Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. I hope the pages can help you learn about caring for foot injuries, or help you with your own injury.
PAD stands for Peripheral Arterial Disease. You are just not getting enough blood to your feet and legs. Who are at risk? The risk factors are smokers, high cholesterol, diabetes, family history of vascular disease, and high blood pressure. As a patient, you can work hard to decrease the blood pressure and cholesterol, get your diabetes under control, quit smoking, and walk, walk, and walk some more.
The video below talks us through the problem, how to test for it, and how to help the situation if we find ourselves in it.
Here is one of my patient's with terrible PAD. These toes were turning gangrene, and needed amputation. Only one side was problematic at the time.
Here are 2 good links on possible testing for allergies to foods when we are chronically inflamed from injury. When inflammation just won't quit, and the health care providers are at a lost, consider testing for food allergies. Consider IgE testing for food allergies.
My wife Patty and I recently celebrated our 35th Wedding Anniversary in Europe. I promised my patient Cheryl a few photos, especially of my beloved poppies!! (and my wife!!) We went from Barcelona, to Eze, to Provence, to Lyon, to Cluny, and finally ah!! Paris. Sorry there is no particular order to my photos.
Old Part of Barcelona
Garden in Aix-en-Provence
The Rhone River from Chateauneuf-du-Pape
Poppy Field in Provence
Roof Tops in Lyon
Lyon at night with Cathedral on Hill
Patty Blake in Cluny
Market Day in Barcelona
Market in Barcelona
Cable Car above Barcelona
Church Ceiling by Gaudi in Barcelona
Parc Guel Entrance by Gaudi in Barcelona
Roof Top Casa Mila by Gaudi in Barcelona
Ah!! Eze
Celebration in Eze above Mediteranean Sea near Nice
View from Chateau Eza, Eze
View from Eze
35th Wedding Anniversary Le Pigonnet Hotel, Aix-en-Provence
Ocre Mine in Provence
Lavender Field in Provence
More Poppies in Provence
Above Aqueduct at Pont du Nord, Provence
Amphitheater, Nimes, Provence
Garden in Provence
Calanques near Cassis
Train Station in Lyon (on the way to Paris!!)
Doing what the French do outside Notre Dame Cathedral
Normal bone density is important. Here is an example of Bone Density Screening showing good bone density in this 54 year old woman. The low back(L1-L4) and hip (Total) areas are used in the screening. I was extremely happy about this great test, since she had a problem healing an ankle injury involving the cartilage, and a low bone density would have been treatment even more complex. Even in the face of normal bone density, the recommended 1500 mg Calcium and 1000 units Vit D3 daily are important with any bone/cartilage injury.
But what if you are low? The video below highlights that simple weight bearing exercises like toe drops and walking is crucial at improving (premenopausal) or maintaining (postmenopausal). With a gradual program, most patients can increase the stress to their weight bearing bones carefully enough to help when bone density needs improvement. Injuries to bone definitely heal slower when bone density is compromised.
This photo shows that the heel padding of one of my orthotic devices was removed. This patient complained sliding forward in the shoe when wearing her orthotic devices. I initially used tongue padding to hold her back, and this helped some.
I also added power lacing to allow the shoe to grab the heel area better, but without making it too tight.
When that did not completely solve the problem, I removed the original neolon topcover and replaced with the blue EVA topcover seen in the original photo.
Since I was trying to stabilize the front of her foot mainly, I then removed the rearfoot posts which always pitch you forward. And, when that did not completely help, I removed the heel area of the topcover completely and the sliding forward stopped. Who knows if I would have achieved the same if this is how I had started. But, I have given you 5 treatment options when this problem occurs.
A. Tongue Padding
B. Power Lacing
C. Less Slippery Topcover
D. Remove the Rearfoot Post (at least thin maximally)
First of all, I cannot express how much gratitude I have for you and your blog. It feels like my only source of relevant information. Thanks again for being such a caring medical professional and invaluable resource.
I've attached two images of my MRIs (one from my left foot and one from my right). Do you mind not posting the MRI images on your blog? Dr Blake's comment: The MRIs show injury to both tibial sesamoids. It was difficult for me to see if one side was worse.
After about 2 months of wearing special insoles that have cutouts around the sesamoids to unload them (my first doctor made these insoles for me), I had an appointment with a second doctor just to get another opinion. My second doctor put a walking boot on the left foot and instructed me to walk with partial support with crutches. I'm also using a bone stimulator (exogen 4000). I had a few questions if you have time.
1. Does it make sense to put a boot on the left foot (because it generally hurts more) even though the MRI shows much more damage to the right foot? Dr Blake's comment: When both sides hurt, you really have to try to minimize pain the best possible in creating a pain free environment. If that means treating the foot more than the MRI, I would do that. Many times the foot that looks the worse hardly hurts, and the one that looks fairly normal hurts a lot. So, go with whatever works. How something looks on MRI is only one indication of how much it may hurt. 2. There seems to be increased pain in both feet, but esp my right. I'm not sure if it's my imagination since I'm thinking about them much more. But is it normal for the feet to hurt more when using the bone stimulator? Dr Blake's comment: First of all, what is on the right side? Hopefully a tennis shoe with insole and dancer's pad. The crutches should take weight off your feet, and on to the shoulders, elbows, wrists, etc. The crutches should not be used to put more weight on the right since that side is also injured. Make sure you are getting even weight on both feet and let the crutches off weight the feet, the removable boot limit the motion in the left big toe joint, and the dancer's pad off weight the right sesamoid. You have to decide if you need more off weighting in the boot of the sesamoids and with the insert and dancer's pad. Perhaps you need higher arch support on the right along with a slight increase in the dancer's pad. And, yes, the bone stimulator can increase pain in the sesamoids, but normally the trio of 2 fifteen minutes ice packs and 1 session of contrast bathing per day for each foot minimizes the symptoms and does not allow the inflammation to pool and cut off the normal circulation vital for your overall healing. 3. My doctor told me to cease all exercise. But exercising is important to me for other health reasons, both physical and mental. It's not clear to me how biking (with my heel on the pedal, not my forefoot) or swimming will impede the healing process. If anything, in the past exercise makes my feet feel better. Dr Blake's comment: It is so important to maintain core strength during this time. I allow as much biking and swimming (no pushing off walls) as possible during this time. Keep your core strong, cardio strong, and just listen to your foot. You will know if you are aggravating the problem in any way. You would really need to try hard to hurt yourself. When you do an activity, ice for 15 minutes afterwards (within 2 hours max). Listen to how you feel. You will need to perfect this skill as you move forward anyway, and probably already have. The stronger the core, the more your legs lift you off the ground, the less stress on the bottom of the feet. This is a well recognized part of any physical therapy practice when treating foot injuries. 4. My first doctor told me there's a chance the seasmoids will never heal and I will never play sports again because he didn't see much, if any, healing when comparing my first (Feb) and second (Aug) MRIs. How do I know if this is the case? The pain has always been pretty mild. I thought I was nipping something small in the bud when I first went to see a doctor so it's surprising that my diagnosis has become so dire. Dr Blake's comment: It is common and unfair for the medical profession to counsel based on the worst case scenario. Doctors, and everyone in the healthcare community, tend to remember their failures and their last patients with similiar injuries. A failure to the health care provider is much more memorable if they were promised complete healing and it never happened. The patient is mad at the provider, the patient assumes the provider made a mistake, and then the provider can very protective when the next similiar case comes through the doors. And then, some doctors want to do surgery and push for surgery in subtle ways like saying conservative treatment will not work. They actually may be telling the truth in their minds. They actually may have never seen a case of this type of injury ever heal completely. And, it could have started when they started their practice and were counseled by practitiioners older, wiser, but without the modern day resources we have today to get things to heal. Golden Rule of Foot: Listen to Your Body First, healthcare provider second. It applies to me and my patients too!! I have certain biases, or too small amounts of time to analyze every detail, I may make a judgement call that is incorrect. My patients need to have some much trust in me that they can tell me I am barking up the wrong tree!! I hope they always feel comfortable to do that. 5. I had this bruise on my left outer shin/calf about 6 weeks ago. Although the bruising is gone, when I touch the area it still hurts as if a bruise is present. Is this possibly related? I'm asking mainly because the left foot hurts more than the right foot even the MRIs show the left foot has milder injury than the right. I also had issues of my left big toe tingling as if it was asleep as well as pain underneath my other toes on the left foot. I'm wondering if all this signals some potential nerve injury? Dr Blake's comment: The bruising is probably from the straps or metal stay on the boot hitting into you. The numbness and tingling is related to the circulation compromise that always occurs with these boots and the velcro straps on the leg that hold the boot on. The injury causes swelling, and veins return the swelling back to the heart. Removable boots compress the leg veins and inhibit the flow of blood back to the heart. This is why I recommend icing and contrast bathing. I also recommend periods of time each day to take off the boot, massage the calf and foot, and perform some foot elevation and calf pumping like they teach on airplane videos to avoid blood clots. Sometimes the friction from the boot liner alone can cause local nerve irritation and changes in the liner/footbed can help. I sure hope all this helps you. Rich
Any thoughts you have would be greatly appreciated! Thank you SO MUCH!
I was diagnosed with a fibula sesamoid fracture on my left foot. I feel like I am walking on a golf ball and that is what I call it now. I walk on the side of my foot to keep the pressure off of the ball of my foot but that is causing knee pain and hip pain.
The podiatrist that I saw took one set of x-rays sold me cushions for my shoes and arch supports to wear. I tried those for 2 weeks and no relief. When I returned to the podiatrist he suggested since the arch supports provided no relief that I try a cortisone shot. The shot took the inflammation out of my foot,for about a week, so it felt like the golf ball went away but the pain was more severe since there was not any extra padding on the ball of my foot.
I returned to the Dr. 2 weeks later and he said there is nothing else he can do surgery is my only option and sent me home. I feel after reading your blog that I really need a second opinion before I let anyone do surgery on my foot. My question is do I get that second opinion from another podiatrist or do I try to see an orthopedic doctor? I am scheduled for surgery on December 28, 2012. Any help or advice is very much appreciated. I have cried with my husband over this whole situation and how frustrated I am please help.
Sincerely,
Kara (name changed)
Dear Kara,
Thank you for paying me the biggest compliment allowing the blog to help you. Please cancel the surgery so that the next 6 months can be dedicated to healing, not hoping the surgery can be avoided. I would not focus on the surgery, even though you may go that route in a much more enlightened frame of mind.
The following checklist should help you focus on what you should be doing over the next 3 months. All of this is in the blog.
Daily Use of Removable Cast with EvenUp on the opposite side. Accommodation if more off weight bearing is needed.
Evaulation of Hormone Levels affecting Bone Healing
Daily 1500 mg Calcium and minimum 1000 units Vit D3.
Ice 15 min twice daily
Contrast Bathing every evening.
Shoe inserts that take the pressure off the sesamoids (under the first metatarsal), normally with good dancer's padding.
Spica Taping daily to restrict toe bend.
Activity Modification to minimize activities which reproduce pain.
MRI ASAP so we have one to compare to in 6 months if necessary.
No more cortisone shots please since they can delay healing and mask pain.
I have many patients in pain. It is a very disturbing, challenging, fascinating problem. This introductory lecture by Lortimer Moseley discusses how pain becomes it's own source of pain. The brain senses a danger that does not exist, or has existed in the past. It is a fascinating talk. Hopefully, for patients living in pain, it is the doorway to a better tomorrow. This is my prayer for you. It has great validity.
Okay any help would be appreciated. 5 years ago I had a stress fracture in my sesamoid bone The one Under my second toe. I continued to work out on it and the pain went away. Dr Blake's comment: You have two sesamoids, extra bones like kneecaps, under the ball of your foot (sub first metatarsal head). One of them is closer to the side of the foot (tibial or medial sesamoid) and the other is closer to the 2nd toe/metatarsal (lateral or fibular sesamoid). It was probably the lateral sesamoid that you injured.
You can imagine the irregularity in the sesamoid that is injured here showing bone remodeling and some break down.
About a year later it came back with a vengeance . I tried conservative therapies for a year. Boots, rest, massage, cortisone. Well the bone had necrosis and was completely removed. Dr Blake's comment: Sound like you did the right thing. Once a sesamoid is removed, the other sesamoid is now more prone for injury and requires a lifetime of dancer's pads and/or orthotics to off weight the area.
A blue dancer's pad is easily applied to the shoe insert that came with the shoe to off weight the area.
Everything was fine and pain free. About 6 months ago I was barefoot trying to get a door open and kicked it hard. I fractured my other sesamoid in the same foot. So stupid of me! It is Once again not healing. I don't know what else to do. It hurts to walk. I am 29 very active and in good shape. I know having the other sesamoid removed can cause problems, but do I have another choice? For this current fracture have tried rest, ice, cortisone, and A boot. Any help would be appreciated. I am scared and frustrated. Dr Blake's comment: Get an MRI now to document the bone edema in the sesamoid and possibly first metatarsal head. Create a pain free environment with boot and off weight pads, crutches if needed, possible RollaBout for prolonged standing, make sure your calcium and VitD are great, get a bone density if any suspicions about bone health are raised by your PCP, 3 times daily do 10 ice pack and/or contrast bathing, avoid cortisone and all anti-inflammatories (NSAIDS can slow down bone healing), use the next 3 months to create a good athletic and dress orthotic that protects well, get a bone stimulator to use daily, use the next 3 months to find shoes that limit the pressure on the area. Goals: 3 months to get the above accomplished and hopefully bring down the pain 90% or so, and use the next 6 months to gradually remove all the protection, one piece at a time biweekly. 6 months after the new MRI you get another MRI to document treatment success and decide how much more to do. I sure hope this gets your next 3 months organized. Keep me in the loop. Rich
first of all thank you very much for your blog, it's very informative.
My name's Pierre and I am based in London. Could it be please possible to have your opinion on my case?
3 months ago, I injured my foot playing football - what you guys call soccer ;). I saw a foot surgeon and after X-Ray and MRI he diagnosed Sesamoiditis.
At first, pain was mild, and I could walk as much as I wanted and could run for one hour at the gym. I couldn't play football though.
A podiatrist made me some special insoles, but I think it made my shoes too tight (they occupied too much space) or they had much "arch" thus putting pressure on toes (is it possible?) and the pain became much worse.
Dr Blake's comment: Definitely, any shoe insole, even designed with the best intentions can place the body's weight in the wrong place, or make the shoe too tight, or create motion when the best is to limit the motion for awhile, or a combination. With orthotic therapy, much experimentation can be needed, and the technician designing the inserts has to have some tricks up the sleeves, and be willing to experiment. There is just too many factors to consider, and even if known, sometimes you just have to take an educated guess on which direction to go. Golden Rule of Foot: If the insert makes the pain worse, remove immediately, re-introduce a few more times, and if still a bother, definitely modify and do not wear until modified.
I then spend a week in a removable cast, but I had to remove it because it was putting pressure on my foot / toe and was hurting even on a rest position.
Dr Blake's comments: The removable casts for sesamoid pain must have an off weight bearing float placed into them unless immediately comfortable. See if the brace shop or Doc's office can do that for you. I typically use 1/4 inch adhesive felt, and may have to increase to 1/2 inch by doubling over.
So i then used for a month crutches with no weight bearing
I have recently had another X-Ray and MRI (I have the CDs but I am not sure if I can attach the contents in an email). It showed the inflammation is worse than when I had the 1st X-Ray & MRI. I was told to rest and take Ibuprofen if pain for the next 3 months before another MRI and maybe operation.
Dr Blake's comment: Non weight bearing to reduce the pressure on the bottom of your foot will cause more stagnation in blood flow and the appearance of more inflammation. It is weight bearing that pushes it back toward your heart and out of your boot. So, the weight bearing cast is important as I mentioned above. I am assuming with this conversation that the MRI revealed no fracture.
I would have the following questions please:
Would you know a specialist for such injury based in London? No
Could you please give me your thoughts/recommendations: insoles, painkillers, calcium supplements, for how long can i walk, excercises / sport I can still do etc. any advice that you think would help basically.
Dr Blake's comment: Even though you are in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, finding a good doc or pedorthist to design a comfortable insole that protects the sore area will be very helpful even if surgery is needed in the future. Part of any program is to create a painfree environment. This is normally with ice packs for 10 minutes three times a day. Anti-inflammatory medication is fine if there is no bone injury. Straight pain killers are typically reserved to allow patients to get a good night sleep when needed for that function. Calcium and VitD supplements when there is a fracture is discussed at length, but it is never a bad idea to make sure you get 1500mg calcium and 1000 units VitD3 daily between dietary intake and supplements. Most patients with pain in and around the sesamoids are limited to biking with the weight on the arch, and swimming, for cardio, and multiple gym routines or pilates and yoga type. You can always pick and choose the positions to avoid or minimize.
What do you think of the surgery: what's the success rate, how long after operation can I run again, are there any sports I won't be able to do again? Dr Blake's comment: What would they be operating on? Inflammation? Nothing you have said makes me want to go down that path right now!!!
Thanking you very much in advance for your time and attention. I would be very grateful if you could please send me your thoughts and a few advices, this injury is getting very frustrating I must acknowledge...
Dr. Blake, I had surgery on both of my big toes in Feb. 2009. It seems to be a hereditary issue since my brother had the same surgery a few years earlier. My father and grandmother had arthritis here too. I had cracked the toe while running for only 3 years. I cracked the bone on my left foot and it also had numerous bone spurs. Since the swelling did not go down after 6 weeks, surgery was performed. I had them xray the right foot, which also had spurs, so I opted to have both of them done. Yes, it was a painful surgery. I got a general and not a local so when I woke up I was in terrible pain. I blame the Dr. on that one.
Dr Blake's comment: I feel that the first surgery was rushed, since inadequate time was given to let the injury completely heal. 1 year with rehabilitation of a big toe joint injury before surgery is not abnormal. The delay helps with understanding of the problem as the various aspects of rehabilitation are put into play. Surprisingly, some do heal avoiding surgery and the possibility of surgical problems. The other foot surgery was in the realm of preventative surgery. You are getting surgery since the problem will only get worse down the line. I personally do not buy into that approach, although many smart people do. I believe surgery should be your last resort, and not done until your present disability warrants that. I know I have strong biases in this regard, and it is important that you know where I am coming from when giving advice.
In 2010, a year later, after training for a triathlon I developed Plantar Faciitis. It came on very slow but by 201i and now 2012 it has stopped me dead in my tracks. I have had pain for two years. I finally got an xray that showed a heel spur also. I have have tried everything, constant exercises, scraping, orthodics (OTC)and have stopped running. Nothing helps. Question? Did my surgery have anything to do with this issue?I am afraid of cortizone shots. Should I have an MRI?
Dr Blake's comment: Big toe joint stiffness with loss of normal bending allows the plantar fascia to tighten and makes it prone for injury. You can usually combat that problem with plantar fascial stretching, especially the towel and rolling exercises described in my blog. You may be been tighter from your surgery, but maybe not. An MRI is needed to rule out a plantar fascial tear. Tears give unresponsive plantar fasciitis a bad name. Plantar Fasciitis normally gets better with stretching, icing, orthotics, activity modification, etc. If plantar fasciitis does not get better, I think of tear, fracture, nerve entrapment, bursitis. The MRI should definitely point you in the right direction.
I am 59 yrs. old. Running was my new hobby. It kept me off of antidepressant after my husbands death in 2006. What do you suggest? Pam
Dr Blake's comments: Pam, there is nothing better than running for the adrenaline, feelings of emotional well being, etc. Get the MRI and hopefully a new course of action will be recommended. For right now, try biking in one of its many forms. It is the best at helping keep the leg strength up needed to get back into running. I wish you well. Rich
I hope you enjoy a classic. Definitely podiatry related with the kicking of a football. Happy Thanksgiving!! Dr Blake
I am very thankful for my great family and friends, for my health and house, for my faith and job. I hope this Thanksgiving finds you with much to be thankful for, and much to look forward to in the coming months and year.
You asked that I email you with how I’m doing. We met on Tuesday, November 6th regarding pain on my right foot at the base of the second toe. You prescribed a pad with an elastic loop to wear around the second toe along with some stretching and icing.
It’s now been 11 days and I can’t say I’m felling much different. The pad is irritating to wear with sneakers or boots because when I slip my foot into the shoe, the elastic loop gets pulled down and irritates the skin at the base of the toe. Sometimes I have to take it off for a while.
I find that when I wear my clogs with an open heel, however, it is much more comfortable. I don’t usually wear clogs but it’s the only shoe that I can wear the pad pretty much all day without discomfort. I’ve been pretty religious about wearing the pad regardless.
I’ve been bad about the icing. I’ve only iced twice since seeing you.
I do the stretches but not daily.
So I haven’t been the perfect patient.
What do you suggest?
Thank you.
Dr Blake's Response:
Hey Alicia (name change), Thanks for the update. Try getting a digital gel pad at the Sports Shop to put under the splint. It is a long finger looking structure, that you can cut into 3rds to place over the one toe. I have also attached the link to Silipos company that makes these things. Then you can put the splint on tighter even. You can also use paper tape on the top of your foot to tape the splint down so it will move less. Attached is the note I wrote. Definitely ice twice daily, since the pain you are feeling is inflammation. Remember to stretch and perhaps buy some Yoga Toes so that we can begin to introduce them. Sure hope this helps. Rich PS If the icing does not bring down the inflammation along, then we can have you ice and go to PT. They would love to work on your foot.
Budin Splint is a powerful stabilizer of the toe joints. When the elastic band is irritative, a digital gel pad can be used initially over the toe, or just tape to hold down the band and prevent it from moving.
Alicia is a return patient I have not seen for about 4 years. Nancy has pain in her right foot and second toe area for about 6 months. Her pain level on a scale of 0 to 10 is about 4 or 5. She is taking some Advil for the pain. Has 2 pairs of orthotics which both have reverse Morton's extensions made by Dr. David Hannaford. She is a 59-year-old. She is 5 feet, 128 pounds. Her activities that she likes are West Coast Swing, water aerobics, Zumba and dance aerobics. She would like to enjoy them without discomfort are her main goals.
SHE HAS NO KNOWN DRUG ALLERGIES.
Medicines she takes a regular basis include
1. Valtrex.
2. Calcium.
3. Vitamin C.
4. Vitamin D.
5. DHA.
She has had no past hospitalizations or surgery. She is on no special diet.
On my examination, I found someone who had pain in the 2nd metatarsophalangeal joint plantarly. It is sore on maximum plantar flexion of the joint, not dorsiflexion. She has full range of motion. There is no evidence of instability. She has always had a short second toe and I think that short second toe may be raising up just a little bit or the 1st and 3rd toes may be going under it. In either case it would trap the second metatarsal head against the ground and cause irritation. If you couple that with her reverse Morton's or dancer's pad, that puts the weight off the first and onto the second, so as part of her treatment I reduced the padding under the 2nd metatarsal head.
Alicia's 2nd toe is much like this. When the toe is being held up in the air by being above other toes, and can not physically get down to it's normal level, pain develops under the metatarsal toe joint. The pressure at push off stays too long in the one place. The splint is designed to pull the toe down into more normal alignment.
DIAGNOSES:
1. Capsulitis symptoms, right 2nd metatarsophalangeal joint, 726.90.
2. Right hammertoe deformity, 735.4.
PLAN: So today orthotic devices were evaluated and on the right side the area under the 2nd metatarsal head of the reverse Morton's extension was removed. I encouraged her to ice twice a day, encouraged her to stretch the toe in a plantigrade direction without pain. I may go to YogaToes once it is less painful. I gave her a prescription for 2 Budin splints and this will be designed to hold the toe down. She is advised that she can easily adjust the bottom if there is any pressure.
