Accessory Navicular Syndrome: Email Advice

Hi Dr. Blake,

I have been reading your blog religiously in light of my increasing foot problems. Your blog is a huge source of trustworthy information and education for anyone suffering from foot problems. Thank you for the time and care you have put into this blog because it is truly rare to find quality, trustworthy information out there regarding some of the more obscure foot problems you write about.

I am writing because I have bilateral accessory navicular syndrome, with my left foot giving me the majority of the pain. I am a 24 y.o. female who has recently moved to NYC (relevant detail).

I was diagnosed with ANS in 3rd grade when a kid threw a frisbee right at my foot in gym class, which caused my left foot to roll. I limped around all day after that, and experienced pain in my arch for the first time. I went to see the podiatrist, and he told me I had ANS and prescribed custom orthotics. He also put me in a small boot and soft cast for about 2 weeks. He mentioned surgery was a possibility if my pain persisted. I continued to wear my orthotics for a very long time without any additional incidents of pain. I did notice that if I walked more than usual, my left foot would be a little sore, but the pain would alleviate with rest.

Dr Blake's comment: This is the typical response in a young child with beginnings of problems related to the accessory navicular. The doc immobilizes, then gives orthotic devices, and everything seems fine for a while. The type of orthotic device may not be supportive enough in the long run, plus needs to be redone with a shoe size change of 1 to 2 sizes. This is a pain for parents. The common problem I see here is that posterior tibial strengthening is not done at this young age, and that could prevent future problems. 

https://youtu.be/QP3Ud4d39dc

Unfortunately, when I left home for college, I got the idea that I no longer needed my orthotics. I met a running coach at a tennis shoe store who encouraged me to leave my orthotics behind to “train” my foot to properly hold itself. I naively listened to him. I became more active during college and started doing things such as running and yoga. Unfortunately, my left foot started giving me more problems during this time, and I was wearing unsupportive shoes often, such as flats and flat sneakers. If I ran/walked more than usual, my foot would ache the next day but it would always recover with rest. I thought that this coming and going of foot-aches and pain was just my “new normal”. But in general, I did not have pain.

Dr Blake's comment: This why there was a war with podiatrists and minimalists unfortunately. Some feet, like those with inherited weakness such as accessory navicular, ligamentous laxity, tarsal coalitions, flexible high arches, plantar flexed first metatarsals with exposed sesamoids, etc etc, should have a strengthening program but with protection. 

Last year I went on a trip to SF, and the combination of wearing new chunky heels, walking up and down the inclines of SF, and overall just A LOT of walking, my feet just gave out. Not only did I experience arch pain, but I also experienced pain at the ball and heel of my foot. Bearing weight on my foot was just terrible. It took me a WEEK of wearing supportive tennis shoes (no orthotics), elevation, and icing it for my foot to feel better.

After that incident, I have just not recovered fully. 6 months ago, I moved to NY and now walk more often than I did in TX. The pain has become chronic and dehabilitating. I went to my old podiatrist and he prescribed new custom orthotics and put me in a soft cast and Cam walker boot for 2 weeks and Cam walker with ace bandage for the following 2 weeks. When he took an Xray of my left foot, he said that I actually have 2 small extra bones instead 1. He also gave me PT exercises to do. However once I was out of the Cam walker and I started walking <1 actually="" again="" allows="" and="" as="" back="" because="" but="" cam="" did="" do="" doing="" exercises="" flare="" getting="" groceries.="" help="" i="" increasing="" independently="" insurance="" into="" issues.="" it="" me="" mile="" much="" myself="" not="" of="" pain="" pt="" put="" recovery="" simple="" slower="" span="" supervision="" the="" them="" things="" time.="" to="" up="" walk="" walker="" was="" with="" without="" would="">

Dr Blake's comment: Without insurance problems, here is where an MRI is crucial to see where the problem lies. Is there inflammation in the accessory bones, posterior tibial tendon, or navicular itself. You can also have a fluroscopic exam  to see how much movement there is between the accessory bones and navicular. If the MRI points to an inflammation/sprain problem, the cam walker, plus orthotics, plus taping can be helpful. If the bone is involved, perhaps a bone stimulator for 6 months while you keep the pain level between 0-2. Also, PRP injections for a sprain, or prolotherapy injections, are showing good promise.

I went to see podiatrist #2. He was very confident in recommending a cortisone shot, with the idea that he would give me 2. He gave me the shot right above my AN bone, and I reacted terribly. I could barely walk home from the subway and the pain was present for 1.5 weeks. I could not bare weight on it at all or wear the Cam walker because I had a bruise where the doctor injected the shot. I took Diclofenac Sodium for an NSAID but it did not really help with pain.

Dr Blake's comment: I am not sure what injection was given, but long acting cortisone shots can not be given around tendon insertions. I hope when the dust settles you are fine.
My doctor podiatrist failed to tell me any possible side effects before administering the shot, and I was completely blindsided. I felt worse than I did before getting the shot. This doctor says he doesn’t know what to tell me. I really want to avoid surgery. He says I can try doing 7-8 sessions MLS of laser treatment or PRP (Platelet rich plasma) injections. Have you heard of those treatments? He tells me that he cannot tell me the success rate that he’s had with these treatments since my situation is unique. He has also prescribed PT but I have yet to find a physical therapist yet.

Dr Blake's comment: Right now without your MRI to elucidate the origin of pain, it is hard to advise you. Laser is being used alot, and I know there are different ones, but I can not tell you if it would help. Sorry. Are you icing twice daily, and doing contrast bathes each evening, and perfecting posterior tib taping? 

https://youtu.be/e1JAewWT9Fc

I haven’t had an MRI yet, but he said he could justify ordering one if I wanted. Money is tight for me at the moment. I am trying to evaluate if it is worth getting an MRI. I don’t know if there is tendon or ligament damage or bone edema, etc.

Dr Blake's comment: Get the MRI, self pay is normally around $400-$500, and they may have installment plans. I am sure the doc wants one, but is trying to be cost containing for you, but the money is worth it at this point. 

I would like to do PT and find someone experienced with this condition. Is there a case in which a patient with ANS/PTT should NOT attempt PT…. for example when should & should not a patient start doing PT? I just don’t know if my feet are ready to do PT.

Dr Blake's comment: The goals you are to use immobilization techniques (boot, orthotics, taping, Aircast Airlift PTTD brace), and anti-inflammatory measures (icing, contrasts, topical or oral anti-inflammatory, activity modification) to get the pain between 0-2 levels. If you can not do that, you use PT, laser, acupuncture, etc to bring the pain down. If not, you go into a permanent cast for 6 weeks to totally rest it. Once you are in that 0-2 range, physical therapy gradually strengthens, changes your gait, makes suggestions about orthotic modifications, does soft tissue and joint mobilization, makes sure your calf is not tight, etc. So, you typically use PT in the restrengthening phase of rehabilitation, but some need it in the immobilization phase also.

https://youtu.be/g0sD0gUbEMU

I don’t feel l pronate with my orthotics on, and my arch does not look collapsed/flat. I rest, ice, and elevate my feet. Epsom salt soaks help a little. Should I be using heat also? The pain is under my arch, and if I walk to much (especially in the CAM walker), my calves, glutes, and leg get sore. If my foot starts hurting while I am walking, there is sometimes a shooting pain up my posterior tibial tendon. I tend to shift my weight more on my right foot now and it is beginning to hurt also. The outer right ankle sometimes aches while walking.

Dr Blake's comment: Always err with ice. Heat can be used to warm the tissue up before exercise. Please get an EvenUp for the other side when wearing the Cam Walker, if you are having problems keeping the hip heights level. You probably should be doing daily calf, hamstring, quad, and glut stretches. You should be wearing your orthos in the Cam Walker, and perhaps taping also. Even simple Kinesio taping for the arch as long as you surround the accessory navicular with the tape can be very helpful. If the pressure of the tape irritates, you can pre-cut a hole out for the bump before applying. 
https://youtu.be/NLfzvAJgyJ4

I am seeking your opinion because my current doctor seems to not have an opinion on my condition. After the disaster of the cortisone shot, he seems to not want the responsibility of making any recommendations. I really want to try as many conservative treatments as I can as I am very adverse to the idea of surgery. However, I don’t want to hurt myself by prolonging  this process.

I appreciate your time and knowledge so much. I can send you pictures of Xrays (might take time) or my foot if you suggest.

Thank you in advance for your help.
-SurgeryAdverse

Dr Blake's comment: I am happy to have you send a CD of the MRI when you get that. They can burn the xray images if done at the same place only. Sounds like you have alot to do before any surgery is anticipated. Glad the orthos have been done right. Good luck and I hope this helps some. My mailing address would be 900 Hyde Street, San Francisco, Ca, 94109.    Rich

Patient's Response:
Thank you so much for your quick reply! 

I hope to get an MRI soon- within the next month. I have a new job and will be getting new insurance so it will hopefully be more affordable. Thank you for encouraging me to get an MRI, your justifications make sense and will hopefully give me & doctors more insight on how to move forward.

I haven’t heard of a contrast bath yet but I will try that. I have tried taping but I’m not sure if I am doing it right. I have been watching your videos and others and will continue to try to perfect it. Sometimes the bottom of my foot feels cramped after I tape which I’m not sure is normal or not. I am icing a couple of times a day and elevating my feet.

Thank you again for your help. I will send you MRIs once I get them. It is so nice to get a second opinion.

Have a great weekend!

Missing Sesamoid in Child

Hello Dr. Blake!

     My daughter injured her R foot in January. Initial x-rays at an urgent care center ruled out a fracture.  She was still mobile but the foot was uncomfortable (a 7 on the pain scale).  We finally went to a podiatrist and they did more xrays.  It was discovered that she is missing one of the sesamoid bones.  So, here we are in a boot 4 weeks later.  Pain is improving but I am wondering what we should do long term.  

     She is 9 years old and very active, just loves to play, no organized sports or dance.  

Any advice you can give would be very helpful!

Dr Blake's response:

Hey Melissa, I am sorry for your daughter's problem. Only a small percentage of people only have one sesamoid, so we do not know alot about that. However, do they think she hurt the other sesamoid? If so, you treat it as a fractured sesamoid with 3 months in the boot. During the 3rd month you have some form of orthotics made for her to protect her, so as she weans out of the boot, she will have the protection of the orthotics. You should be icing once a day now, and doing contrast bathing every other day in the evening as a deep flush. She should have a healthy diet. You should learn the skills seen in my blog of spica taping, designing dancer's pads, and Cluffy wedges, since they can all come in handy in the months after coming out of the boot. Hope this helps some. Rich

Question from fellow podiatrist

Hi Dr Blake,

I had a patient who presented today with pain in the anterior as well as anteromedial aspect of both knees, hamstring pain bilateral, ITB pain on left side and numbness on soles of both feet. The patient has had the knee pain for over 30 years due to a fall during sporting activities. Severity is about a 7/10 and standing / walking makes the knee pain worse.

Patient only has hypertension and takes medication for it.

On examination, there was limited knee flexion, hip internal rotation, MTJ ROM, 1st MPJ bilaterally.

STJ axis was severely medially deviated for the right foot where the line of the axis exits through the mid arch area.

The STJ axis was medially deviated for left foot, however it was less severe with line of axis exits below the 1st metatarsal head.

Supination resistance was very hard for right foot(where I could not even move it) and hard for left foot.

The patient RCSP was 8 deg inverted (right) and 6 deg inverted (left)

Jack's test was moderate for both feet with no arch increase / windlass mechanism activation.

Did not do a gait assessment as patient uses a walker and he finds it difficult and painful to walk.

My diagnosis was patellofemoral pain syndrome with medial plica irritation bilaterally as I was able to reproduce the symptoms on palpation bilaterally. The patient also had tarsal tunnel as the Tinel's sign was positive bilaterally. I have also ordered knee x-rays.

My thoughts are that the excessive pronation is causing compression on the tibial nerve as well as increasing the stress on the patellofemoral joint. Besides that, the tight and weak quads, tight hamstrings may also be causing patella maltracking as well as irritation of the medial plica as the quads have to work harder during gait.

In terms of treatment, I have advised patient on footwear and icing. I have also learnt some tool assisted massage which I can use for the tight quads and hamstring since I think the patient is not able to do quad and hamstring stretches as he is using a walker. I am also thinking of supine straight leg lifts as part of the tx plan to strengthen the quads.

As far as orthoses prescription go, I am a bit lost. Do I just use an accommodative device

or use a Fettig modification on an inverted type device?

Have you had cases like this where the STJ axis is medially deviated but the RCSP in inverted and also where the STJ axis is laterally deviated but the RCSP is everted? What kind of orthoses prescription do you use for these cases?

I find this case to be challenging and your thoughts would be greatly appreciated.

Regards,

Dr Blake's response: Thank you so very much for the question. First of all the deviation of the subtalar joint is only one part of an evaluation. Medial deviation is a sign that the foot has a tendency to pronation, whereas lateral deviation is a sign of the tendency to supinate. However, other forces can override this, especially sagittal and tranverse plane external forces. I suspect his external hip position is pulling his whole foot laterally, and the rigid nature of his knees and feet can not alter that. That being said, this is a typical presentation of an elderly patent who needs accommodative orthotics with valgus wedging added to the ortho after dispense. The soft based full width orthotic devices will give him great shock absorption and added stability. After dispense, correct any lateral instability (aka supination) with some form of valgus wedge. And you are correct to work on the tight and weak muscles to ease his walking. Hope this helps. 

Paper Tape for Blisters: Stanford University Study

http://med.stanford.edu/news/all-news/2016/04/stanford-trial-shows-paper-tape-can-help-prevent-foot-blisters.html

And see some of my other posts on blisters.

http://www.drblakeshealingsole.com/2010/04/general-principles-on-blister-care.html

http://www.drblakeshealingsole.com/2010/06/back-of-heel-pain-or-heel-blisters.html

Baseball is Back!!!

​Two 90-year old guys, Leo and Frank, had been friends all of their lives. When it was clear that Leo was dying, Frank visited him every day. 

    One day Frank said "Leo, we both loved playing baseball all our lives, and we played all through High School. Please do me one favor: when you get to Heaven, somehow you must let me know if there's baseball there."
 
    Leo looked up at Frank from his deathbed and said, "Frank you've been my best friend for many years. If it's at all possible, I'll do this favor for you."

    Shortly after that, Leo passed on. 

    A few nights later, Frank was awakened from a sound sleep by a blinding flash of white light and a voice calling out to him, "Frank... Frank ..."

    "Who is it?" asked Frank sitting up suddenly. "Who is it?"
 
    "Leo-- it's me, Leo."
 
    "You're not Leo, Leo just died."

    "I'm telling you, it's me, Leo" insisted the voice.
 
    "Leo!....Where are you?"
 
    "In Heaven," replied Leo. "I have some really good news and a little bad news."
 
    "Tell me the good news first," said Frank.
 
    "The good news," Leo said, "is that  there's baseball in Heaven.  Better yet all of our old buddies who died before us are here, too. Better than that, we're all young again.  Better still, it's always springtime, and it never rains or snows. 

And best of all, we can play baseball all we want, and we never get tired."

 
    "That's fantastic," said Frank "It's beyond my wildest dreams!  So what's the bad news?"

    "You're pitching Tuesday." 

Life is uncertain - eat dessert first!!!

Fracture yet Still Smoking: Important Video

Low Back Pain and Orthotic Devices: Email Advice

Hello Dr Blake-

I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM

I found a pair of orthotics that were  custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.

My question is would you be able to to make a new pair of orthotics for my back pain  since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.

Thanks-

Dr Blake's response: 

     Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control. 

     When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also. 

     The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done. 

     There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich

Calmare Pain Therapy: Email Correspondance

Dear Dr. Rich,

Yes, I finally got through to Dr. Gutierrez and signed up for the treatment, starting Monday, March 21.  My symptoms were perhaps not typical; most people start with a lot of pain and it gradually reduces.  My neuropathy pains have always been intermittent and worse at night;  a major problem has been sensitivity of the soles of my feet.  So for the first treatment my pain level was zero  before treatment, but they did it anyway.  However, that same day I noticed a marked improvement in the sensitivity of the soles.  The second day I wore a pair of thin soled shoes and before the treatment walked around on rough ground including a gravel path, and it felt OK.  This was something I absolutely could not have done before.   Again zero pain at the start of the treatment, but I am sure the treatment was beneficial.  I don't know if Dr.Gutierrez though I was a hypocondriac, since I was supposed to have more pain.  I ended up having only 3 treatments;  I questioned  whether getting all 10 proposed treatments would be beneficial.  The shooting pains I had for the past year or more had been less lately and have not recurred.  Dr. Gutierrez agreed for me to stop after the 3rd session (and not have to pay for all 10) with the understanding that if pain returned I could "start over."

I am happy about the outcome and grateful to you for telling me about it.  The other symptom of neuropathy, which they call "compression" or feeling like the feet are overstuffed sausages, with difficulty  flexing the toes, is apparently not helped by this treatment.  And then there's the arthritis which is still active.  However,  any progress is welcome and I am now able to wear all my shoes, some of which I could not get my feet into a few months ago, and walk much more comfortably.

So, many thanks, and I hope Calmare gets full approval.

Best regards,

A Little Flight Humor: on your way to your Foot Doctor's office of course

https://youtu.be/TxNrizGdhtY

Sesamoid Injury: Email Advice

Hi Dr Blake,

     I have been to the doctors and they said I have a fracture in my sesamoid bone and sesamoiditis (yes I had an x-ray). I woke up on the 7/03/16 with this horrible pain which has subsided but I do still get some pain. I can't put any weight on my foot or move my foot up or down or my big toe. Its very debilitating. Yes I had a x-ray. I think it was caused by starting a new gym class in January which is high intensity cardio. I don't normally do alot of cardio, but thats when I really started to notice that the ball of my foot was uncomfortable but it didn't hurt until I woke up last Monday morning and couldn't walk on it.

 Do you know much about the condition? It is probably one of the top injuries on this blog. See the link to the original posting below. 

http://www.drblakeshealingsole.com/2010/09/sesamoid-fractures-advice-when-not.html

 and or recovery times? This is very variable, up to several years, but 3 monthes in an environment maintaining 0-2 pain seems crucial to obtain quickly. Try to get my patients to understand Good vs Bad Pain and the Magical 80% Rule.

http://www.drblakeshealingsole.com/2013/12/foot-pain-dilemma-of-good-vs-bad-pain.html

http://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html

And anything extra I should be doing? I have been doing the RICE method and using crutches. 

Would u know how long it will usually take for me to be able to put weight on my foot so I can hobble around without crutches?. This is based on maintaining 0-2 pain levels. You need to weight bear also for bone mineralization and healing/strength. So, figuring out how to weight bear with the minimal amount of irritation is crucial, and then to gradually increase the stress to the tissue. 

Or if doing exercises to increase blood flow will help? Motion of moving the joint, boot in general, and ankle is very important to circulation. No movement equals increased swelling and pain. No weight bearing equals increased swelling and pain. 

If so what kind of exercises?.  I have been asking around about this condition and not alot of people know much information on it, including the doctors. I just have my foot bandaged at the moment and using crutches to get around which is very difficult.  Typically the first exercises are active range of motion while you do your evening contrast bathing. You pretend your big toe is a paintbrush. Also, as soon as you can start metatarsal doming and Single leg balancing the better. With the balancing, you place the sesamoid area in the middle of 4 one inch high books with a center hole created to place the sesamoid. 

https://youtu.be/GY-mJjXmeIc

Shin Splints: A Possible Resource

I received this email advertisement. I briefly reviewed it only, so can not recommend it in part or whole. I can say that I am impressed by the some of the thoughts, and hated not to pass the information along. Sorry, but you will have to use your own judgement on this. Dr Rich Blake

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You see, pain is a symptom but it's also a signal from your body telling you that something is wrong inside... It’s your body’s way of alerting you to underlying conditions that are causing your pain... and if you ignore those underlying problems and only treat the pain itself, you’ll never get the lasting relief you want.

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Be sure to keep me posted on how you are doing...

Have a great day.

John

Post Sesamoid Removal and Neuroma Care: Email Advice

Thank you for inviting me to email you about my foot trouble.  

     In the middle of February 2015, I was in a car accident in which someone pulled out from a side street across my line of traffic.  I slammed on the brake and tried to swerve but ended up hitting him in the rear driver's side. My left knee got jammed into the dash and by that evening my right foot had started swelling up and got quite painful. 

     I went to walk in clinic to get checked out and they xrayed my foot. (Dr Blake's comment: x rays do not show small fractures ever or it can take up to 4 weeks).  She said she did not think there was a break.  A few days later I followed up with my primary who went by the urgent care's report and said it was sprain so ice and rest it and take a lot of advil.  I did, it was getting no better.  I went back to my primary a week later because both my neck and foot were not getting better so she sent me to PT.  My neck got better, my foot had no improvement.  It was hurting so bad it was waking me up several times a night. 

     After several weeks my PT said he thought it must be broken so  I went back to my primary who finally sent me to a podiatrist.  The podiatrist sent me for an MRI which showed the tibial sesamoid was indeed broken.  The podiatrist said that Urgent Care missed the break because they did not take the xray at the right angle. Now the pain I was experiencing was a sharp pain in the big toe joint area.  Driving was excruciating.  I also had pain between the 2nd and 3rd toes.  It felt as if there was a baseball under that joint, which changed to feeling like there was cotton stuck under there.  Sometimes it felt like it was burning. (Dr Blake's comment: This is nerve hypersensitivity kicking in. It is pain generating more pain by making the nerves hypersensitive inorder to protect you, tell you to get off it). 

    My podiatrist did not really address that concern but regarding the sesamoid he said that my options were to be completely non weight bearing for 2 months but that may not even work, or get the surgery (keeping in mind  by this point it has been about 2 months since the accident).  So on May 5, 2015 I had the tibial sesamoid removed.  After the surgery the doctor told me that not only was it broken but the cartilage between that bone and the joint above was blown out so he had to clean that up a bit. 

Dr Blake's comment: This was good news so you know the surgery was 100% necessary to avoid further injury to the metatarsal. 

    I went back to PT but stopped since it did not seem to be helping.  Last October I went back to the podiatrist because the big toe joint was still really hurting and the neuroma was still really bothering me.  He scanned my feet to make orthotics and gave me 2 cortisone shots at the big toe joint.  At first he was saying the pain was due to a bunion, but after the shot and after the difficult time he had administering the shot due to scar tissue he said the pain could be from the scar tissue.  He still did not address the neuroma.  The cortisone helped some for the pain.  I think it was late December before he gave me the orthotics.

Dr Blake's comment: I love to get orthotics to patients right after surgery, if they do not have them already, since I want them walking with sesamoid area protection. 

     In January, I went back because I just could not take the neuroma and at first he just wanted to pass it off as being because of a bunion but then he actually looked at my xrays and said that no that did not look to be the case so he gave me a cortisone shot between the 2nd and 3rd toe.  It helped take away some of the burning pain I was getting.

Dr Blake's comment: This doctor is just slow at doing good things!!!

     I wear the orthotics consistently in well fitting athletic shoes, but they don't seem to make much a difference. Actually the orthotics are so hard (and I did put a thin cushion on them) that when I get home I want to take my shoes off, but I don't because the doctor said not to go barefoot. My job keeps me on my feet alot on concrete floors.  I do have some antifatigue mats around and use them whenever possible.  But I find that if I have to stand or walk on those floors for even a half hour I can feel that neuroma and it feels like my foot is blowing up like a balloon. 

Dr Blake's comment: It is common to need up to 3 shots to calm a neuroma down. See if you can get the second one soon. 

     The big toe is becoming again painful (a sharp pain on the underside and side), but not all the time.

Dr Blake's comment: The surgery for a damaged sesamoid and undersurface metatarsal bruising can take up to 2 years to feel great. Typically a PT will be the most help getting the range of motion better, reduce the scar tissue, and get the muscles strong. I am assuming you are doing met doming exercises and simple self mobilization. Does spica taping help you?

     I went for a second opinion who said he had very little time, just said he recommended a couple more cortisone shots at that neuroma. 

Dr Blake's comment: What a comment!!! I apologize for the sacred profession of medicine. 

 I would like to get back to a normal life but if I try to walk too much, or run I pay dearly.  And I am not sure what to do.  Any suggestions would be greatly appreciated.  I can send you xrays if that helps.  Thank you so much for your time!

Dr Blake's comment: So, I would have the doc do at least one more neuroma shot with cortisone. Read on my blog about neuomas to see if there are other suggestions, like metatarsal pads. Get referred to a PT known in your area for feet and see what they say about the big toe joint and the neuromas. Keep me in the loop. Get a new MRI 2 weeks after you next shot. I would be happy to see the images. Just email me them by taking photos of each frame. What shoes or qualities in shoes have you found helped the most. 

Possible Sesamoid AVN: Email Advice

Good morning Dr. Blake

I found your blog by searching help for my condition, I was just diagnosed with an avascular necrosis of the sesamoid bone. 

I have an increasing pain since last august, at the beginning that was nothing, just like small cramp when I was walking but it gets worse since November. I did X-Ray and MRI and my doc in France concluded a " contusion " of the sesamoid bone and I had some insoles to wear in my shoes, but it doesn't do any real difference and the pain continue to increase. 

Finally, I saw a doc here in the US and he told me that was a AVN after taking new X-ray and MRI where we can see more cyst in my bone. As I understood, that the worst case we can have for this bone, and I don't even remember any event in my life around last summer as a bad jump or a fall ! I don't smoke, I don't drink any alcohol except a glass of wine every two or three weeks.... 

My doc wants me to wear a walking boot for 6 weeks to try to ease the pain, and he will give me my options then... But he never talks about healing the bone, only release the pain ! 

Is there anything we can do to heal the bone ? Dis it happens to someone ? I'm only 24 years old, I never had any bad health problems before, I don't run, I'm normally active but doing low impact workouts for years... I'm getting very pessimistic, I will enter in one of my most important year for my career as I will graduate soon, and I'm afraid that this condition would ruin all my hopes ... 

Dr Blake's comment: 6-9 months of Exogen bone stimulator, along with some weight bearing with orthotics and dancer's pads can turn this around. I believe avascular necrosis can only be diagnosed on CT scan, so consider getting one. If the bone has fragmented, definitely consider surgical removal. 

Does the surgery help ?  My doc told me that if we remove the bone the other bone can get the same... Will I walk normally again someday ? :( 

Dr Blake's comment: Since you did not deserve this, is there any problem with bone density or Vit D deficiency?If you are a vegetarian or vegan, you may want to temporiarily change or at least get a dietician to consult.I have never seen the other bone have a problem, but sure it could. This is one of the reasons you try to save the injured one now, even if it seems alot of time. And it is never at a good time to injure this bone. 

And my other foot begins to be painful too, but the X-ray shows nothing abnormal ... 

I'm trying to walk less as possible, I'm wearing a " step " bracelet and I set the vibration at 5000 steps, and try let it vibe as late as possible in the day ! But i'm working in a lab and you always have to go get stuff in other buildings or just walk in you own building because your experiment requires to go to different rooms.

I also stopped to workout, I was doing occasional weight lifting (no squat or lunges) and some " horizontal " bike, a thing I can do without using the ball of the foot, but I don't have the feeling it helps my bone. Should I stop everything ? I stopped for 2 weeks now. 

Dr Blake's comment: We need circulation, leg strength, cardio, and weight bearing. This is a good time to test things out to see what does and does not bother you. Simply putting the pedal of a bike on the arch can off weight the area enough to help. 

Sorry for the tone of my email, I'm completely down by the news...

Dr Blake's comment: Send me a photo of the 3 xray views when you can to see what they are calling AVN. And ask about a CT scan.

If you have any advice to give me, I would be so grateful ! 

Best,

Sesamoid Injury with Possible Surgery:Email Advice

Hi Dr. Blake,

I just discovered your blog and wish I had found it when I first looked for information on sesamoiditis.  

Almost two years ago I slipped on wet pavement and fell.  My foot only hurt a little immediately after but by the next morning it was painful to walk.  However, I'm a  teacher it's so difficult to take a day off (especially last minute since it takes several hours to create good sub plans).  So I decided to see how it felt in a few days.  I wore tennis shoes most of the time and it started feeling better.  However, a few weeks later when it got worse, I ended up with an appointment at an urgent care clinic.  That doctor had x-rays taken and said it wasn't broken and gave me a "post-op" shoe which he told me to wear for two weeks.  After two weeks, it felt better but not healed.  I had planned to continue wearing the shoe but the sole cracked in half.  Since it was over the two weeks, I decided it should be fine.  I realize now I should have followed up with my regular doctor immediately, but I didn't until the pain was bad again.  She said to try the post-op shoe again since that worked before.  And the same thing happened (including the shoe breaking after a couple weeks).  At that point I made an appointment to see her and she contacted the podiatry department for my health plan who said that I needed custom orthotics for sesamoiditis.  They referred me to a doctor out of my health plan because none of the doctors within my health plan make them.  However, that doctor was on vacation for a month.  At that point I had been reading about sesamoiditis as a chronic injury.  So I asked to see a podiatrist within my health plan to confirm the diagnosis and get some suggestions for what to do in the next month.  That doctor just suggested over the counter shoe inserts and a sturdy shoe (which I was already wearing most of the time).  He also looked at my initial x-rays and said that there may be a fracture  but there was no way to get a better picture of that area to determine because if where it was, but that the treatment would be the same and I needed to get the custom orthotics when the other doctor was available.  (When I eventually met with the orthotics doctor, he said an MRI would tell and was surprised I was told that there was no way to tell if it was broken or not but also said that the treatment was the same so I didn't worry about it.  He also said that he thought I would be in more pain if it was broken--but I wasn't sure he knew how much pain I was in because every time he asked me to walk barefoot he expressed surprise that I was walking entirely on the side of that foot and not putting any pressure on the ball of my foot.)

So finally a couple months later (6months after the injury) I had the orthotics but no treatment plan was ever discussed other than "wear the orthotics."   And I wasn't sure who I was supposed to be asking since the one doctor was out of my health plan but the other one hadn't seemed very helpful.   So after a couple months when I was feeling better I figured even a broken bone was only 6-8weeks and started going barefoot in the house.  Of course the pain got worse and eventually I contacted the podiatrist within my health plan since follow-up visits with him would be covered by my insurance.  

He ordered a bunch of x-rays that he said showed that it was not broken.  He blamed me for stopping treatment early even though I had never been given a time frame for treatment and still had to ask him multiple times in that visit to get a straight answer on when he felt I could stop wearing the customer orthotics for everything except sleeping and showering.  (He finally said two weeks without pain and I could try without them.)  

He also gave me some stretching exercises to do and said that I was probably putting a lot of pressure on the ball of my foot when I walked and the stretches should help change the way I walked.  At that point he said surgery was a possibility but I should try stretching it and staying off of it for longer and that the stretching would help me have a better outcome if I did need surgery.  The problem was that several of the stretches required that I put my weight entirely on my right foot.  So the stretches were making it worse.  Thinking that he was the doctor so wouldn't have told me to do those if they weren't necessary, I kept trying to do them even though they hurt and some I could just never make myself do every day.  Finally, I went in to see him again and he said I should only be doing the ones that didn't hurt.  I was also about to go on a long-planned extended family vacation to an amusement park.  So I asked about precautions for the trip.  He gave me a boot that he suggested using.  My friend had also suggested asking about cortisone shots so he also gave me one of those (although I researched later and saw a lot of negatives on those and wish that I hadn't).  I ended up renting an electric scooter after a few hours using the boot because it hurt my legs and hips. 

I saw the podiatrist a few months later.  At that point I wasn't having pain during the day although it was often achy at night when I took my shoe off to go to bed.  He suggested icing it and also suggested I could try short walks in the house barefoot.  School was about to start again so I said that I would wait for a month to see how being on my feet more affected me.  Unfortunately, I made a poor choice to take my kids swimming just as school started.  I told myself I would be very careful and get out if I felt any pain.  But I didn't feel the pain until the next day.  I was embarrassed to admit to the podiatrist that I over-did it like that after insisting I was going to be extra cautious.  So I just went back to being very careful, icing it, etc and tried to heal it again.  I tried using the boot at school for a couple days but it felt worse when I did that so I went back to my regular shoes & orthotics.  It was slowly getting better.  But a few months after that we cleaned out our guest room so I was carrying stuff down the stairs to the garage and the next day it was very sore again.  It got a little better but was still a little sore at the end of the day.  Then last week I was walking and I stepped down and had a sudden sharp pain in the ball of my foot.  Since then it has been very painful even first thing in the morning.  

I've made an appointment to see the podiatrist again but I really think he's going to recommend surgery (which is another reason I haven't gone back to see him in several months).

I feel like I just told you my whole life story, but I know you've mentioned looking at the big picture on your blog.  You've also mentioned that you respond to comments that have a more general audience.  So I"ll sum and ask my question in a way that may be easier to respond to:

I am nearly 40 and have been dealing with sesamoiditis for almost two years.  It gets better but the pain returns if I try even a moderate level of activity (even when wearing custom orthotics).  I'm not very active.  I'm not a competitive/professional runner or dancer who needs to get back into shape.  I'm just a mom who wants to walk to the park and play with her kids again.  At this point, would I be better off just having surgery rather than continuing what seems like a losing battle to get my foot to heal?  

If you think there are measures I should still try to avoid surgery, then I have one other question.  My doctor has ordered x-rays but I see you recommend an MRI consistently.  Since my injury was almost 2yrs ago, would it be worth it to push for an MRI now or should I just go with what my doctor uses/expects.

Dr Blake's response: I am so sorry for your situation. You would have every right to have surgery due to the length of time you have been suffering. Surgery is every successful and you just want to make sure your surgeon has done these and knows the subtleties of the surgery and post op course. How much PT? What happens if the joint freezes up? How long in a removable boot afterwards? Etc, Etc. 

     That being said, surgery is done for a non-healing fracture, not sesamoiditis. This is why I would recommend an MRI to make sure everyone really knows why you hurt. I have seen situations where the original fracture had completely healed, but the metatarsal head developed arthritis, or a bursitis had developed, or excessive scarring. So, without an MRI to tell you that the only source of your pain is a non healing fracture, I could not at present recommend it. Also, non healing fractures can heal with 9 months of Exogen bone stimulation, rigid sole shoes, orthotics that do off weight the sesamoid, dancer's pads and spica taping, icing and contrast bathing, and making sure your bone density and Vitamin D levels are healthy. 

     So, step 1 MRI. Based on the MRI results, step 2 can be another smarter approach at conservative management if seems reasonable or surgical removal of the damaged bone. Keep me in the loop and I sure hope this helps you. Rich

Thanks for any help you can offer!

Fat Pad Atrophy Article

http://meeting.nesps.org/abstracts/2015/85.cgi

Someday it will be easy to get an injection to restore the fat pad when you need it. 

Hallux Valgus/Bunion: Email Advice

Thank you so much for taking the time to provide this advice! I am a 30 yo with hereditary hallux valgus. I rarely ever had bunion pain - even through 16 years as a ballet dancer and 4 years on pointe! About 6 months ago I took up two new hobbies: a Japanese martial art called katori and ballroom dancing and my MTP joints have started aching. These conservative options are exactly what I was looking for in hopes that I can slow the bunion progression. I'm especially grateful for your recommendation of a night splint. I spent hours reviewing these but could never decide which is best and which are bogus. 

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

I have a few questions, if you’re still monitoring this thread and have the time to answer:
1. What is your opinion on menthol-containing products like Tiger Balm and Biofreeze? Would they be a good idea in conjunction with the massage? Definitely!!
2. I found one video you posted on bunion taping (incidentally, I have learned a lot on Lisa Howell’s site). Would that work with Rocktape? Definitely!! If not, might you recommend a method for bunion taping with Rocktape? There are so many options for taping that I have no idea where to start. 

http://www.drblakeshealingsole.com/2011/05/taping-with-kinesiotape-for-bunions.html

3. I also found the video you posted demonstrating metatarsal doming exercises, and I’m eager to start those. Are there any other exercises you recommend for strengthening the small muscles of the feet? (Besides the balancing one in another of your blog posts on bunion care – I can balance on each foot with my eyes closed, but I make sure to do that regularly!)

http://www.drblakeshealingsole.com/2015/07/bunion-and-general-foot-strengthening.html

I would really appreciate any advice. I’ve read through much of your blog and you seem like exactly the type of podiatrist I would like to find! I will, of course, go see a local podiatrist, but it will be a few months before I can see one on my HMO plan and I want to start as soon as possible to relieve pain and, most importantly, slow the progression of the deformity.

Dr Blake's comment: Thanks for your kind words. I hope this helps some. Rich