicating load points.

Thank you so much for your help and support. I truly appreciate it! 

Best regards,

Dr. Blake's comment: Thank you so very much for writing. As I write this, I know it must be late on the East Coast of the US. It probably does not matter at this point how you did this, but you have injured the sesamoids. Okay. Some doctors take them out after 3 months of treatment, and others like myself drag their feet delaying and hopefully preventing surgery. It is a whole spectrum. You really have to treat the injury as if you just got it. Depending on your insurance, an exogen bone stimulator distributed through Bioventus works well most of the time. This is a 9 month assignment to get the bone strong. Contrast bathes 4-7 nights a week will act like a deep flush to the tissue. Order Dr. Jill's dancer's pads to protect the sesamoids yourself, along with learning how to do spica taping, and cluffy wedges. Make sure your winter shoes are stiff to help immobilize the tissue as many hours a day as possible as you are trying to create a 0-2 pain level environment for healing. See my buddy Dr. Steve Pribut (link below) in DC for local hands on. Keep me in the loop. Good luck. Rich

I know there are some good articles supporting shockwave therapy as a noninvasive treatment for sesamoid problems, but it may be just too costly.

https://www.vitals.com/podiatrists/1zwb65/stephen-pribut

Sesamoid Pain in a Rock Climber: Email Advice

First of all, thank you for you wonderfully helpful blog and for your tremendous generosity in spreading your knowledge to help others. 

I have read through a lot of your blog and videos regarding sesamoid injuries, and have a couple questions about my particular situation. I am an avid rock climber -- and it is a pursuit I would like to continue at a relatively high level (weekend warrior) as much as possible. 

Last November (2017) I noticed a pain in the ball of my left foot. The appearance of the pain was fairly sudden, although I do not remember it occuring with a specific move; however, I do believe it occurred while climbing. The pain would really only be present when putting significant body weight on that portion of my foot (big toe or sesamoid area), or when I would try to bend the toe forward or backward to a large degree. It bothered me primarily while climbing but was generally not bad while walking. I never noticed any swelling or discoloration. I figured it was a minor tweak and didn't pay much attention. For unrelated reasons, I ended up having to take three months off from climbing (Jan - Apr 2018, though I still played some recreational tennis occasionally), and when I returned to climbing, the pain was not any better when that part of the foot was weighted, so I finally went to see a podiatrist. To be clear, the pain was generally only present when standing with most of my bodyweight on a very small chip of rock using just that portion of my foot/toe -- not while walking normally

Xray did not show anything, so was given diagnosis of sesamoiditis, and since the toe really only bothered me while climbing, it was suggested that I try some over-the-counter 3/4-length orthotics inside my climbing shoes (not very realistic) and sent on my way.

The toe did not bother me much for a couple months (although the pain during specific climbing moves was always there), but after a week-long climbing trip, it flared up significantly to the point where there was some pain/soreness even just while walking/standing. Upon returning to the podiatrist, an xray showed "small lucency to the medial sesamoid with concerns for fracture" so the podiatrist said there might be a small fracture there but basically suggested there was nothing really to be done, and that given that my symptoms were mild and intermittent, I should just modify my levels of activity to avoid overly stressing that area ("let pain be your guide").

It is true my symptoms are mild and manageable for every day activity. I can walk with no pain. However, for climbing, I would like to heal the bone to the point where there is no pain when I weight that area. Reading up a bit more about sesamoiditis and sesamoid fractures, I am wondering:

1/ Is it still advisable to go through the immobilization phase (given that the initial injury was 10 months ago, and that current pain levels are in 0-2 range)? I'm hoping the answer is no, but is an immobilization phase important for healing (even if the potential fracture occurred months ago)? If so, what level of immobilization? Tall boot? All the time / even when sitting at a desk or in bed?

Dr. Blake's comment: So many injuries do not heal unless placed back , even 10 years later, in the Immobilization Phase. However, we would need an MRI to know how inflamed the bone is, and really if you have something to gain by resting. Many of my patients go into the small anklizer boot for 4 months, for all activities other then their main sport, to give themselves a chance of healing. You already have the 0-2 pain level down, so hard to know if you will gain anything. How is your overall bone health? Has your Vitamin D been tested lately? Have you had a bone density? Good diet? 

2/ If it's OK to skip the immobilization phase, what would you recommend now? Contrast baths and runners pads/orthotics, no climbing on that foot, no tennis for some (what number?) weeks, then reintroducing those activities? (Given my low levels of pain, it doesn't seem like my podiatrist will be up for doing an MRI or bone stimulation.... or even custom orthotics...)

Dr. Blake's comment: Yes, I can tell you have been reading the blog!! Thank you!! All of these should be used. Contrast bathing once to twice daily as a deep bone flush is the most important. Common sense says you should pick on the bone less, so Dr. Jill's Dancer's Pads stuffed into the rock climbing shoes is also key. Orthotics have too much bulk and the main part in the front to protect, so just go with the dancer's padding protection. Really, the MRI is important to tell us what we are dealing with. It can be the structures next the sesamoid that are injured changing the treatment plan. You hurt with rock climbing, so I do not care if you do not hurt walking, unless you want to just be a walker. Some patients only hurt running, and they would fire me as their podiatrist if I told them to stop running forever and just walk. Get my point? The MRI is also baseline in case we need them again. Get them and send them to me if you want my read. 

3/ Any suggestions on how to best go back into climbing/tennis and over what length of time? I feel like both of these sports are situations where there might be sudden severe weighting on the pain spot (not repeated weighting like in running), and I don't want to risk re-injury, but I also wonder how to know when I've healed. Currently I'm not playing tennis and am avoiding any left-forefoot-weighting (and generally minimizing use of left foot) in climbing and basically having no pain, so I'm not sure how to tell when things have improved to the point where I can start weighting the left forefoot and/or playing tennis.

Dr. Blake's comment: This is exactly why we get the MRI. A very positive MRI today may mean that the sensitivity you feel loading the sesamoid may be there for up to 2 more years. Let's find out now, and it saves so much anxiety for the next 2 years. I find with negative x-rays, a positive MRI for bone swelling, you do contrast bathing daily, 9 months of bone stimulator, protect the bone with dancer's padding, and we see where you are at next June. That is the next time you really think about it. You wear the boot four hours a day to rest the overall tissue. You modify activities and cross train to stay as healthy as possible. Hope  this thought process is helpful. 

Thanks in advance!

Sesamoid Pain: Email Advice

Dear Dr. Blake,

I am a runner who partially tore the medial band of his plantar fascia in March 2017. Started a run/walk comeback in Nov 2017 and developed some sesamoid pain around Thanksgiving. 

Traditional X-rays were ok about 20 days after onset of pain, but the improvement has plateaued after using dancer’s pad for last four weeks or so. Had an MRI on Jan 2, which showed sesamoiditis. Report is attached. However, everything I read in the literature suggests that MRI is not great at showing how far along the continuum of bone injury one is and there can be different treatment paths that are best for different degrees of the catch all “sesamoiditis”.
Dr. Blake's comment: First of all, the MRI report showed healing of the tear!!! Hooray!! It showed some wear and tear of the cartilage of the big toe joint (mild arthritis) and showed swelling, no sign of a break, in the fibular sesamoid. In my mind, you have to put sesamoid swelling in the category of a stress fracture to treat the worst case scenario. That sesamoid swelling, without a sign of any fracture lines, could be a stress fracture or bone bruise. Sesamoiditis just means there is inflammation at the sesamoid from any cause. The injury to the sesamoid area has gone deep enough to affect the bone. Therefore, the bone must be mechanically protected with off weight-bearing padding, and there must be enough decrease of big toe joint bend to create a healing environment: normally 0-2 pain levels. This is how you know how much or little to treat, what does it take to get to 0-2 pain? This does not change if you do not know if it is a stress fracture. Without evidence of a fracture line, an Exogen bone stimulator is usually not utilized or approved by insurance. I love that to strengthen the bone, even if just bruised. You may be able to get via the bone changes in the first metatarsal which you do not know if new or old. If it is a new cartilage injury, a bone stim would be wonderful, as you could be looking at microfracture surgery. It was injured because it is one of your personal weak spots, so why wouldn't you want it stronger. Contrast baths daily are crucial with bone edema to remove the swelling on a consistent basis. Helps prevent avascular necrosis, bone death from too much swelling cutting off normal circulation, along with a bone stimulator. Acupuncture would also be great if the practitioner knew how to get the blood flow greater in a small bone like this. 

I live in the Chapel Hill, NC area and have been to multiple podiatrists, who all gave me bad advice on how to deal with chronic plantar fasciitis I had leading up to the tear. I realized this after reading all the research papers on a plantar fascial injury. This is why I am reaching out to you as someone who seems to be up to speed. 

Dr. Blake's comment: I am getting older by the minute, so you do not realize how good that little compliment makes me feel. Thank you. 

Would you be willing to look at my images and recommend how I treat this? The MRI data are 144 megabytes, but we may be able to figure out a way to get the data to you.

Dr. Blake's comment: Sending a CD always works. But patients do use Dropbox for my google drive. My address is 900 Hyde Street, San Francisco, Ca, 94109. Good luck Rich

Thanks very much for your time and Happy New Year!

Sesamoid Pain: Email Advice

Dear Dr Blake,

I found your blog through a search engine and I have read stories on your blog, I feel positive that you may give me a proper advice. I have this pain below my big toe on right feet for almost 2 months since October 22,  developed during my sister in law wedding. I am not a sports person nor do running or dancing. After I return to Singapore, I felt my toe bone hurts very much. I have trouble walking and have to walk while dragging my feet to work. I ignore it for over a month. It is an on and off pain.

After one month of pain, I could not take it, I google about my symptoms and found out it may be likely is Sesamoiditis, which match my condition very well. I read other doctors advises such as stop wearing heels, take as much rest as possible, massage with ice and etc. It helps my condition however with my work nature that requires me to walk a lot, the pain came back. I am still thinking if I should go to see a doctor and do Xray. As I do not have insurance to cover the cost, this is a big dilemma for me. I am afraid it may take a toll on my finance. 

I have switched to a better support shoe and I am also looking for an arch support sole to help my feet to recover faster. Dr Blake, do you think I need to see a doctor? 

Dr Blake's comment: I am sorry for your dilemma. Unfortunately, everyone would tell you the same. Please see a doctor and get the right treatment. Severe sesamoiditis, as you may have, requires months of protection. You must create the 0-2 pain level environment quickly. See if you can find a doctor to put you on a payment plan. You have to treat this as a stress fracture with 3 months minimum of some form of immobilization. You could get adhesive felt from a supplier, and build a dancer's pad to off weight and put yourself in a flat stiff shoe, I use postoperative shoes to start the process. Experiment with spica taping, cluffy wedges, OTC arch supports to protect, immobilize and off weight. Good luck. Rich

Thanks for your assistance in advance.

Regards,