Bone Scan Post Off Weight Bearing Right Side

Bunion Bootie: Have any Readers Tried it?

Definitely need someone's feedback on this one. Looks great, but!!! Thank you in advance. Rich

Strengthening After An Injury: Email Advice

Dear Dr Blake

Re: Left leg fracture: Closed non-displaced lateral tibial plateau

I really need some help. I've been scanning the internet looking for advice and your's is the first site I've found that addresses by question. You see, I'm living temporarily in Thailand and it's almost impossible to advice from the doctor here, he just says - keep the leg still.

Two weeks ago I tripped over and caused this injury. I now have a full leg plaster which I will keep on for two months, maybe longer. It was only two days ago that I even began to consider atrophy, and now I realise this is a big problem.  I really wish to lessen the affects of atrophy as much as possible. You mention isometric strengthening exercises in your blog, but then say to consult my physio..  which I can't do.  I have started to use the exercise you described, but wondered if there anything else you can suggest? Is contracting and releasing the whole leg useful? I wiggle my toes up and down several times throughout the day (is that useful?)  I am an active and fit 57 year old woman (yoga and swimming) and wish to return to full fitness in the most efficient way. 

Your advice would be very much appreciated

Kind regards,

Jill (name changed)

Dr Blake's Response: 

Jill, I will try to get one of our physios to respond also, but I will also put a call out to any readers that have knowledge that can comment directly on the blog. Since I am a podiatrist, treating a fracture at the knee is not within my scope, but I sure talk to patients who have it. 

The full leg plaster casts will certainly cause tremendous atrophy and will take 6-12 months to regain strength and motion. So, your question is perfectly timed. Any area of your lower leg that you can move, you should move. The simpliest, but still powerful, form of muscle strengthening is active range of motion. The exercises can not put stress on your injury, or any other body part. Simply taking the hip muscles 3 times through their range of motion will be very helpful. The hip moves in 6 planes (front, back, in, out and inward rotation and outward rotation). If the ankle is out of the cast, do the same (up, down, in, and out) with it's 4 directions. Try to do these motions every few hours and it should take less than 5 minutes.

The knee muscles to strengthen are the hamstrings and quads. The hamstrings pull the lower leg backward and the quads pull the leg straight. To perform an isometic exercise you attempt to move the body part in the desired direction (for the quad you are trying to straighten your knee). The cast will not allow you to move, so you push against the cast for a count of 6, rest 4 seconds, and then repeat 10 times. You try to do this every 2-3 hours. 

If you are doing the exercises, the area of the fracture can not hurt. 

Please ask the doctor, if you promise to completely stay off the leg, how much faster can you get out the the cast!! I sure hope this helps. Rich

Another response from Dr Blake:

Jill, I talked to our orthopedist Dr Susan Lewis. She says that this fracture can be very unstable, even if nondisplaced, and should be immobilized for minimum of 8 weeks. She did not like the idea of you getting out of the cast early, so sorry!! Best to overprotect it now, and then rehab the leg after. The exercises however are still fine. Rich

Sesamoid Injury: Email Advice

Dr. Blake,

I just found your blog yesterday and am kicking myself for not doing so sooner.  I am beginning to incorporate some of your advice (contrast soaks, exercises) to see if they help, but in the meantime I would appreciate your input on my case.  I've been dealing with what the average doc would probably wave off as mild sesamoiditis, but it has severely impacted my quality/enjoyment of life since I have yet to find any form of exercise that does not flare it somehow.  I am 30 years old (female).

To start at the beginning, in June or July of 2011 I spent an impromptu afternoon walking around a downtown art fair in less than ideal shoes and by the end of the afternoon was suffering pain in the ball of my left foot.  At the time I was running with some regularity, which I promptly stopped, and I switched to wearing more supportive athletic shoes 24/7.  I tried icing and advil for a few days, and then I just tried to rest the foot as much as I could.  After several months and significant improvement, I went for a short run and discovered that no, it wasn't all better. 

 I went to my university's clinic where a PA quickly diagnosed it as sesamoiditis and sent me for an xray, which came back negative.  He prescribed PT, and there I received weekly ultrasound and icing treatments over two months (Oct-Nov 2011) and advice to switch to a stiff soled shoe like a Dansko clog.  Before getting clogs I tried a dancers pad, but it seemed to make things worse.  They showed me how to tape my foot (a different approach than your videos show), but that also seemed to aggravate the pain.  I had reduced flexibility of the big toe joint and throughout the arches of my foot, which PT improved.    By the end of 8 sessions my pain was improved though not gone, and I found I still had to limit my amount of activity to keep the pain at a low level.  However, since I wasn't gaining any more significant improvement, PT said to just do what I was doing and it would, by the looks of it, continue to slowly improve.  They sent me on my not so merry way.

I continued wearing the clogs and over the 2011 Christmas holidays I began having pain all throughout my left foot, which I suspected was from compensating/walking funny to avoid the sesamoids.  It spread up the outside of my foot/ankle and was more debilitating than the sesamoiditis.  At this point I went back to the university clinic and requested a referral to a podiatrist hoping for a second opinion and maybe orthotics or something, anything, helpful.

  I first saw the podiatrist in January, and he quickly diagnosed the new pain as peroneal tendonitis but hearing the original xray was negative decided not to pursue any imaging for the sesamoid (which was still sore and easily flared, but overshadowed by the tendonitis).  He asked me to get motion control shoes to control my pronation, injected the tendon with cortisone, and gave me a prescription to have orthotics made.  I switched shoes as he suggested, and those and the cortisone cleared the tendonitis up quite a bit within a week.  

However, the sesamoid was still sore and still easily flared.  It took weeks to get an appointment for the orthotics at the place he sent me (based on my insurance), and my luck was when I got there the guy I saw had a chip on his shoulder about orthotics for sesamoiditis.  In my first appointment he might as well have called my podiatrist a quack and said he saw nothing wrong with my gait or feet and that more ice and strengthening exercises were in order before making me orthotics. 

 At this point I was open to just about anything if it might help, so I didn't question him as soon as I should have.  However, his exercises aggravated my foot instead of helped, and months later he was still resisting making the orthotics I was referred to him to get.  I finally put my foot down and asked the podiatrist if he could refer me ANYWHERE else.  In the meantime, the podiatrist gave me a 2nd cortisone shot for the tendonitis (which helped further) and one in the ball of my foot (which flared the pain horribly and never recovered past the point it was before the shot - I declined any further attempts). 

 I got a referral to the other place in town for orthotics where my insurance would pay, and it was a breath of fresh air.  The pedorthist said he would need to correct all 3 zones of my foot (heel, mid foot and forefoot) for pronation, to support all 3 arches, and build up the forefoot under 2-5 to compensate for the prominence of the first metatarsal area.  Overall he said he could easily see how I ended up with sesamoiditis given my foot type.  I finally had orthotics in my shoes in mid May of this year, and we spent most of the summer tweaking them, eventually cutting out more under the seasmoids and big toe to attempt to offload it as much as possible.

  I eventually plateaued again, with as much relief as I'd ever had, but with a foot that still flares if I am on my feet for any significant amount of the day.  At the same time, it gets sore if I sit still for too long at my desk (being careful to keep that foot flat on the floor).  At this point looking back I feel like the one person I saw with any good sense was the pedorthist, but he's done everything he could think of trying.  I guess my main question for you if I showed up in your office would be what, or who, do I try next?   My plan right now is to try a week of contrast soaks and icing, add in some exercises and see how that goes, and then pursue another local opinion.  However, I'm not sure who I should be seeking out - an orthopedist, sports med, a different podiatrist...?  

I'm sorry for the very long email, but any time or advice you can spare would be greatly appreciated!  Already, your blog has given me a glimmer of hope that I was beginning to think was completely lost.

Sincerely,

Susan (name changed)

Dr Blake's Response: Hey Susan if I have one strength in life it is that I first look at the Big Picture of a situation to gain perspective, then get into the details. Soooooo, what is the Big Picture here? 

First of all, you have no diagnosis!! I will go up to 2 months without a documented clear-cut everyone will agree with this diagnosis, but if the patient is struggling, stop and get one. How do you get a clear cut diagnosis with negative xrays? Order an MRI. And if the MRI is negative, then you order a  bone scan or nerve conduction study or even thermography. What ever makes sense, but you make the diagnosis!

Second of all, you must go back to square one and Create A Pain Free Environment. You have learned alot along the way on how to reduce the pain level. You must get rid of all the pain for the next 6 months to stop the pain cycle. If that requires you to get a removable boot, please do. 

Thirdly, who sees the majority of ball of the foot problems in athletes? I believe that is sports medicine podiatrists, although there are exceptions. Check the membership of the American Academy of Podiatric Sports Medicine for someone in your area. See if your local running group has a doctor that they would recommend for a chronic foot condition. It may be an orthopod. I agree not to go back to the same doc in this case, since he did not even want to get another xray. Some sesamoid fractures do not show up until several months have passed. 

Fourthly, since I am putting you back into the Immobilization/Anti-inflammatory Phase of Injury Rehabilitation, definitely 3 times per day do either ice pack or contrast bathes. Over the course of the next month, that may allow you to gradually increase what you are doing without increasing your pain. 

And lastly, keep strengthening as long as there is no pain. You can do single leg balancing on a 2 inch book with the big toe floated off the edge. You may be able to do met doming/arcing. Ride a stationary bike with the pedal in the arch, not the ball. Be creative to stay strong and fit, while you are trying to figure this out.

Now, I must go, but please keep me in the loop. Rich

How To Cope With Pain Blog: Just Wonderful!!

I am presently doing a lot of research for a patient with severe pain. Just uncovered this blog. It is fantastic!! Rich

http://www.howtocopewithpain.org/blog/

Video on Calcific Achilles Tendinitis

ReachuP Foundation: Cofounded by Podiatrist Dr Joan Oloff

This is an announcement from Podiatry Management Online Service. Kudos to these great women!! See the link below for more excitement!!

CA Podiatrist Teams up With Soccer Legend for Charity Event

Soccer legend and Olympic, U.S. National Team, and World Cup soccer hero Brandi Chastain will host a co-ed all-star celebrity soccer match and post-game Radio Disney concert on Saturday, September 22, 2012 at San Jose Municipal Stadium in San Jose, CA. For the second year, the game will support the ReachuP! Foundation, which Chastain co-founded with Los Gatos podiatrist, Dr. Joan Oloff.

(L-R) Brandi Chastain and Dr. Joan Oloff

"What Dr. Oloff and I have come to realize is how young girls continue to crave inspiration and connections with mentors. The ReachuP! Foundation was created to provide a community where young girls can be inspired, empowered and challenged to reach beyond what they feel their limitations may be," said Chastain.

Source: OurSports Central [9/7/12]

http://www.reachupworld.com/#!home/mainPage

Sesamoid Injury: Email Advice

I desperately need a 2nd opinion, but my insurance won't pay for one. I was hoping you could help! I have been dealing with dysfunctional sesamoids since April 2010. I developed sesamoiditis after running 2 marathons in the span of 8 days. (Probably not the smartest idea, but I was in great shape at the time).
Dr Blake's comment: I prefer my patients run one marathon every 6 months, because the 1-2 months of maintenance running right after a marathon is crucial to repair tissue that has been stressed out in the process. 

 I quit running completely, was non-weight bearing in crutches + walking boot for 3 months and returned to normal activity shortly thereafter (but never returned to running). I was never completely pain-free, but it was only sporadic and I have a pretty high pain tolerance, so it was easy for me to ignore.
Dr Blake's comment: High pain tolerance is great at times, but not when recovering from an injury. I try to keep patients in the "good pain" range of 0-2, but that may not be a good gauge for these patients. They either become hypersensitive to their injury, or keep the pain level at 0. Even though we strive to create a pain free environment for healing, in actuality that is an environment in the good pain range of 0-2.

 I just (incorrectly) assumed that quitting running would solve my problems, and it would eventually heal. Fast-forward to May 2012.. I wear painful 6-inch heels (bridesmaid requirement) for my brothers wedding and am nearly unable to walk the next day. I go back to my doctor and MRI and CT show a fractured sesamoid with complete destruction of the cartilage around metatarsal and resultant cyst formation in the metatarsal.
Dr Blake's comment: I am assuming that these tests were never done before. If anyone has a diagnosis of sesamoiditis, and undergoes the course noted above, and is still in significant pain after 6 months when stressing it (ie running, high heels, basketball, etc), then one of two things is occurring. The sesamoid is not being protected well enough with orthotics and dancer's pads, or the sesamoiditis is really a fracture, or both.

 My doctor (physiatrist) prescribed 3 months non-weight bearing in a cast and crutches. I got the cast off yesterday and am currently in more pain than ever before. He now wants to fit me with a graphite shoe insert for 6 weeks before even considering referring me to a surgeon. Is he on the right track? I don't really have any options to see another doctor (this guy is supposedly the best person to see for my injury under my insurance), but I would really appreciate another opinion. Thanks for your time!!
Dr Blake's comment: I am so sorry for your dilemma. And, I will try to get you focused on what should happen in the next few months. Remember that you were doing fairly well for a while even when the MRI showed all of that stuff. That stuff was lurking below the surface before you put on those 6" heels.The hope is that you can get this calmed back down. I am not sure that graphite plates are appropriate, since they immobilize, but place alot of pressure on the sesamoid. You are more likely to be helped with orthotics and dancer's pad to float that area. A good podiatrist or pedorthist should be able to manufacture one. Even if you have surgery, you will need orthotics to off weight the area for a long time, so you might as well get them now. 
     The logical progression of immobilization, and you are still in the Immobilization/Anti-Inflammatory Phase due to your pain, is Non Weight Bearing Casts/Crutches until there is no pain, then weight bearing casts and sometimes crutches until there is one month of no pain, then a slow weaning off time gradually going from cast to athletic shoe/orthotics/plate ?/dancer's pad/spica taping. This gradually progress can take 2 to 3 months since you have to keep a painfree environment that you are establishing with each new level.
     The anti-inflammatory part right now should be contrast bathing one time a day (usually evenings), and ice pack twice daily. See the various blog posts on the hows and how muchs.
     The Golden Rule of Foot that applies: You take the first MRI so you have a basis of comparison with the second MRI. A second MRI should be done in 6 months to see if you are improving and by how much. A recent patient Jen, even though she has had a flareup, was still 70% better with her followup MRI. That gives us great hope for complete recovery. If you decide to avoid surgery and remove the sesamoid, you should wait 6 months to get a followup MRI. It will tell you alot.
     So, in my perfect world for you I would keep you in the removable boot for at least another 2 months, while I got a bone stimulator approved and started using, got some great orthotics, learned how to spica tape, iced/contrast bathing 3 times daily, had PT help you advance from non weight bearing to weight bearing, and I would be happy to review any CDs of xrays or MRIs you want to send. 
     I can not emphasize enough, so I am leaving it for the end, that you may very likely co-exist with some of that stuff seen on MRI and that some of it (if not all will completely heal). You desperately need to begin to put weight on your foot. Non weight bearing is very very hard on an injury. The nerves get hypersensitive, the muscles weaken, the ligaments tighten, and the bones decalcify. Your rehab, and this is true even if you have surgery, must include nerve desensitization, gradually weight bearing, gradually re-strengthening, anti-inflammatory, and mechanical support. Another Golden Rule of Foot: For 1 Day in a Cast it takes 2 Days to Rehab (it is even longer with non-weight bearing).
     I love working with physiatrists since they attempt non-surgical treatment. Really sounds like this doc is trying hard to avoid surgery. See if he/she can work with a physical therapist and podiatrist or pedorthist to get the other parts of the treatment going. I sure hope this helps you. Rich
     
     

Bone Scan from Talus Injury

There are many reasons I will order a bone scan for a patient. A radioactive dye is utilized to glue itself to phosphorus molecules. Bone is made up of water, calcium, and phosphorus. If a bone scan is hot, there is active bone metabolism going on. This patient injured her talus bone wearing unsupportive shoes. If you look at the upper left and right images, the marker points to the talus as a bright spot that is not present on the other side. Bone scans are wonderful since you do get both sides as part of the normal exam for comparison. It is the comparison of the injured side to the noninjured side that makes bone scans unique and quite special. Comparing the two sides by location and intensity of dye uptake can give you a great idea of what bone activity is occurring. In this case, the dye uptake in the talus clearly shows that strong healing is occurring.

The image on the lower left further localizes the spot (and this is the exact location seen on the MRI). The image on the lower right shows me in Quimper, France, in 2007 in front of one of those famous French doors.

So, the bone scan was very positive. The patient was told that great healing is going on. We have to continue for the next 6 months in a great pain free environment to let the healing continue. It is impossible to know how fragile the system is. This particular patient will not be running soon, but walking has been fine, elliptical will be introduced soon, and she is using orthotics to stabilize her ankle, a bone stimulator from Exogen, and daily icing and contrast bathing.

Sesamoid Fracture: Email Advice

This is my 3rd or 4th correspondence with a patient whom 6-7 weeks ago broke her sesamoid bone under the big toe joint. She is still in the Immobilization/Anti-inflammatory Phase of her healing which should go on for about 5 more weeks in the removable boot, than up to 12 more weeks weaning out of the boot keeping the pain level minimal. 

Hi Dr. Blake,

It's me again. I'm glad to say I've seen SOME improvement with my sesamoid fracture. I'm finally able to put my the whole surface of my foot on the floor. I've been very hesitant to put all my weight on my foot but I have been testing slightly, solely for reference purposes.

Dr Blake's comment: Patients really feel with this injury that their foot is made of fragile glass which will break easily. I normally find that patients will protect the injury more than they probably need to, but I am not complaining.  

I'm still using the boot for when I do a lot of walking outside of my house. At home, however, I usually don't use it just so I can see how well I'm doing (plus I don't walk that much at home).

Dr Blake's comment: This is not advisable since you really want to stop all motion across the big toe joint at this time. But, my second best case scenario is that the patients at least do not increase pain when they are out of the boot. We are trying to create a pain free environment for the best healing.

- I'm noticing that I still don't have mobility in my toe as far as bending, it's very slight.

Dr Blake's comment: You are in the Immobilization Phase of Injury Rehabilitation. There should be no attempt at increasing range of motion. You need to quiet the joint down. The joint will get looser initially as you begin walking without the boot, and the second time as you begin running. Now is not the time to try to increase range of motion. 
- The swelling in the ball of foot area is still there. When I touch it, it feels pretty solid. Not squishy like the natural padding in a foot. This makes me wonder if it's actually swollen or if it's something else?

Dr Blake's comment: Swelling is the natural process of bringing it healing tissue. Since you are immobilizing to a large degree, it is hard to move the excess swelling out of there. Keep icing and contrasts to maintain and not let the swelling get out of control, but it is impossible to reduce it now since it is part of the day in day out healing process.
- I've continued to ice it and was doing the contrast baths like you recommended. However, I can't tell if they're working or not since the swelling seems the same.


As for my podiatrist. I saw him after 4 weeks, he checked the pain in ball of foot area. He kind of put some force and asked if it still hurt, I said yes but not as much as my previous visit 4 weeks ago. He didn't really say much, he just said to come back in another two weeks.

He also gave me some spenco insoles. I think he mentioned that if I felt it improving I could try seeing how it felt with the insoles, if not just stick to the boot.


Anyways, the point of this email is just to see if everything I mentioned is normal. I know you mentioned it was going to take at LEAST 3 months if not more for it to heal. 

Dr Blake's comment: Everything does sound normal for this time, but this is a time to get the right protective orthotics, learn how to spica tape, find a physical therapist to help you in the 3 to 6 month Restrengthening Phase. The true Return to Activity Phase is started in the Restrengthening Phase, and will take you up to the 1 year anniversary of the injury. 
I'm trying to keep track of my progress but sometimes it's hard to know if there's been actual improvement or not since this whole thing is slow and frustrating. 
Also, the actual ball of my foot doesn't LOOK like it's improved because it still seems to look swollen. I'm mostly concerned with this since it makes it seem like it's not improving. My podiatrist isn't very reassuring with the whole healing process, he doesn't communicate very well with me. I'm actually debating whether I should switch to a different one. Any recommendations for the Monterey Bay area?
Dr Blake's comment:  2 of the Podiatrists I know in the area are Bobbie Yee and Gordon Hamblin. I know that they have the skill level to help you along this path. Good luck. Rich

Deidre (name changed for privacy)

Video emphasizing Iontophoresis for Plantar Fasciitis

 

This is a sound video on some of the tools available through physical therapy to help with plantar fasciitis. They show a nice variation also of the soleus stretch that I am going to start trying. I have not shown on my blog yet Iontophoresis for local inflammation of an area like the plantar fascial heel pain. This video highlights the Iontophoresis which I have found to have great results. Hope you find it useful. Rich

Ball of Foot Pain: Email Advice

Dear Dr. Blake,
I have had a severe foot pain for many years that I cannot understand. The pain is located on the bottom of my foot, in between the first and second toe area, next to the joint of the big toe.  Can you look at my xray image and tell me if you see anything that might be causing it?  I'm concerned that a piece of bone has broken off of my large toe, underneath, and it isn't being detected because the x-ray is taken from the top, as best as I can tell.  Also, can you explain what the white circle on the right of the big toe in the xray is?
I'm sending the other view in the next email.

Thank you very much for your help.

Dear Margaret (name changed), 

     There are 2 very obvious possibilities, and probable a dozen of other ones. Pain between the first and second joints can be caused by the big toe sliding off of the joint laterally (towards the second) which is happening with you. I placed the pointer on the part of the base of the toe that is actually off the joint. You can see where the normal part of the first metatarsal head ends (the white strong part). You have a 2 mm subluxation of the toe on the metatarsal. If I placed your knee cap 2 mm out of its normal groove with the femur and had you move your knee, it would start to hurt very badly. You can check the blog on how to tape the big toe medially (bunion taping with kinesiotape or 3M Nexcare tape). Tape the toe over for a week and also use a medium gel toe separator (found in bunion posts) and see if you can see any relief. I do not see any bone spurs or chips. 

     The second reason is that the 2nd toe is subluxing toward the 1st toe. This happens alot with long 2nd metatarsals. See how the second toe sits on the 2nd metatarsal, and compare to how the 3rd toe sits on the third metatarsal. The 3rd joint is straighter, the 2nd toe looks like (and is) leaning over to the first toe. This again can give you pain in that area. Tape the 2nd toe to the 3rd and 4th for a week with 1 inch tape. See if that eases some of the intensity.

     I am very impressed on how white the 2nd toe is, but it could be just my copy. Whiteness on bone means stress. The second metatarsal should be whiter than the 2nd toe, since it handles more weight bearing. In your case, the toe is whiter than the metatarsal. Something is rotten in Denmark. 

     Another common structure in that area is the deep peroneal nerve. It can get irritated by the above mechanical problems, or other causes of stress like over pronation and some weight bearing repetitive stress like high heels or elliptical. The nerve can actually be irritated at your back around discs L4L5. Is the quality of your symptoms nervy--burning, tingling, electrical, buzzing, etc? 

     Since you have had severe pain, have you been able to get an MRI? That would probably help us immensely. Any other clues you can email me I will attach later to this post. Everyone is curious at helping you. I hope this helps some.  Rich At least tell me what helps the pain temporarily and what definitely bothers it. Thanks

Dear Dr. Blake, 

Thank you very much for your post. I will try to tape them the way that you suggested to see if that helps.

This all started when I was rear-ended on the interstate about 6 years ago by a 4 x 4 truck, about a 4000 lb truck, going about 75 mph.  I was going about 55 mph. The truck had a crash bar on the front, so it jettisoned my car forward, my car being only 1800 lb. In response to realizing the truck was about to hit us, I braced for the impact and floored the gas pedal to the floor. The last thing I remember was it felt like I stepped on a marshmallow, before I momentarily lost consciousness. I came to in time to get back up on the steering wheel, and get the car to the side of the road. I had no memory of what happened during the brief moment I lost consciousness.  No help arrived the scene for over an hour and half, and by then I was somewhat cognizant, and did not realize the extent of my injury, so I did not go to the ER.  Bad mistake. 

The next day my right foot really hurt, but I could not put the full weight on it because my pelvic area hurt so bad. A doctor told me later that I had smashed my knee in the dash. Right around the time we were starting to deal with the foot pain, I lost my insurance, so it went untreated for a long time. To avoid the pain at the ball of my foot, I have learned to curl my toes up when I walk to keep weight off that area. 

In these x-rays, I see a piece of bone, it looks like, near the little toe, in between the 4 and 5th toes area. I can feel it sometimes, its like something sharp is in my foot, cutting it. And when I look at the big toe, it looks like a fracture sideways. 

I am curious as to what is that white circle by the big toe on the xray on the right of the big toe, is that just where the xray overexposes?  I saw that on other foot xray's I saw on the internet.  One doctor told me a long time ago when I said "Thank God, I didn't break my foot"' and he commented "But you did" but he never went into any explanation of where it was broken. Can you tell?  Is it possible for a piece of broken bone to be behind the big toe on the xray, and it can't be seen?  I can tell from all the xrays I've looked at on the internet, that reading xrays is really an art that requires a lot of skill and experience.

Thank you.

Margaret,
     Wow!! You were very lucky! The white circle is called a sesamoid bone and it is normal. You could have injured it or the ligaments under the big toe joint in your accident. Look up a condition called Turf Toe to get an idea. There are a myriad on structures that could be injured and give you these symptoms. The X-ray below is called a Plantar Axial. You should get that, and an MRI, or at least the plantar axial. It will show if any structures under the big toe joint are injured. Here is an example.

Hallux Rigidus: Email Advice

Hello Dr. Blake;

Found your blog and although I am a medical professional at a major hospital system and work with orthopedic surgeons I am trying to get as much up to date advice about my problems with Hallux Rigidus before I make a decision to go forward with surgery.

Although I am 60 years old I am a very active individual.  I was a Quarterback at a major university and suffered alot of turf toe.. I have realtively low archs and long toes.  I have continued with basketball, racketball, running etc. over all of these years.  I was diagnosed with Hallux rigidus over 15-20 years ago.  It never bothered me or affected my activities until a few years ago.  It is bilateral but quite prominent on the left foot. 

I have seen two othropedic surgeons and a DPM (podiatrist) about 2 years ago where they took x-rays and sent me to a sports medicine PT to have carbon fiber insoles prepared in which I have been using the last 2 years with fairly good results.

The xrays rays showed Grade3-4 involvement and as expected the amount of osteocytes on top of the joint esp the left foot is severe and in essence my joint is fused naturally. ( less than 10 degrees of flex)

Lately the bump ( osteocytes) have been causing me discomfort and I have noticed my ankle starting to be sore ( possibly from compensation)

I truly believe i will need to do something soon but I am so unsure and not wanting arthodesis due to recovery time and the unknown on how I will be able to be as active with a fused toe. 

I have read some reports that they have been actually trying arthroscopy for decompression to lessen down time.

My question on who to go to and does it make any sense in considering decompression with grade 3-4?  I know implants have not worked out well.

My othro friends just want to do the fusion - not crazy on that idea

any other ideas or insights would be helpful.

Bob (name changed)

Dr Blake's response:

Hey Bob, If you beat Cal (where I went) then I am not sure if I should be giving you advice, but I have not time to check the records. 

I share your concerns with fusion. 10 degrees is still 10 degrees of motion, and 0 is total immobility of that joint. 

I have no problem when the spurs begin to create problems to have those removed. This is called a Cheilectomy or arthroplasty (joint remodeling). At times, surgeons just do too much remodeling and cause the arthritic joint to move too much. So, the surgeon needs to have done some of these to know how much bone is safe to remove. Cheilectomies have a bad name since, for surgeons, it is not "to cut is to cure". Cheilectomies work wonders on many patients, but can have a long rehab period of up to two years. This is normally due to excessive bone swelling post surgery and inadequate bone removal or excessive bone removal. They can take a lot of post operative thought in the process. After surgery, the orthotics have to be changed, and the foot may have more pain!!

So, If I was in your shoes, I would find a surgeon comfortable doing Cheilectomies, some knowledge on who they work for, and no rush to do a fusion, since your joint is slowly and naturally fusing itself. The body can adapt quite well to a gradual process, but not so easily to a sudden change. This change is felt throughout the body and probably all of civilization. And, after I found that surgeon, I would have the bone removed that is causing the problem, and attempt my 3 to 24 month rehab, whatever it takes. I have never seen an active person do active weight bearing sports after surgeon, although you could be the next Lance Armstrong!

I work with surgeons day in and day out. They are like you and me. And they do what they feel comfortable with. You do not want a surgeon who deep inside wants to do a fusion do a cheilectomy on you. For many reasons, unless they are quite evolved, this could be disaster. I sure hope this helps you. Rich

Breast Cancer Awareness: These Statistics Will Save Many Lives!!!

Hey Dr. Blake,

I recently developed another infographic that could be a good fit for your site. I just wanted to reach out and share.  It highlights and illustrates the numbers behind breast cancer in order raise awareness.

You can check it out here:

Title: Code Pink
Graphic/Video: http://onlinenursingprograms.com/code-pink/

Let me know what you think,  I would love for you to publish it if you find it suitable for your site.

Thank you,

Physician Burnout: Be Kind to Your Health Care Provider

This is an article from Podiatry Management Magazine online service. Thank you. 

U.S. Physicians Suffer More Burnout Than Other Workers

Physicians in the United States suffer from more burnout than other workers in the United States, new research shows. A national survey of more than 7,000 U.S. physicians reveals that close to one half report having at least one symptom of burnout. "The fact that almost 1 in 2 U.S. physicians has symptoms of burnout implies that the origins of this problem are rooted in the environment and care delivery system rather than in the personal characteristics of a few susceptible individuals.

"Policy makers and health care organizations must address the problem of physician burnout for the sake of physicians and their patients," the authors, led by Tait D. Shanafelt, MD, Mayo Clinic, Rochester, Minnesota, write. The survey findings were published online August 20 in the Archives of Internal Medicine.

Source: Pam Harrison, Medscape News [8/22/12]

Dr Blake's comment:

I have definitely felt the burnout of most physicians as you try day after day to squeeze in one more patient, and then another. The work demands are excessive and the paperwork overwhelming. Add if you are trying to do a decent job in helping people, more time restraints. 

How do physicians fight burnout? Most limit their practices to the highest paying aspects: surgery, testing, work compensation cases, legal cases, various procedures. But, what then happens to the common sense care, the KISS care, the hand holding and sage advice time? 

I hope this next generation of physicians, and all health care providers, will figure it out. I find I need to eat well, limit my week night outings, stay organized, not multi-task, exercise regularly, and re-invent who I am as a doctor every 3 years or so. And, not take myself or the bureaucratic chaos I am in daily too seriously. 

This blog has been one way to re-invent myself. Before the blog, I was busy raising my family. Before that, there was all the excitement of starting a practice. 

Even though there is a lot of work organizing a blog, it is not the amount of work that tends to cause burnout in any job, it is the feeling of hopelessness over getting the work done, or the feeling of lack of respect, or the feelings of failure when things do not go well (normal part of the art of medicine). This blog gives me none of that and so has become a very healthy part of my practice. It adds health to my practice, making me feel that I am making a difference. 

Day 4: Conservative Treatment of Complete Achilles Tendon Ruptures

Day 4: Conservative Management of Complete Achilles Tendon Ruptures

     Even though a complete tear of the Achilles Tendon is typically managed by surgical repair, it can be managed well with below knee casting and physical therapy. The literature and my experience point to equal successes and failures with both techniques. Re- rupture rates are slightly higher with conservative treatment, but do exist with surgery. The other complications of serious note all involve surgical problems--excessive scarring, post op infections, and wound healing issues. We always give my patients both options, and the majority go for surgery. Given a good rehabilitation with physical therapy, both types of patients are at the same point one year after injury. All of my patients who have conservative care are at risk for re-rupture in the 45 days following cast removal. If re- rupture occurs, surgery is normally chosen to fix it. With modern day physical therapy, my patients get to 110% strength of their good side. The fastest patient to begin running post rupture with conservative treatment was at 6 and 1/2 months post injury. Since this technique needs the full teamwork between physician, patient, and therapist, there are only certain situations that this perfect storm will gel.

Email Received by Dr Blake

Dear Dr. Blake,

I am a 38 year old adjunct professor of occupational therapy/integrative health at and I recently sustained a right Achilles Tendon Rupture on the evening of August 13th. I went to the ER where my right foot was placed in a posterior cast and was told to see a doctor. I was able to see the doctor on August 15th where I was told that he recommends surgery for all of his Achilles Tendon rupture patients. He was not interested in supporting me through a nonoperative treatment approach. No ultrasound or MRI imaging was ordered.

After having done an extensive literature search on the topic so far and the fact that I have worked in physical rehabilitation for over 20 years I feel comfortable with choosing the nonoperative approach to my Achilles rupture treatment.

I came across an abstract of your article titled Achilles tendon rupture. A protocol for conservative management and I was hoping you might share the protocol with me.

I currently do not have a doctor following me and am willing to to pay out of pocket for a physical therapist that would be interested and open to supporting me through an Accelerated Functional Rehabilitation and/or the protocol you recommend. Do you feel this is an appropriate path to take?

Thank you for your time and consideration. I look forward to hearing from you.

Kind regards,
Sarah (name changed)

Dr Blake's Response:

Sarah, thanks for the email. My approach has worked well, but requires 3 months of cast immobilization, normally done by a doctor. The first 6 weeks are crucial to be non weight bearing with your foot maximally planantarflexed at the ankle. I actually change the cast every 2 weeks to gain more plantarflexion with each cast. Due to various reasons, I have started the process up to 5 weeks post tear with no noticeable change in outcome. At 6 weeks, I begin to change the direction towards a more and more dorsiflexed position. These next 6 weeks are weight bearing, although initially not much due to the size of the cast. I carefully measure the amount of ankle joint dorsiflexion with each cast change. The last two weeks of weight bearing casting must be at 0 degrees of dorsiflexion to be on schedule to remove the cast at 12 weeks. I love to use a muscle stimulator under the cast from 6 to 12 weeks. From 12 to 18 weeks, you are still being protected in a removable cast as you begin the re-strengthening process. Here is where the physical therapist becomes the most important part of the team. Keeping the activity below the fatigue/re-rupture level of strength, and keeping the strength/flexibility ratio perfect, and gradually increasing power/endurance/ cardio takes a skilled PT. With the uniqueness/unfamiliarity of this conservative approach, I find that most patients and therapists go naturally slower than need be, but there is no rush. Let me know if you want more info, and good luck! Rich

Sarah's Response:

Dear Dr. Blake,

Thank you so much for your prompt and thorough reply!

I have a particularly unstable lower back and I have found the cast to be quite cumbersome. I ruptured a disc when I had an ACL reconstruction in 2000 and I have trepidations about potentially doing the same thing in this situation.

Would a cast boot system such as the VacoCast (http://www.vacocast.com/pro/) set at maximum degrees of plantar flexion be appropriate for me to use now with the continued non-weight bearing status for 6 weeks as you mention? It seems the VacoCast would put a much less load on my spine over these next several weeks.

Thank you for sharing your wisdom!
Kind regards,
Sarah

Dr Blake's response:

Sarah, Could not get a stong feel from their website pro or con removable vs permanent cast. Normally, patients must be at 15 to 25 degrees of ankle plantarflexion in the first 2 to 4 weeks. This says it only goes to -10. Could you check with them on Monday if it can be adjusted but to -20 at least. Thanks. Rich This is important to bring the ends of the tear into as close proximity as possible!!!

Sarah's response:

Hi Dr. Blake,

After looking at another non-op study protocol it appears that they put a 2cm heal lift in the VACO cast boot system and gradually reduced the height of the heal lift (1.5cm then 1cm) every 2 weeks after the 6 week mark. Would this be satisfactory to achieve the 15-20 degrees of plantar flexion?

Thank you!

Sarah

Dr Blake's Response: 

Sarah, The acid test if it is enough lift is that when you walk you feel no pull on the calf. So, all theory aside, I guess we will have to see when you try on the Vaco Boot if you feel no tension. I also remembered two patients last night that needed crutches for the longest time with their achilles. One had an opposite knee problem, and the other was back issues. With crutches you have 3 or 4 feet inside of 1 or 2 to balance on and protect your spine. Also, for the next 6 to 12 weeks you probably want to look into renting a Roll A Bout. They are also a way to stay non weightbearing with a stable back. I love them. Rich

Sarah's Response:

Great recommendation Dr. Blake. I will rent a Roll A Bout! :)

I will make sure there is noooo tension on the Achilles. Thank you!

Sarah

Sesamoiditis: Email Advice

Hi Dr. Blake,

Thank you so much for your helpful blog. I have been diagnosed with sesamoiditis in both feet. The pain in my left foot is much worse than my right but the MRI shows significantly more swelling in the right foot than the left. Does that make sense to you? Is it possible that the pain is being caused by something other than the sesamoiditis?

I also had a question about taping. Is taping necessary if bending the toe does not cause pain? Flexing my toe does not seemingly increase my pain but I'm wondering if I should tape anyway. 

Finally, I had an MRI but my doctor was unable to determine whether I had a fracture or not. Should I be concerned that even with the MRI he cannot tell? Should I look for someone else to treat me condition? If so, do you have any recommendations in the Boston area? 

Thank you so much!

Dr Blake's Response

     The diagnosis of Sesamoidits is much like Shin Splints, a catch all word or phrase that could mean alot of things. X-rays are historically inaccurate, missing subtle injuries like stress fractures, that you do not want to miss. So, I relie on MRI imaging more than anything else to show bone, ligament, or tendon abnormalities. Since you had an MRI, and there is still a question of fracture or not, it is probably just the interpretation. Some docs use the MRI to look for a visible crack, when a stress fracture will show none. The question I need to know is whether there is any changes in either Sesamoid on T2 imaging where the Sesamoid should be black but it appears white. That is a stress fracture and should be treated accordingly.  So, it is definitely possible that your pain can be something more than just inflammed sesamoiditis, since I rarely see sesamoiditis cause swelling.

     You need to get a copy of the official MRI report, but I would get a CD of the actual images. Try to find the ones that look like the images from my blog and see what you can gather from this. I will be happy to look at the CD or any images you send. 

     In regards to swelling, deep swelling that you can not see can be much more painful than superficial swelling. It is why patients can come in with enormous ankle swelling after a sprain and say that they are still running on it. And, why a drop of swelling due to an ingrown toenail can bring patients to almost tears.

     Taping is a possible help for some activities. You need to practice taping for various activities about 10 times to get good at it, and see if you can tell a difference. For your injury taping is equivalent to an ankle brace post ankle sprain. 
     
     The 2 sports medicine podiatrists that I know in the Boston area are Lloyd Smith and Michael Robinson. You can get their numbers off the website from the American Academy of Podiatric Sports Medicine. I hope this is helpful.Rich

Day 3: Bone Stimulators

Day 3: Bone Stimulators

     I have used bone stimulators to help heal fractures that are notorious for slow healing for the last 25 plus years. The early versions had to be embedded initially under your skin with a minor surgery. But then happily came the external ones which could be used as long as you had a cast on (they were embedded into the cast). These ran for 24/7 sending an electrical impulse across the fracture. If you know that in electricity like dating that opposites attract, these bone stims placed a negative charge on 1/2 of the fracture, and a positive charge on the other 1/2. These units still exist, but send the current from a patch into the skin. For the last 10 years or so, I have used the Exogen unit from Smith and Nephew. It actually uses ultrasound to merely increase circulation to the bone directly. You apply a patch connected to some wires to your skin and twice daily for 20 minutes while you multitask stimulate your bone. I use this on many types of fractures, but particularly the 3 most stubborn fractures in the foot: Sesamoid, Jones Fifth Metatarsal, and Navicular.

     To drive home the importance of bone stimulators, there is the first paragraph from an email I received today.

Dear Dr. Blake,

I am writing to first update you to say my sesamoid is now healed!!! Actually as of a few months after my April 2011 email below to you :)) After being quite upset with my progress the Doctor finally recommended we try to get me a bone growth stimulator. My insurance wouldn't pay for it ($3500) but FORTUNATELY the company that had them offered me one for free based on my situation. IT WAS A MIRACLE! To this day I am so thankful for that that company and that device. After just a few days of use I noticed "something" different. After two weeks it felt better and by May/June I was surfing again. I still remained ginger with it for the next several months. When walking, popping up on my board or doing yoga related sequences where flexion is called for. The tenderness remained for a throughout 2011 but very light which I think was simply from not using the tendon/muscles for so long. So by winter 2011/12 which was well over a year from the injury, I was finally doing most things I never thought I'd be able to do again! I highly recommend the bone growth stimulator. I also thank you so much for your words of encouragement along my healing progess. Without you I may have lost it.