Sesamoid Injury: Email Advice

This is a comment to one of my posts several months ago. 

Thank you for the information Dr. Blake.  I saw the podiatrist this week and he suggested removing the bone all together. Dr Blake"s comment: The sesamoid bones are two in number and dwell under the first                              metatarsal at the ball of the foot.  He mentioned using an incision on the top of the foot and the bottom of the foot. Dr Blake's comment: I favor a medial or side incision if it the tibial or medial sesamoid, and                             a plantar incision if it is the fibular or lateral sesamoid.  He prefers the top so there is not a scar on the weight bearing part of the foot. Dr Blake's comment: If the plantar incision is in the wrinkle just lateral to the weight bearing                             surface, the visualization and ease of removal is worth the scar risk.  Do you have information of which would be the better way to go? Dr Blake's comment: This is definitely surgeon's preference, and since I do not do surgery, I am                              a little out of touch if recent research is involved.  Do you have pictures of the actual procedure? Dr Blake's comment: Sorry, but I do not.  I think I am coming to terms with having surgery.  Is there a specific amount of time to wait that is suggested before surgery? Dr Blake's comment: Most wait 6 months to see if improvement is noted with the MRI scans                             conservative care.  I know you mentioned it would be acceptable after three months, but is there a golden time frame? Dr Blake's comment: No golden time frame. These things must be individualized. Top                             athletes may have surgery several weeks after injury, you and I years if                             treatment and testing showed initial improvement.  Thank you again for the information your blog offers

Musings from a Footstool: New Year's Resolution for All Mankind--Just Keep Moving As Best You Can

This great video highlights the health and excitement that await us if we keep moving this year. Double or triple your calorie expenditures from last year. Walk around the block once or twice. Park a few extra blocks from the restaurant. Have a meeting with colleagues while walking. Take your vacation this year with more exercise in mind. If you can not walk, consider a stationary bike for home. Movement is the secret to health. Make sure you keep going. Let's make 2012 a Healthier Year. 

Hallux Limitus Surgery: Comments on One Doctor's Protocol

Received this email from a patient Jeff I had just. He is deciding on surgery for his Hallux Rigidus. There are many great points brought out in this correspondence. All of my comments are in red.

Dear Dr. Blake,

I so appreciate the opportunity to meet with you and discuss options for my great right toe.  As we discussed, I was scheduled for a Cheilectomy (joint clean out procedure) with a good podiatrist on January 20, 2012.  After our meeting, I emailed the doctor and told him I wanted to postpone surgery.  He was very understanding and said I should only do surgery when I was ready.  I wrote him again and asked him if he would order an MRI, so that both you and he could have more detailed information on my toe. 

 
Dr Blake's comment: I told Jeff that an MRI can reveal the extent of injury to the joint much better than X-rays and I would want them to be part of my pre-surgical workup if it was my toe. 

Here is part of his response that addresses the MRI:


'Hi Jeff,

I have no idea why your doctor suggested an MRI. We use MRI to evaluate muscles, tendons and specific anatomy, like soft tissue masses. Occasionally, we will order one if we have tried everything else and are puzzled. Your problem, Hallux Ridigus, is straight forward. You have arthritis in your 1st Metatarsophalangeal joint. An MRI is not going to give any additional information in your case. Although it would go to your health plan, it is completely unnecessary! 

MRI of Hallux Rigidus patient with surprise sesamoid injury and marked bone inflammation on the plantar surface making it difficult to walk.

Dr Blake's comment: This doctor just has not used MRIs for this problem and therefore does not know where they fit in to the process. There is nothing wrong with this, but I would say MRIs can help categorize the damage in the joint by intensity and location, can show other injuries that  could co-exist with the Hallux Rigidus like sesamoid arthritis. Every Hallux Rigidus is not the same, and could require different approaches. At least in 2012, where MRIs are now a proven entity, some vital information can come from it that could effect the management of the post operative period. 

I am listing our standard approach for treatment for Hallux Rigidus:

X-rays show significant arthritis to your great toe joint Arthritis is a progressive loss of cartilage and results in stiffness and pain. 
The pain from the arthritis can often be effectively treated with the following: 

1. Period of rest from any aggravating activities: e.g. Long walks, jogging, hills, stairs. Low impact exercises would allow for consistent cardiovascular exercises without exacerbating foot pain. Such exercises include stationary or regular biking, swimming, water aerobics, circuit-training weight lifting. 
2. Wear shoes with good motion control: 
3. Graphite plate inserts help reduce bending at the big toe joint. These can be purchased at Shoes N Feet in San Francisco or other Shoe stores.
4. Occasional cortisone injection is probably the most effective non-surgical means of reducing pain. Relief is temporary but may last 2 months or more. Cortisone injections cannot be done indefinitely but several done 4-6 months apart, as needed, are safe to do.
5. If non-surgical treatment fails to adequately address the pain, surgery will likely be required. 

Dr Blake's comment: This is a good starting point, although I have never had the graphite plates help (but they are worth a try!). Since Hallux Rigidus means cartilage breakdown, avoid cortisone shots unless you are already for surgery, not if you want to avoid surgery. Cortisone can temporary help the joint, but by masking pain, can speed up the breakdown of the joint. Use cautiously. In all my years of treating Hallux Rigidus symptoms, whether to avoid surgery or after surgery, the following treatment modalities have proven crucial for patients and should be tried pre-op (you may get lucky and avoid surgery):

1. Functional Foot Orthotics to change the gait pattern and weight bearing across the joint.They can also be used to limit joint motion with Morton's Extensions.
2. Spica Taping to Limit Joint Motion
3. Shoes selected to have the right amount of heel lift, forefoot padding, forefoot flexibility or stiffness, toe box room, and upper construction.
4. Padding to off weight shoe pressure (may vary in different styles of shoes).
5. Daily icing and/or contrast bathes to reduce inflammation, which decreases the fragileness of the joint.
6. Physical therapy to initially de-inflame the joint, and then strengthen the foot and work proximally at the core and down to change stressful gait patterns.
7. Accupuncture to increase circulation for healing, and stimulate the immune system for greater healing.
8. Removable casts to immobilize the joint for several months or part time on a daily basis while the joint is getting calmed down. 
9. Glucosamine and other OTC anti-inflammatories.
10. Flector Patches or diclofenac gel to reduce inflammation.
11. Activity modifications to avoid irritating the joint for 1 year, but allow as much cardio-vascular fitness possible. 
12. Too many others to mention (treatment should be tailored to the individual with protocols  designed to create a pain free environment in a general fashion).

A lot of individuals with this foot condition eventually need surgery to decisively treat the painful arthritis. This most often involves fusion (or arthrodesis) of the great toe joint. This is the surgical gold standard to treat big toe joint arthritis in an individual who wishes to remain active. It best and most predictably eliminates the pain from arthritis in a decisive manner and long-term. Counterintuitively, locking the motion in the great toe by surgical fusion, does not interfere with those who want to walk actively or even jog. Only limitations are with going en pointe in ballet dancing, > 2.5 inches of high heeled shoes, and probably sprinting. Sometimes, it can be a bit difficult to get your foot into a tall boot. 

Dr Blake's comments: I have treated 1000s of Hallux Rigidus sufferers and never had to resort to a joint fusion. I have only seen one patient with a joint fusion from another doc and it did not turn out well. It should be the last resort of surgical treatments. The big toe is the most important joint for push off. I just came off the basketball court, I can not imagine doing what I did without the function of the big toe. Maybe it is a better surgery than I realize, but if you can not push through the big toe joint, the push off must be more laterally causing problems related to over supination. That can give you foot, ankle, knee, hip and back problems. Also if you can not roll through your foot, you forward motion is blocked and all the problems related to Sagittal Plane Blockade may occur. So why fuse? Why not try to save the joint, and if surgery is needed, minimize the surgery (even if it has to be redone in a few years). 

Postoperative recovery in most cases involve: 
1. 2 wks of non-weightbearing to the operated foot in a cast 
2. 4 wks of weightbearing in a cast subsequent to the initial non-weightbearing period 
3. 2-4 wks of weightbearing in a orthopedic boot or shoe after the casting period. 

If you're not inclined towards surgery at this time, consider the recommendations above. If you would like a cortisone injection, let us know what days and times would work best for an appointment, and we can have you scheduled with one of the foot and ankle specialists. 

Dr......

So...I'm not going to be able to get an MRI from Kaiser, but have ordered one from Health Diagnostics for January 3rd. 

If you have any additional information about your thoughts on the MRI, and why you think it is helpful,  please feel free to share your thougths, and also let me know should you wish me to share those with my  doctor.

Dr Blake's comments: Jeff, please get the MRI as a self pay ($500 approx). I will see you after to discuss, and then my comments will be available to your doctor. Please look at all of my blog posts on Hallux Rigidus/Limitus, schedule an hour for the upcoming appointment, and we will have more fun.

I look forward to discussing my MRI results with you when they are available.

Thanks for your help, and happy New Year.


Jeff

Shoe Design: Where Should a Shoe Bend When We Push Off??

Video on Shoe Flexion Testing (Creating Flexibility When Needed)

Classic Shoe Flexion and Shoe Torsion Tests 

Here is the bottom of a running shoe with multiple cuts or striations that allow for shoe flexibility as you roll up onto the ball of your foot in push off or propulsion.

The pink material demonstrates where the ball of the foot should bend the easiest in your shoe flexion test. The multiple striations make it easy to accomplish the bend needed.

Here is a shoe where the bend is not only in the wrong position but the cuts or striations do not go all the way across the shoe. The bend of course at the big toe should be the greatest, yet in this example their is no attempt to allow for this bend.

There the pink material shows where the shoe should bend, yet it lies between the two striations!! The bend at the ball of the foot should be even with the big toe joint (widest part of the foot/bunion joint), and then slightly go back towards the arch as you near the baby toe side.

And, just for fun, here I am demonstrating a rocker shoe that is not meant to bend at all. You are encouraged to roll right on through and you should not attempt to push off. 

Knee Pain: The Role of the Feet

Here is an email I received yesterday and my response. 

Dr. Blake,

I am in a conundrum.  Spend out of pocket to see a podiatrist or spend out
of pocket to see a PT.

I am Flat footed
In 1990, my right knee hyper-bent with 150 lbs of backpack weighing me down
with my right foot stuck in snow as the left foot slipped downward.

Current symptoms:

  - Clicking knee cap
  - Kneeling on carpet, great pain until the knee cap pops into place from
  pressure upwards
  - Grinding knee upon flexing
  - Pain on the inside of the rt knee and lower left quandrant of patella
  - Pain and tightness from right side of knee up to the hip
  - Pain behind my knee at the back (anterior)
  - Extreme pain in knee and hip when rising up from a kneeling position
  - Pain and tightness on the inside of my thigh at the knee
  - Feeling of being swollen in the knee itself
  - Walking in running shoes with support is OK at best
  - Walking in dress type shoes with no support results in pain after 25
  yards or so
  - When I use to take spin classes, the instructor noted an outward or
  inward? movement of my leg/knee and asked me to keep it straight, which I
  could not.


I have sat at a desk for 8hr/day for the last two years ~ the first desk
job in my life and this may be part of the problem.

I am self pay ~ no health insurance.

What would the cost range be for a diagnosis by you, treatment and possibly
orthotics?
How long would it take, should we work together, to know if your regiment
for me is working?
At what point would it be wise to pony up for an MRI?  Do I need one?

I am 53, and until recently, in good shape if not great shape.  I need help!

Best always and Happy New Year!

Robert

Robert, Thank you for the email. This is definitely a question about timing of treatments when both can be very helpful.


    With that much knee pain, you are 

really in the immobilization/anti-inflammatory phase. Orthotics would

be part of a restrengthening/return to activity phase. The immobilization is any thing that creates a pain free 


environment, from braces, to shoes, to activity changes, and yes, to orthotics if that is what it takes. 


     I would tend to have a PT cool  your knee down first, and then add orthotics when you are ready to

increase your activity again. Orthotics can play a role when you are

throwing everything in to the treatment arena but the kitchen sink (an approach used with unlimited funding).

Definitely, cool the knee down with PT and Icing. The icing for the knee

must be 30 minutes 3 times a day. Yes, 30 minutes is normally needed to get deep into the knee. 





    Try to stay away from anti-inflam meds since they can slow bone healing. Get an MRI, around $500 self

pay, if your symptoms plateau (look at it one month at a time).


    Try to create a pain free environment over the next month, which may mean staying in your most stable

shoes. You can also try Sole over the counter Arch Supports (get one of the

soft athletic versions). These are easy to adjust.You have already established a relationship between your feet and


 knees, but see if you can get them calmed down, less fragile, over the next several months. 

 Email again with  other unanswered questions. Rich

Goals of Running This Year: Consider Marathon Matt's Programs

Matt Forsman, aka Marathon Matt, has many great programs through the year. Of course, if you are not in the San Francisco Bay Area, you will need to find another similar program nearer to home. I hope this is a great athletic year for you all. Remember 30 minutes of exercise daily in the recommendation from the American Heart Association. 

The Rundown-January 2012 IN THIS ISSUE Spring Fling LAUNCHES TOMORROW @ 10AM! Marathon Matt's Power Chili Recipe The lowdown on Oaktown 13.1 (1/8) & Spring 13.1 (2/18) Passport 2012...your journey begins here  SPRING FLING LAUNCHES TOMORROW @ 10AM! Score a deal on spring/summer programs, FREE entries into Rock N Roll Arizona, and more via the Marathon Matt Fan Page on Facebook THROUGH 1/6!  Some of you participated in my Cyber Monday game on Facebook & scored some excellent discounts off all my programs in 2012   Given the positive response to this promotion, I'm doing something similar with my 'Spring Fling' game running from 1/3-1/6! This promotion will be similar to the Cyber Monday promotion with a few wrinkles. Here's how it will work:    1)'Like' the Marathon Matt page.    It's easy. Click the link below , click the 'thumbs up' like button on the top of the page and you're set!      2)Stay tuned to the riddles I post on the Marathon Matt page between Tues, 1/3 & Fri, 1/6.     Unlike the Cyber Monday game, I WON'T be posting every hour on the hour.     So, you'll need to be on your toes. It's possible some riddles/discounts will only be valid for 30 minutes. Others may be valid for two hours. Unlike Cyber Monday, the Spring Fling game will be live for several DAYS (Tues. 1/3-Fri.1/6 from 10AM-5PM).    3)Score discounts on my Spring programs (Oaktown 13.1 (1/8) & Spring 13.1 (2/18)). The 'Spring Fling' moniker probably tipped you off, but the discounts I'll be extending are ONLY applicable to my SPRING programs (Oaktown 13.1 & Spring 13.1). Unlike the Cyber Monday game, there won't necessarily be a consistent increase in riddle difficulty and discount amount. This means a $30 discount may randomly appear in association with a particularly tough riddle that's live for 30 minutes only to be followed a few hours later by a softball riddle only good for $10 off. You can get a leg up now by simply 'liking' the Marathon Matt page-   Become a Marathon Matt Fan! Marathon Matt's Power Chili Recipe  The cold, wet months of winter are upon us. On the upside, it's chili weather! Before I delve into this recipe, I have to give credit where credit is due. This recipe is a variation on a wonderful recipe I got from Micah Dickerson. Thanks for the inspiration, Micah!    Ingredients: 1.5 pounds of ground turkey, a cerrano pepper (finely minced), one medium yellow onion (chopped), ginger (one tablespoon finely minced), 3-4 cloves of garlic (pressed), a can of Guinness, a can of tomato paste, one can of kidney beans, one can of black beans, quinoa (one cup), a large can of whole tomatoes, one carrot (chopped), one ear of corn (just the kernals), chili powder, chipotle powder, cumin, coriander, cinnamon, and curry powder.  Directions:  Saute the onion, cerrano pepper, garlic, and ginger in 2-3 tablespoons of olive oil until onions are soft. Brown turkey in the aforementioned. Once the turkey is browned, pour the can of Guinness in and reduce for a few minutes. Add tomato paste and the large can of tomatoes (with tomato juice). Make sure to break/crush the whole tomatoes.      Add the chopped carrots and corn kernals.  Mix in 3 tablespoons of chili powder, 3 tablespoons of chipotle powder. Through in a dash of cumin, coriander, curry, and cinnamon.   Mix in the kidney beans and black beans and let simmer for 5-10 minutes on low/medium heat.   Add a cup of quinoa (if desired) and cook until quinoa is soft/tender. Be advised the chili will be quite thick after mixing in the quinoa.    I like my chili pretty spicy/hot, so I sometimes add additional chipotle and/or chili powder.   If you're looking for another solid winter recipe, check out my chicken quinoa soup recipe as well- Chicken Quinoa Soup QUICK LINKS Oaktown 13.1 launches on 1/8 Spring 13.1 launches on 2/18 The City 13.1 launches on 5/19 Marathon Matt PSOAS Massage/Bodywork MV Nutrition Greetings! Welcome to 2012! I hope your new year is off to an excellent start. May all of your resolutions come to fruition. If any of them are running related, I might be able to help you out ;)   I've got BIG things planned for 2012 including a total of SIX half marathon training programs, a handful of 'fitlanthropy' programs for those of you wanting to get fit AND be philanthropic, and much more.  Score discounts off my spring programs via my 'Spring Fling' running from 1/3-1/6!     My first program of the year, Oaktown 13.1 launches on Sunday, 1/8 @ 9:30AM at the Presidio Sports Basement. Not too far behind Oaktown 13.1 is Spring 13.1 launching on 2/18.     But, before these programs get rolling, I'm giving you a shot to score some discounts this week!  Spring Fling runs from 1/3-1/6 and is like my Cyber Monday game on steroids. As an added bonus, I've got TWO FREE ENTRIES TO THE ARIZONA ROCK N' ROLL MARATHON on 1/15 in the mix! Check out the details to the LEFT.  Come celebrate the new year with me at Presidio Sports Basement on Sunday, 1/8 from 11AM-1PM!  Even if you have no intention of joining Oaktown 13.1, I'd STRONGLY encourage you to join me at Presidio Sports Basement from 11AM-1PM for a little launch party madness! Why? FREE BEER FROM LAGUNITAS, DJ MATT HAZE SPINNING, RAFFLE PRIZES UP FOR GRABS, BAGELS, ZICO COCONUT WATER, and 20% OFF AT SPORTS BASEMENT!    Seriously, what do you have going on between 11-1 on Sunday that could compete with this? The lowdown is on Facebook-  Marathon Matt's Launch Party Lowdown Oaktown 13.1 gets rolling on SUNDAY, 1/8 @ 9:30AM. Spring 13.1 launches on SATURDAY, 2/18 @ 9:30AM!  In 2012, I've got not ONE, but TWO spring programs lined up.   The first program gets started on SUNDAY, 1/8 @ 9:30AM. This program is based in Golden Gate Park and includes a coached run workout on Wednesdays @ 6:30PM & Sundays @ 9:30AM.   Oaktown 13.1 will have you prepared for the Oakland Half Marathon taking place on 3/25!   The program is $120 through EOD 1/7. For more of the details, program amenities, and registration click the button below-    Not to be outdone, Spring 13.1 launches on SATURDAY, 2/18 @ 9:30AM!      This program is based in the Marina and meets on Tues @ 6:30PM, Thurs @ 6:30PM (Accelerate bootcamp or Need for Speed), and Saturday @ 9:30AM.      Spring 13.1 will have you prepared for the American River Parkway Half Marathon in late April/early Mayand/or the Divas Half Marathon in SF on 5/6.     The program is $140 through EOD 1/24. For more of the details, program amenities, and registration click the button below-            Accelerate is BACK on 2/20/12! If you enjoyed Accelerate bootcamp with Gaby Miller of Ab Fab Fit in 2011 and want to accelerate your running fitness, we've got you covered. Meeting on Mondays & Wednesdays @ 6:30PM from 2/20-5/9, you're looking at an incredible deal...20 workouts for $100! *NOTE-As an added bonus, all Accelerate participants receive $10 off my Spring 13.1 program! Passport 2012...your journey begins here.. I always feel a bit awkward when people ask me about my 'running club'. This is in large part because I don't think of what I manage as a 'club'. Nothing against running clubs, but when I think of clubs, I think of casual, informal gatherings that may or may not have a specific goal or direction and have no clear beginning or end. Without sounding too grandiose, I like to think of what I do as providing 'running journeys' (or 'odysseys'). Maybe I read too much JRR Tolkien as a kid, but I always think of the following quote when I think of what I do, 'The greatest adventure is what lies ahead. Today and tomorrow are yet to be said. The chances, the changes are all yours to make. The mold of your life is in your hands to break.' So, are you ready for an adventure or two in 2012? Are you ready to meet some remarkable people? Are you ready to discover things about yourself that you didn't know? Are you prepared to do things you didn't think you were capable of doing? Join me this year!  As always, the earlier you register, the better price you get. Marina Journeys 2012    Spring 13.1 launches on Sat, 2/18 @ 9:30AM      The City 13.1 launches on Sat, 5/19 @ 9:30AM        Halloween 13.1 launches on Sat, 8/18 @ 9:30AM      Touchdown 13.1 launches on Sat, 11/17 @ 9:30AM    Golden Gate Park Journeys 2012    Oaktown 13.1 launches on Sun, 1/8 @ 9:30AM      Home Run 13.1 launches on Sun, 7/1 @ 9:30AM

Musings from a Footstool: Why Arch Height Really does not Mean Much.

Happy New Year 2012

    I want to start this year's blogging about feet getting back to my roots. In podiatry school I learned the basics of how someone should walk or run, how to measure their bone structure, how to predict what structural or movement abnormalities would cause what type of problem, and how to design inserts to help these findings. I loved it so much, I took an extra year studying biomechanics in fellowship, and earned my Masters in Science in Education since I could now teach it. 30 years later I am now trying to teach you my readers the truths I learned in school, the truths I learned in my podiatry practice, and the truths that have been dispelled over the years. Some generalizations I was taught as gospel truth was only accurate 50% of the time (but these general rules are hard to get rid of).

 

     So, as I sit on my foot stool on January 1, 2012, and I ponder these things, I must laugh a little, cry a little, and stay motivated to keep on trying to educate. Let us tackle one thought for the next few minutes. 

Many professions dealing with feet make a big deal about arch height. Think of your conservations at a shoe store. You were told if you had a high arch foot you need a neutral shoe for shock absorption since all high arch feet pound too much. You were told if you have a low arch foot you need a motion control shoe. If you have a normal arch you can use a stability shoe, or perhaps a neutral shoe as well. But all this is based on low arch feet always pronating, high arch feet always pounding too hard, normal arches never doing anything worth mentioning. This is so wrong. 

     4 days ago I had a patient with a high arch. She always knew she had a high arch. She would tell friends she had a high arch. She asked me and I told her she had a high arch. Why am I saying all this, because the Spenco In Store Computer meant to help pick out an Arch Support for her told her she had a normal arch. 

    In my 4 years of podiatry school, 2 years of residency and fellowship in biomechanics, I never focused too much on whether the patient had a high or low or normal arch. It really did not matter. What mattered was how they moved. Did they pronate? Did they supinate? Was their shock absorption poor? Did they function asymmetrically possibly indicating a functional or structural short leg syndrome? It was these things that lead to treatments to help them? A normal arched foot can do a lot of bad things? A high or low arch can function perfectly normal. 

     So, I say from my foot stool we should abandon shoe selection or Over The Counter Arch Support criteria based on arch height, and doctors/physical therapists should focus patients on what their individual biomechanics dictate. Stealing a line from Sue Sylvester from Glee---And This Is How I C it. Dr Rich Blake