Posterior Tibial Tendon Surgery with Gastroc Recession

Hi Dr Blake
     I am interested in your advice...I was a very active runner until I began having lots of issues with my posterior tibial tendon and eventually, after about a year of non-surgical treatment, I was diagnosed with a navicular accessory bone.  

     I had it removed 5 months ago, along with a gastroc recession.
Dr Blake's comment: 
     The restrengthening progress of surgical procedures to arguably the 2 most important muscle/tendons in your foot and ankle can be a 1 to 2 year progress. That does not mean it will take you that long to get back most of your power within a year. Typically, 30% improvement is seen by 3 months post surgery. The 3 to 9 month period is slow with gradually improvements up to 60-70%. Then, the 9-15 month part of the rehab is where the true power comes back as the internal scar tissue is finished it's long course of remodeling and thinning out. This, of course, is predated on a physical therapist who knows how to rehab this successfully, and you patiently go through the Phases of Rehabilitation correctly---Immobilization, Restrengthening, and Return to Activity. 

 My question is about how long it should take to recover?
Dr Blake's comment: So, at 5 months, you should be out on any immobilization devices like removable casts, you should be in orthotic devices and taping your arch daily, you should be increasing your walking, and perhaps started on a Walk/Run Program (although that can take up to 9 months to start). The restrengthening should be well underway with toe raises, posterior tibial theraband work, single leg balancing, and core strength workouts. As much biking, elliptical, and swimming the better as long as nothing causes limping. Read my post on "Good Pain vs Bad Pain" and do not drift into the Bad pain that often. Recovery is always a Bell Shape Curve, with some faster than others. There are so many variables at play. However, monthly you should be progressing, and keeping that 0-2 pain level Painfree environment while you get stronger. July 2013 should have more time on the bike, more toe raises, 5 more reps of theraband, easier time at doing the Single Leg Balancing, etc. than June was. You are in a time of plateaus. 3 to 9 months post surgery can go slow. With each 2 week or month plateau, it is up to the doc and PT to decide if normal, or if changes in your program are necessary. 


 I saw the surgeon at 4 months and he was very vague,and while I can do a bit more than I could Prior to surgery (cycling, some elliptical, bit of walking) it still gets quite sore.
Dr Blake's comment: To really see where you are at, you need to stay in the 0-2 pain level Good Pain Side of Rehab on a day to day basis. That is really where you are at. Find what limitations you have in attempting to maintain this level, which honors your tissue's ability to take stress, and write those down. It will take you 2-3 weeks to get a feel of really where you are at and then you can compare July accurately with August, and August with September, etc. Remember pain leads to swelling and scar tissue, and we need to reduce build up daily.

 I am doing several strengthening exercises and calf stretches, and back off when the pain gets worse but in the last few weeks I don’t feel I’ve made that much progress. Is this normal and when do you think I should expect to be able to start running?
Dr Blake's comment: When can you run? The answer is typically easy and that is when you can walk for 30 minutes at a normal pace without increasing in pain above 0-2, then you can be started on a 30 minute Walk Run Program. I have that program in this blog. 30 minute Walk Run Program has 10 levels that you progress through slowly and carefully, and you are only starting with 3 minutes running. I hope this all makes sense. Listen to your body. If you do not have help from a PT, get some if possible to give you guidelines on how to progress over the next 4-6 months carefully. Good Luck!! Rich
Ciara (name changed due to Witness Protection)

5 Mechanical Causes of Injuries and Pain Syndromes: Video Intro

Plantar Fasciitis: Educational Video on Basics of Treatment

I hope you enjoy my first attempt with this wonderful program called PowToon to make educational videos.

Plantar Fascial Stretches For Central Heel Pain??

Will these stretches assist with pain that i'm finding in the center of the heel? I know that Plantar Fasciitis is typically at the base of the heel, closest to the arch, however I can press the center of my heel pad and feel pain. Thanks

Dr Blake's comment: 

Thanks for the comment. Typically, the stretches help some, but ice massage on a frozen sports bottle for 5 minutes 3 times a day works the best. The center of the heel pain is typically bursitis pain, more than fasciitis pain. Hope this helps you. Rich

http://www.drblakeshealingsole.com/2010/05/quick-tip-7-rolling-ice-stretch-for.html

For Heel Bursitis, massage under the heel itself, in that 2 inch wide area, for 5 minutes  three times per day.

Nerve Symptoms: Start with Neuro-Eze but Evaluate the Cause

After several months trying to heal my sesamoiditis I started getting sporadic tingling sensations all over my foot, and a numb feeling around the sesamoid and along the inside of my big toe. After reading this post I subsequently bought neuro-eze with the hope that it would alleviate these symptoms. However, I have been hesitant to use it because the description on the bottle says that it helps with neuropathic pain, and I do not have any nerve pain and I'm not entirely sure if what I have would be defined as neuropathy. Would you still recommend to using it for my symptoms of tingling and numbness?


Dr Blake' s comment: 

   Yes, it is a good starting point for the neuropathy (abnormal nerve sensations). Patients with neuropathy get just numbness/tingling, just pain, or a combination of the 2, but it is still neuropathy. Neuro-Eze in my experience works on 50% of those cases. That being said, please have a neurologist or physiatrist look into the cause of this problem. Is it coming from your back because you limped for a while? Did the swelling around the sesamoid trigger some excitable nervous activity that now needs to calm down? Is it a totally separate problem called peripheral neuropathy related to pre-Diabetes, Vit B12 deficiency, osteopenia, etc? I hope this helps you. Rich

Fitness Tidbit of the Day from Lisa Tonra

Fitness tidbit of the day:

Gals: are your thirties well behind you? (I'm right there with you!) Have you noticed that your knees seem to be moving a bit more towards each other, perhaps even looking somewhat knock-kneed? You might 'need' to look a bit more south, towards your feet! It's always wise to check with your podiatrist to rule out more serious conditions and those requiring orthotics or other external support, but a few simple exercises performed in bare feet can make all the difference in knee health. Try this simple routine:

1. Warm-up: While standing, lift all ten toes off the ground and lower them. Now lift all ten toes off the ground and spread them as far apart as possible. Finish with lifting one heel off the floor at a time, rolling from one side to the other. Repeat each move for 12 repetitions.

2. Heel Raises: Standing on both feet, raise your right heel and then set it down. Do the same with the left heel. Now holding onto a firm surface, such as a counter top or chair back, rise up onto both heels simultaneously. Do one set of each movement for 12 repetitions.

3. 'Domers': Standing with feet flat on the floor, lengthen toes along the floor as broadly as possible, then pull them inwards towards you while keeping them on the floor. Try to keep your toes straight rather than curling them under your foot. Return toes to starting position and repeat 12 times.

Strengthening these small-but-mighty muscles of the feet will help increase your foot and lower leg strength, enhance your awareness of foot mechanics and give your knees a big positioning boost! Good luck!


About Lisa:

Lisa Tonra, a twenty-year veteran of the fitness/wellness business, holds credentials from ACSM, NASM, and BASI Pilates and is currently a Physical Therapy graduate student. She specializes in injury 'pre-habilitation,' prevention and recovery for all sports-related and overuse conditions. Lisa can also design, implement, coach and monitor fitness routines for all recreational athletes, fitness enthusiasts and beginning exercisers. Her philosophy is a simple one: "There is a (sometimes hidden) fitness enthusiast in all of us! It’s good to set a short-term fitness, health or lifestyle goal to get yourself up and moving, but challenge yourself to take the longer view of 'training for life.' What are Your Body Goals? I can help you achieve and maintain them, and do it injury-free!" 

Visit Lisa's personal website here: http://yourbodygoals.com

Peroneal Subluxation/Dislocation Syndrome: Video Presentation

Video on Importance of HbA1c Test for Diabetes and Stability of Diabetes

Morton's Neuromas: Success with Alcohol Shots

Excellent article about Morton's neuroma which has plagued me for six years. Had some success with alcohol injections, but my podiatrist moved to Kansas before completing series of shots. Replacement podiatrist doesn't believe in their value. Can you recommend another doctor in Wilmington, NC? The pain is severe after 45 minutes of hiking which is my passion.  Prefer NO surgery.  Also, your search function on my iPad keeps taking me back to the same article when I try to access potential treatments you recommend.  Thank you for any help with identifying a doctor who,shares your values and expertise.  

Dr Blake's response:

     There are the podiatrists in North Carolina from our national Sports Medicine Academy--AAPSM. They are normally the best place to start.  

Christopher J. Gauland, DPM		2140 West Arlington Blvd. Ste. D	Greenville	NC	27834
William J. Johncock, DPM - Fellow	828-327-3029	419-B 2nd St. N.W.	Hickory	NC	28601
Robb A. Mothershed, DPM		3057 Trenwest Dr.	Winston Salem	NC	27104
Jeremy Thomas, DPM Website	919-851-3435	204 Ashville Ave Ste 40	Cary	NC	27518

There are some of the other articles on Morton's Neuromas, but many more throughout the blog. Sure hope this helps. Rich

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

http://www.drblakeshealingsole.com/2011/05/evaluation-of-possible-mortons-neuromas.html

http://www.drblakeshealingsole.com/2010/08/mortons-neuroma-treatment-options.html

Foot Possible Stress Fractures: Email Advice

hi doc,

i'm a former patient (i can't remember when exactly, but it has been a while). at the time i was seeing you, i had problems w/ stress fractures in both feet (revealed via MRI). you had me do contrast baths, taping, wearing orthotics and i had to wear a walking boot at one time or another on either foot.

during a recent tennis match, i was forced to make a shot which had me land a bit awkwardly on my left foot. i felt "something" right away, but it wasn't enough to prohibit me from playing the remainder of the match. since then, i've felt some things that make me think (more like know) that my left foot is broken. i've had the same type of throbbing at night that has kept me awake at night on the top and bottom of the ball area of the foot. there is no swelling, only slight discomfort when walking - pain in the 3-4 range that varies during the day - and the pain is not constant.

i've been able to play tennis, but i've been taping my foot (amazing how i remembered to do it just like that!) for support.

think it's best to actually come in or do you think i can just tape and immobilize for a while to see if that has any positive effect (or possibly no effect)?


very truly yours,

Dr Blake's comment:

     Ralph (name changed), thanks for the email. It is so difficult to play tennis (or most sports) with a stress fracture, that you either have a small one, or just a sprain of the ligaments. I agree that it sounds like a stress fracture however by how sudden it came on. These scenarios are always stress fractures until proven otherwise. Stress fractures always give swelling, but with some of the deep ones, you can never see the deep swelling. Small stress fractures, if given time to heal, normally take 3 months to heal. So, you can wait the 3 months, and if you are not appreciably better, than let's take some xrays. Read my blog post on Good vs Bad Pain, and avoid bad pain. No limping or sharp pain while playing or you will hurt something worse like your knee. If wearing the old removable boot during the work day makes it feel a lot better, I would do that (even for 4 hour periods can rest the area and help healing). Remember to get 1500 mg Calcium and 1000 units Vit D, check the foods you eat for average amounts and supplement if you have to. If tape helps, tape daily for 2 weeks longer than you think you need too. 3 times daily work on the inflammation with 10 minute ice packs and/or contrast baths. I sure hope this helps. Rich

Hallux Rigidus: Email Advice

Hi Dr. Blake




I'm an active 52 year old female with end stage hallux rigidus. My condition was caused 27 years ago when my big toe was jammed into the joint playing soccer.



Each year I would assign a percentage to inconvenience the pain disrupted my daily life. Once the bump appeared about 2 years ago the percentage went up to 90%.



In the past 6 months I've had 3 opinions. Podiatrist wants to clean the joint then a joint replacement in 10 years, orthopedic 1 wants a fusion, orthopedic 2 (top doc in major east coast city) said joint destroyed and severely arthritic. Fusion is my only option.



Your blog is incredible and helped me ask great questions. No one offered spica taping which I just tried a few days ago with great pain relief.



I haven't seen much on what the risks would be if no action is taken. I understand the disease is progressive. Can the joint break.
Dr Blake's comment: No the joint can not break. It is gradually self fusing, but that produces both bone and soft tissue inflammation. The soft tissue inflammation can be controlled with icing 2-3 times per day, occasional cortisone shot or oral cortisone burst, contrast baths 3-4 times per week, spica taping to limit the bend of the joint, NSAIDs occasionally, bouts of PT or acupuncture, and activity modification. 
The bone inflammation is also helped by contrasts baths, possible off label use of a bone stimulator, physical therapy, off weighting the joint with orthotics and dancer pads, and occasionally use of removable boot, stiff hiking boots, carbon graphite plates. Hang in there and see if the above can help you get this calmed down. You were good to get the opinions, of course, if you have any surgery, you would have to get an MRI and possibly CT Scan to analyze the present situation better. Rich



I'm very hesitant to fuse. Although I was told its self fusing. Is it ok to let the body self fuse. I can tolerate the daily pain for the most part.



Thank you for dedicating your time to helping those of us living with this crazy condition.

When Working Out: Understand the Laws of the Environment You are In

When you are feeling rushed and in a hurry,  maybe it is time to stop and appreciate the wonder all around you. These photos are from Centurion in Pilanesberg Game Reserve, South Africa . The guy in the car was honking, trying to get past the elephant.                                                                          Road rage, it affects us all...

Should we Cool Downafter Exercise?

New York Times article on whether or not we need to cool down after exercise sent by one of my patients. 

http://well.blogs.nytimes.com/2013/04/24/do-we-have-to-cool-down-after-exercise/?hp&_r=0

Cipro and Prednisone's Negative Impact on Tendons

Hi Rich,




A friend said I should tell you I'm finishing cipro (for stomach bug) and was on prednisone recently (related to shingles) in case that makes me more prone to a tear or injury. I guess that happens with some corticosteroids and antibiotics.



I'm taking it easy. Let me know if this changes anything.



Thanks very much.   Dr Blake's comment:   Hey Nakima (name changed), You are suspectible for 2 weeks after stopping Cipro to injury tendons. Please finish the medications, wait 2 weeks, and then increase activity and exercises. You have a double whamy with both those meds. Lucky you. rich

Achilles Tendinitis: Avoid Cortisone Injections

This was a comment posted today on 6/28/13.

First I want to say that I've had Achilles tendonitis in both ankles for the past 5 years. I've had cortisone injections every 6 months for the first 2 years from my local Doctor then went to a Physiotherapist and had 6 months of Shock Wave treatments that didn't help.

Dr Blake's comment: Please try to avoid any type of cortisone injection around the achilles tendon. I am so hopeful that ultrasound guided injections will be the wave of the future, but it will take many years to prove that any injection of cortisone around the achilles tendon is not potentially dangerous. Remember health care providers: do no harm. Use physical therapy, acupuncture, body work, orthotics, stretching, strengthening, etc to help the achilles. 

 I then went to a Specialist and received more injections which only helped for about a month each time and then I was back again for more. Then on the 24th September 2011 I sprained my ankle as I was getting out of bed - yes, before I even touched the floor with my foot. I heard a very loud crack and it hurt really bad - even my husband heard it! It started swelling and aggravated my Achilles tendonitis to the point where I couldn't wear my shoes.

Dr Blake's comment: This is probably a partial tear of the tendon causes or aggravated by the cortisone. 

 I had to buy a pair the next size up if I wanted to go somewhere. It stayed very sore and swollen for months until I had a intensive set of cortisone injections in February 2012. It helped (until now) and the ankle swelling and tendonitis went away but I still have a strange swelling on the top of my foot. It starts where my toes join and then goes up the foot almost to my ankle. It swells and hurts more if I'm on my feet a lot or even just a few hours so I'm going to try your hot and cold bath method to see if it helps.

Dr Blake's comment: This was a comment from the contrast bathing post.

I still have the Achilles tendonitis (in both ankles now again) and was referred back to a different Physiotherapist. After 5 treatments he said I had too much inflammation in my body and couldn't treat me - the more he and I worked on it, the worse it got. The strange thing is, all my doctors etc. have told me doing The Negative Heel Stretch is the only way it will help it but in one of your videos, you say they should be avoided.

Dr Blake's comment: Here is the video associated to that comment.

 I've tried doing them (because my doctors have told me) but I had excruciating pain and had to stop. It only makes my problems worse and for some reason they don't believe me. Anyway, I'm going to follow your advice with the calf, ankle and foot stretching instead and hope it works.

Dr Blake's comment: Definitely push to get an MRI so that we can analyze the 3D of the tendons. Please stay away from cortisone and let the MRI put us into a specific direction. 

Surgery of the Future??

My wonderful friend Kenn sent me this great video highlighting one Israeli company and there great advances in non invasive surgery. I love the Star Trek reference, because this is what I dream about for the surgery of the future!!!

Golden Rule of Foot: Keep It Simple Stupid

Golden Rule of Foot: Keep It Simple Stupid

     Yes, the famous KISS principle applies here as in most aspects of life. So, it is a great start to the Golden Rules of Foot that podiatrists live by. For every treatment plan, there are simpler and more complex modalities. Patients can help you decide if you go for the big guns or start slowly. I make mistakes all the time being too simple when more complexity is needed, and too complex when simple will do. So, I allow my patients a vital role as we discuss options. It is the nature of a sports medicine practice anyway for the doctor/therapist and patient to team up to work together on the problem(s) at hand.

     One of my patients today just injured her posterior tibial tendon. Because of many factors, including the fact that she ruptured the other posterior tibial tendon 15 years ago, I immediately ordered an MRI to know what direction to go towards. This would be considered a more complex approach, instead of a more simple xray, with course of icing, anti-inflammatory medication, and ankle brace. But, the seriousness of possible missing a tear and immediately treatment thus I could not take a chance. The more one uses an MRI you see when and where it really makes a difference. No KISS Principle today.

     One of my new patients today was in for a second opinion regarding big toe joint surgery. Very serious stuff, but her conservative care was very lacking, and the surgery suggested very complex with joint replacement. I started her icing 3 times daily, spica taping to hold the joint still, Cluffy wedge to place weight on the first toe, and dancer's pads to further off weight the big toe joint. Simple stuff to start for a serious problem. She is to call or email in a month and also send me her MRI done 6 months ago. Here I am starting with the KISS principle since it seems helpful and direct.

     One of the interesting factoids I have learned is that complex is exciting, interesting, and seemingly professional to most doctors, therapists, and doctors. They expect treatments to be something the patient do not do on their own. Add a laser into the discussion and everyone gets excited. Medical schools and seminars emphasize complex treatments and testing. And this is how the KISS Principle gets ignored, violated, battered, and destroyed daily in most medical practices. Students who rotate occasionally through our office seem bored with simple solutions and definitely are not taught this stuff. I rarely see a bunion patient with toe separators by their podiatrist as an example.

     I am internationally known for my orthotic designs, yet I use OTC orthotics routinely when KISS applies. I always prefer icing and contrasts to oral medications or injections. If a patient said that they would rather have surgery than to ice 2 times a day for the rest of their life, I would have a vigorous discussion of why that may not be prudent. The KISS principle can be boring, time consuming, and non-flashy, but 90% of the chronic pain patients I see have a very inadequate KISS based conservative program of treatment when I first see them. These are patients that have seen up to a dozen of health care providers. I also give credit for this dilemma to the patients for not following through on simple treatments, or implying to the health care provider that it sounds too simple (the provider hears that as an attack that they are "simple minded.") How often are simple treatments ended because they only gave 20% pain relief when 5 simple treatments additively could give 100% pain relief.

     When you are going through treatments, find what works even partially, and stick to them for 2 months longer than you need to due to pain. Make your treatments additive (One from Column A, One from Column B, etc). Add complexity when needed, but if the treatment complexity seems more than the seriousness of the injury, ask questions. And if the treatment simplicity seems not enough for the seriousness of the problem, ask more questions. I sure hope this thought process is helpful. Dr Blake
   
     

Smart Socks: They are on their way to Help Athletes and Diabetics

I am so excited about the future. These two videos give a little look into why I am so Happy!! Socks to help me treat my runners and socks to help me treat my Diabetics. 

First Metatarsal Position: Important to Know with Metatarsal Problems

One important measurement that bio mechanic specialists evaluate is the relationship of the first metatarsal to the second metatarsal head. The foot should be centered under the ankle joint (therefore not pronated or supinated). One thumb on bottom and index finger on top grab the second metatarsal head and stabilize it. This will be the reference point. With the other hand, grab the first metatarsal head also from top and bottom. See where the first metatarsal head lies in relation to the second metatarsal head when the thumb fingernails are parallel. Then move the first metatarsal head up and down noting the overall motion and position. The motion is ideally 5 mm up and 5 mm down. In this patient, the left first metatarsal moved only 2 mm total (4 mm down and -2 mm up). This is called a stable plantar flexed first ray. Ideally the first and fifth metatarsal heads are lower than their adjacent metatarsals.

On this patient's right foot, the first metatarsal rested 3 mm above the second metatarsal. The overall motion with 6 mm (6 mm up and 0 mm down). This is called an elevated first ray or metatarsus primus elevatus (I love to talk like I am smart!!) This is an unstable first metatarsal that will not hold up the arch, and causes instability in the foot. It can be the cause of bunions or produced by the formation of a bunion. When recognized, orthotic modifications like the Cluffy Wedge or Morton's Extension  can be used, and if surgery is being done, corrections for the elevated bone can be done. With an elevated first metatarsal, the weight goes more to the second and sometimes third metatarsals leading to pain syndromes like metatarsalgia, capsulitis, neuromas, and hammertoes. 

Non Healing Sesamoid Fracture: Email Advice

Hello Dr. Blake,

I am glad to see that you are taking emails again. I hope you are well. I have been immeasurably blessed by your blog. I have learned so much and have passed your site on to my fellow foot sufferers. Who knew there were so many of us? Being in the fitness industry, I am concerned about the high and increasing occurrence of foot injuries. Never again will I take foot health for granted.

Dr Blake's comment: Sounds like we are in this together to help with foot health. Thank you. 

If you get a moment I would appreciate any thoughts you might have regarding my sesamoid fracture. I have become weary---I was so determined to get this puppy healed but sadly it is not cooperating. I am somewhat distressed that surgery may be looming.

     I am a 53 year old female.

I teach elementary P.E. (I agree with your post regarding kiddos and increased exercise btw) and I am a certified Zumba Fitness Instructor. 

     In August 2012 I doubled my Zumba Fit classes from 5/week to 10 per week.

Dr Blake's comment: Golden Rule of Foot: 10% increase per week is safe, more than that we are at risk for injury. 

     In early October I began to have discomfort in the left ball of the foot with minimal swelling on the top of the great toe joint after Fitness classes. Additionally, I regularly wore high heeled platforms every weekend to church, events, weddings,etc. I attended a wedding late Oct. and danced in said heels at the reception. At the end of October I recall a sharp pain in my left ball joint while teaching Z Fitness---doing a heel toe move.

     Thereafter, I began having chronic discomfort and swelling coupled with acute pain after fitness classes. I had x-rays  with an unclear diagnosis; the possible beginning of both a bunion and arthritis. Dr. advised foot rest, no Z classes, shoe inserts and come back in 4 weeks. I called the 3rd week and requested the specialist to look at my X-rays as I was not improving. When that did not happen I went to another Podiatrist. He looked at my Nov. x-rays and said I clearly had a sesamoid fracture.

Dr Blake's comment: It is good to get a second opinion when not improving, even when you plan on going back to the original treating physician. Health care providers just got to get over it!!! It is best for the patient in many ways--physically, emotionally, spiritually.

     He put me in a walking boot to be worn 24 hours daily. I began using an Exogen bone stimulator 2xs daily. My next set of x-rays showed no change.  I upped my calcium--Vitamin Code Grow Bone and Ezorb. Icing 2-3 times daily and contrast bathing. I went to crutches and a knee scooter for 6 weeks. Major swelling and pain continued.

Dr Blake's comment: Immobilization tends to thwart any reduction of swelling hoped for. The major swelling reduction comes with weight bearing, elevation, painfree massage, and motion. I would expect however the pain to be subsiding.  

ua I went to a TuNai therapist who aligned my ankle and foot. We watched the swelling go down in that session! Amazing!! Continued 1 weekly TuNai therapy for  4 weeks. Got a custom orthotics boot. X-rays every 3-4 weeks showed little to no change.
Dr Blake's comment: After the first 6 weeks or so, the xrays lag behind the healing, and may not be very reliable. By this time, they are a waste of radiation in general. Best to go by symptoms. 

      I slowly weaned to walking with custom orthotics in my athletic shoes and have been wearing them to date. I occasionally wear Ugg converse sneakers with purchased orthotics. I added Vitamin Code D3 and a supplement called Repairzyme. I had quit drinking diet soda and caffeine back in September for other health issues.

     I had an MRI: Radiologist report:'..medial sesamoid bone...indicating edema. An irregular, jagged cleft btwn 2 portions of medial sesamoid....seems to be a small tear in the intersesamoid ligament and probably the plantar plate btwn the intact flexor hallucis longus tendon and the lateral sesamoid.  Osteoarthritis of the great toe MTP joint...some arthritis spurring along the inferior  surfaces of the 1st metatarsal head.' 
Dr Blake's comment: It is the osteoarthritis in the joint that I am most concerning with. It suggests you have a healing medial sesamoid fracture (in some stage of healing), and arthritis in the big toe joint that may be chronic.

    I began having slightly increased pain and swelling in the last 2 weeks. I went last week 6/20 to TuNai therapist and she painfully pulled my big toe joint into place and I have had relief. I have 2 more sessions scheduled. I continue to ice and I have increased the Exogen to 3xs daily.  I made an appointment to consult with an orthopedic surgeon. My reasons are twofold; to get a 2nd opinion and to consider surgery. Waaa! I have been adament about avoiding surgery. I am not so adamant now, but do not relish the idea of my bone removal. I am concerned about life post surgery--teaching P.E. and Z classes. No more cute wedge shoes (I know--so ridiculous) but cute converse Uggs just don't quite cut it at church and weddings (smile). 
Dr Blake's comment: Surgeons tend to be blind to the arthritis when they are dealing with bunions and fractured sesamoids. Do not have your sesamoid removed unless you are sure it will not continue to heal and you are convinced that the arthritis is not the major cause of your pain. Arthritic big toe joints cause swelling to collect around the sesamoids, which make them hurt on physical examination. 

What do you think? Is there any chance of healing at this point (outside of a miracle?)?  I understand it can take up to 1 year to fully heal and I would wait if that was happening. But shouldn't I be seeing some healing at this juncture? 

Dr Blake's comment: I will feel better giving you advice seeing the 6 month MRI comparison of sesamoid bone edema and first metatarsal edema. 

I value any input you might have Dr. Blake. 

Attached are recent x-rays.

Attached are images from MRI.  

I truly appreciate your valuable time and expertise of my dilemma.

Thank you.

Be Blessed.

Dr Blake's comment: So, I think the sesamoid is healing enough to warrant another MRI at 6 months. You need to go back and do what you can creating a pain free environment. You should have several conversations about the possibility that the sesamoid is healing and you really may have Hallux Rigidus/Limitus joint pain. I hope this helps you somewhat. Rich

Tibial Sesamoid Fracture showing sesamoid fracture line and line extending into the first metatarsal. I would love to see this same image in T2 imaging where the bone is black when healthy.

Bottom slice of the foot showing the normal fibular and fractured tibial sesamoid

Another view of the fractured sesamoid with no break in the cartilage under the first metatarsal head. However you can see that the consistency of the first metatarsal head is irregular with bone cysts suggestive of arthritis.

This is called the Eqyptian Foot with the long first metatarsal--first metatarsal length should be approximately 3 mm shorter than the second metatarsal. Long term stress to the joint occurs with that alignment. See the obvious increase whiteness of the first metatarsal to the second signifying stress. These are joints that get arthritis. 

Icing: How much of a good thing can you do?

Hello Dr Blake:

Is it possible to ice too much? I have a sesamoid injury and I am currently icing 4 times a day for 10 minutes and then a contrast bath. But if I ice, say 7 times a day, would this be more effective?

Dr Blake's comment: 

    Thanks for the email. Ice typically cools the area 4 times longer than you use it for. Therefore, 10 minutes of icing means another 40 minutes of anti-inflammatory action. I love the idea of patients controlling the inflammation with icing every two to three hours. You will keep the area cooled off round the clock. The skin and nerves in the area have to be watched for lasting redness or tingling/numbness. If so, start to back off the icing 50% or give yourself 1 day off to regain status quo. Sure hope this helps. Rich 

http://www.drblakeshealingsole.com/2013/02/ice-pack-for-easy-molding-around-foot.html

http://www.drblakeshealingsole.com/2012/05/ice-as-aid-in-athletic-rehabilitation.html

Posterior Tibial Tendinitis: Email Advice with Further Response

Dr. Blake,

I have struggled with bilateral posterior tibial tendinitis for a long time.  The first bout I had for roughly three to four years.  It had a devastating impact on my life.  It finally went away for a couple of years, only to come back about six weeks ago.  Since the latest onset, I have done a great deal of research.  Your blog is far and away the most helpful and hopeful resource I have found.  Thank you for taking the time to help educate and inform people about this condition.  Your generosity is apparent when one considers that the vast majority of people reading your blog will never become paying patients.

Dr Blake's comment: Thank you for your kind words. It has been as rewarding for me as helpful for others. It definitely forces me off my butt at night and to sit down at the computer. Please tell me where the pain is in the posterior tibial tendon, and whether that point of maximal soreness is on both sides. This would be the weakest link in the chain. 

Also, what factors do you think helped it go away? It can help in the present rehabilitation. 

The pain is always present on the posterior side of my ankle bone—that is the point of maximum soreness.  The pain creeps a couple inches up the tendon towards my calf.  When it is bad, it goes all the way up the tendon, and around the bottom of the ankle bone into the arch.  The area around the navicular is very tender when you palpate it.

Rest and ice help the pain go away.  I’m currently icing my feet three to four times a day.

I have had a complete work up of my condition through a variety of doctors.  This includes an MRI of the left ankle, and a series of plain films of both feet.  These were done in the last couple of weeks.  Three years ago I had an MRI of the right foot.  I have been through the full panoply of conservative treatment: multiple orthotics, RICE, PT, walking boot, nightly interferential current, NSAIDs, etc.  There also was a suggestion that I might have ankylosing spondylitis, but that recently was ruled out by a rheumatologist.

Dr Blake's comment: I am assuming that your tests were negative. Make sure you get copies of all these tests for your records. What did the reports say?

The May 5, 2009 MRI report is included in the Rebound records I sent you.  I had forgotten that the MRI was of both feet.  The impression of the left foot is:  “OS naviculare edema consistent with os naviculare syndrome.”  Interestingly, that condition was not found in the right foot, yet my symptoms in both feet are generally identical.  The report also indicates on the left foot a peroneus longus tendon partial tear.  My doctor minimized this finding—I think he said it might have been an artifact.

This week I went to a new podiatrist to address this new onset.  The podiatrist said that I have an accessory navicular bone and he saw a small amount of edema in that area.  However, he is perplexed as to how I could have PTT.  He said there is no arthritis in my foot, good joints spaces, good alignment, good arch, etc.  The posterior tendon is intact.  He doesn’t see any reason for putting unusual stress on the posterior tibial tendon.  He also said that I have essentially exhausted all the treatment options he would consider.

Dr Blake's comment: An accessory navicular can give chronic pain at the insertion of the tendon into the arch. Is this where you hurt?

Yes, I do hurt there.  But the pain is more consistently present on the posterior side of the ankle bone.  I apparently don’t have an accessory navicular on the right side, but I have the same problems on the right side.

The rheumatology angle warrants a little more discussion.  I saw two rheumatologists during my first bout with the condition.  The first one said I do not have AS.  I then had a complete work up with an orthopedic surgeon specializing in foot problems.  He finally concluded that I might have some type of autoimmune condition.  So, at his suggestion, I saw a second rheumatologist.  That doctor made a tentative diagnosis of AS.  I was put on a trial of Humera.  The PTT finally resolved some time later.  Whether or not that was related to the Humera, I cannot say.  Now, after the latest bout, I contacted that second rheumatologist only to learn that he is about to retire.  So I recently went to a third rheumatologist.  She is the one that said I do NOT have AS.

Dr Blake's comment: A diagnosis of Ankylosing Spondylitis is made by symptoms and a positive HLA-B27 blood test. What were those findings? Any back pain associated with this pain syndrome?

I do have a positive HLA-B27.  This was re-confirmed recently.  I occasionally have mid-back pain, but it usually resolves in four or five days after I start doing yoga each morning.  Then it won’t come back again for months.  Every several months I have some low back pain, but it also goes away after yoga.  So, I don’t really have consistent back pain.  I’ll get you the records from the rheumatologists.

Part of the frustration of dealing with my condition has been proceeding along the dual track of working up the mechanical tendon etiology vs. autoimmune etiology.  This most recent bout was precipitated by two things.  One, I modified my running style to a short stride and higher cadence.  I’ve since learned this puts more pressure on the posterior tibial tendon.  Second, I went on a very vigorous up-hill mountain bike ride that required a great deal of standing up on the pedals.  I haven’t ridden a mountain bike in 10 years.  It is my feeling that these activities started this new bout.  Therefore, I do think there is some kind of mechanical problem going on.  I also think that I tend to have a higher-than-usual inflammatory response to trauma, which might be contributing to the problem.

Dr Blake's comment: So, are you do anti-inflammatory things to help this recent bout? 

The posterior tibial tendon is an ankle plantar flexor, an ankle and sub talar joint supinator or pronation decelerator, and a midtarsal joint stabilizer. So, you can have normal foot mechanics, but dramatize the posterior tibial tendon by getting off the seat of a bike too much. 

I took two Aleve twice a day for several weeks.  I now take the Aleve only occasionally after the rheumatologist cautioned me about side effects.

I would like to come see you.  I live in Portland which is an easy flight.  I’m going to be in San Francisco on July 22 and July 23.  I could also come sooner which, in fact, I would prefer to do if possible.  What I would like to do is to first get you all the existing imaging studies and chart notes.  I realize that it would probably take you a lot longer than the amount of time you are allotted on a typical new-patient office visit to thoroughly review all the records and then see me.  So, I am happy to pay you for the extra time as you see fit.

Thanks so much for taking the time to read this far.  Please let me know if and when I can make an appointment to see you.  I very much look forward to it.

Dr Blake's comment: I will be honored to see you. Mail all of the images and records to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109 and we will go from there. Call my front desk at 415-353-6400 and arrange a one hour appt for one of those days. Bring all your orthotics. Thanks Rich

PS. Please email me with more answers to the below questions. 

Sesamoid Fracture: Email Advice to MRI or not MRI

Dear Dr. Blake,

Thank you for creating this wonderful resource, which helped so much. It's been extremely helpful as I recover from a fractured fibular sesamoid. You often recommend a baseline MRI with follow-up at 6 months to monitor healing, and I'd like your opinion on whether I need one. 

I'm female, early fifties, and was hit forcefully near the ball of my left foot 3 months ago.  I was out of the US, and was prescribed rest, ice and elevation after a fluoroscopy showed no fracture. I had a huge bruise, and swelling at the ball of my foot and base of my toes, which was mostly gone after 3 days. 

After 10 days the pain was minimal, and I stopped limiting my walking. Unfortunately a week later I developed swelling and pain after carrying a heavy bag on the way home.  The x-ray (3 weeks after initial injury) showed a sesamoid fracture and I was put in an aircast with dancer's pad. I'm forwarding them with two later sets in case they're helpful. After 2 months in the cast I'm now in athletic shoes, and am allowed to swim and do more walking as well as the stationary bike. My orthopedist predicts a very slow healing process, but that I won't need surgery.

With the dancer pad I sometimes feel mild aching or burning (up to 2, rarely 3) on the sole at the base of my first two toes, and some tingling across the top of my foot.  So I've started trying just a thick cushioned insole without padding, to remove pressure there. Should I be concerned about this? Overall, pain is 0-1 when exercising.
Dr Blake's comment: No, sometimes with fibular sesamoid injuries, the one closest to the second metatarsal it is hard to not have the edge of the dancer's pad hit the injury when turning, etc. You, however, as you increase your activity, may want to go back to a thinner dancer's pad (under 3rd through 5th metatarsals). 

Thanks to this blog I'll be getting a bone stimulator and bone density and vitamin D tests. However my doctor doesn't see the need for an MRI, and I'm not sure whether having one might change my treatment in any way.  Could there be something important that may be missed without one?  Should I pursue this, by getting more opinions?
Dr Blake's comment: I never regret getting a useless MRI. What is a useless MRI? It is one that someone without an injured sesamoid says you do not need. It is a baseline for another MRI possibly 6 months later if needed. When it is needed, you are awfully happy you got the first one. And we are not just talking about the sesamoid. You had blunt trauma, which can produce more unpredictable problems, so the MRI is even more important in your case.

Further comments by Dr Blake: She was kind enough to send me xrays from 4/13, 5/13 and 6/13. Both sesamoids had irregularities, and the big toe joint itself looked slightly arthritic. This is going to make MRI interpretation more difficult, thus we may be opening a can of worms. However, I still think it is a good test for her to have. The sesamoid injury showed no fracture displacement, so healing so be complete at some time.