Foot or Knee Surgery First: Email Advice

Dear Dr. Blake:

I have a too short first metatarsal due to surgery about 7 years ago.  In addition, my second and third toes are longer than my big toe.
Dr Blake's comment: A short first metatarsal is like removing the third leg off a tripod. If the first metatarsal is short, it tends to be above the ground, and as you move forward the lack of support on the first metatarsal will cause your arch to collapse. You can also develop a compensatory supinated gait which allows you to stay on the outside of your foot, but it is jarring to the knee, hip, and back. 

I was never able to walk correctly afterwards. My foot turns outward and now my second and third toes curve toward my big toe.  Also, the tendon in my big toe may be too short now.  There is pain under my knee on the same side as the tendon in my big shortened toe.

Thank you very much for the video on spica taping for big toe joint pain.  I  had a family member spica tape my big toe last night and oh what relief!  I was able to walk better today than I have been for a long time.

I am now in the situation where I need both knee and foot surgery.

Can you give me your thoughts about whether I should have knee replacement surgery or foot surgery first?  Is there a correct order in which to proceed?
Dr Blake's comment: Foot surgery typically requires a period of weight bearing on the tibia with a device called a RollaBout. You I am attaching a video I did of the device. If you think that your knee can tolerate that for several months, do the foot surgery first. However, we mainly recommend to our patients to have the knee surgery first since the walking is so limited for 3 months, and then when the knee can tolerate the RollaBout, go ahead with the foot surgery. 



Also, are there any other things I can do to provide relief while walking?  Any thoughts on surgical procedures that may help and non-surgical things that I could do that may help.
Dr Blake's comment: I spend all day trying to take feet like yours and design inserts to help balance out the weight. Based on gait abnormalities, I work with a physical therapist to make gait changes, and add appropriate strength and flexibility work. Go to the AAPSM website for a local podiatrist that can help you start. I am not a surgeon, so advice regarding surgery may be worth what you pay for that advice!!! I hope this helps. Rich

Thank you very much again for the spica taping video.

Thank You,

The patient responded again.

Dear Dr. Blake:

Thank you very much for responding to my email on your blog.   I appreciate this.  I am trying to find my way in order to fix my foot problem.  It hasn’t been easy.

My too short metatarsal is causing me to walk on the outside of my foot and my knee is bone on bone on one side and my hip hurts too.    I have what you called “supinated gait” and this has done damage to both my knee and hip.  You are “spot on” with what happened to me.

I contacted a three orthopedic foot surgeons this summer and each proposed a different way of treating my foot:

One wanted to perform a metatarsal fusion with bone graft on my big toe and then shorten the second and third toes.  (Healing time = 12 plus or minus 3 weeks)

Another wanted to do an osteotomy on the first toe .  And then shorten my second and third toes.  (Healing time  = 8 weeks)

The third surgeon I consulted wanted me to get my knee fixed first and then to do a tendon transfer to solve my walking problem  (Healing time about a year)

It has been very confusing for me, since each doctor has proposed a different solution to fix my foot.     Also,  I need to keep on working to bring in a paycheck.

I don’t know which procedure would work best for me since I am not a doctor and each person is proposing something different.    Do you have any insight on which procedures tend to work best to fix  a foot with a problem like mine?

Does a metartarsal fusion with bone graft usually work to solve a problem like mine?  I am afraid to have the joint fused  permanently.   Of the patients you have seen with a problem like mine, what procedure seems to help them best?   Do bone grafts usually fail?   I am afraid that the fusion will affect my gait.  However, I am not walking very well now.

That spica taping is helping me walk.

Thank you very much.   I appreciate it.

Dr Blake's response:

     I am not a surgeon, but I do follow patients whom have had surgery. Definitely have the knee surgery first, and begin working on orthotic devices that do the same function as the surgery. You can make orthotics to lessen a supinated gait, that act as a fused big toe joint, that bring the ground up to a short first metatarsal that is elevated, etc. The orthotic device, designed by a podiatrist, physical therapist, or orthotist should begin to discover how to make you comfortable and make your gait better. I have many patients avoid surgery be wearing orthotics or in the process of making the orthotics and analyzing the foot we learn what needs to happen in surgery. It is common in the San Francisco Bay Area for patients to have the instep fused in your case (where there is no pain in the big toe joint) and the first metatarsal dropped lower to bear weight during the procedure. This requires 8-10 non weight bearing, and then 3-6 months of gradually getting function back in the foot. You want to know a good orthotic person before you do this type of thing. I hope this helps some. Rich

Toe Hyper-Extension Injury with Fractures (Including Jones Fifth Metatarsal Fracture): Email Advice

Hi Dr Blake.

     I've been reading your website/blogs for the past 5 months waiting for my right foot injuries and fractures to heal. I'm completely confused about what's going on with my right foot and can't get any straight answers from my doctor. 

    The night I got injured, I guess I lifted my right foot a little higher than usual (I had fallen asleep on the couch) and my toes caught on the decorative and rough transitional tile on our floor causing all of my toes to completely bend under my foot while my body was still in the forward gait movement. I felt pain across the top of my toes (which is weird because the top of my foot shouldn't be on the floor) and when I went to complete the step and put my foot down, the pain was incredible. I fell forward and caught myself on a table before falling to the floor. My foot was in agony and I could not put any weight on my right foot. There was a lump on the side of my foot (base of 5th metatarsal) and cuts across the top of the 4 lesser toes. I guess my toes got crushed under my foot from my weight dragging across the tile floor. 
Dr Blake's comment: All of the tendons that go into the tops of the toes would have been over stretched giving you the pain on the top of the foot and even into the front of your leg. 

    When my husband took me to the doctor and x-rays were taken, he told me I did have a fracture and then said "multiple" fractures. He said I fractured the base of the 5th metatarsal and called it a styloid process fracture.  He didn't say where the other fractures were. He also said I sprained my ankle. He never checked my toes or forefoot. He said I had an easy fracture and I'd be good to go in 6-8 weeks. He gave me a walker boot and said to ice and elevate as much as possible. 
Dr Blake's comment: This is a common problem in medicine. The most obvious injury is recognized, but we all know that the golden rule is "It is better to break a bone, then sprain a ligament." You probably have a lot of soft tissues sprains and strains. This is such an unusual injury, that no specialist will have much experience with it. 

    I had been brought into his office in a wheelchair because I couldn't walk and didn't have crutches, so I was surprised that he thought I could put that boot on and walk out of there. My husband told him again that I could not put any weight on my foot and asked him for crutches and he told us that if we really thought I needed them we could purchase them ourselves at a medical supply store. After 4 weeks, new x-rays, and he said fractures (plural) were healing and to get out of the boot and put a sneaker on. What? By this time my foot was 3 times the normal size and the top of my foot under the skin was blue across all the metatarsal bones. The swelling on the bottom of my foot was horrible - my toes never touched the floor - and I couldn't bend any of my toes. When we pointed this out to him that my foot was getting worse and we were worried about lack of circulation, he told me to wear a post-op shoe instead of a sneaker. He forgot about the ankle sprain and I never was able to wear the post-op shoe because of the pain in my ankle.  Seriously.
Dr Blake's comment: Okay, he/she is clearly treating mentally only one part of the injury. If the metatarsal fracture was the source of all your problems, you would be fully pain free weight bearing by this point. Definitely, you need an MRI to make sense of the soft tissue part of your injury. 

    At 8 weeks, my foot was now 4 times it's normal size, still blue under the skin across the metatarsal bones, bad pitting edema, tension and strain in big toe, 2nd toe and 3rd toe. The 4th and 5th toes seemed dead, still can't bend them, and there was a horribly painful spot between the 4th and 5th toes on the bottom. Doctor took new x-rays and said all the fractures were healed. He said the biggest fracture still needed a little more time but it was basically healed. He said to put a shoe on and walk. Now I'm thinking I'm crazy. Why doesn't he see what my foot looks like and that it's ice cold! He still did not check any of my toes or my forefoot or my entire foot and ankle.  He was basing everything on the x-rays and the "protocol" for the type of fracture he said it was. He went on vacation and my foot got worse so his office had us see another doctor.
Dr Blake's comment: Hooray!!! As patients, we have to be our own ombudsmen. All doctors, including myself, get tunnel vision sometimes. Many times I am shocked when at a followup visit I thought the patient would be perfect, and they were much worse. So, that is when you have to look deeper, and look for something else. Unfortunately, when you look at treatment plans in text books, they mainly talk about one injury at a time. This is difficult when patients present with injuries, like yours, that can have 6 or 7 different injuries at once, some needing different treatments. 

    He said I had a couple fractures at the base of the 5th metatarsal and one was a Jones. He ordered an MRI and told me start non-weight bearing. The MRI said transverse fracture going all the way through the bone was UNHEALED. I was told to stay non-weight bearing and start bone stim. Nothing was done about the pitting edema in my foot or the circulation. The 2nd doctor didn't check or touch my foot either. We asked the doctor what he was going to do about immobilizing my foot to keep it from moving and from me hurting it. He gave me an ankle tubigrip thing. How was that going to protect my foot?  He said I was non-weight bearing so I didn't need anything but that. I didn't understand why they weren't doing anything about the circulation issue and swelling in my foot so my husband took me to a local medical supply place and they recommended a knee high compression stocking to wear. After 3 days, the swelling and pitting edema was a lot better on top of my foot.
Dr Blake's comment: At least you are starting to move in the right direction. Jones fractures may not heal and could require surgery. You need to find a doctor who does that type of surgery that you trust. We know you have a Jones Fracture, but you also have swelling out of control, and other soft tissue injuries. Did the MRI speak on any injury at your toes/tendons/ligaments? Remember, swelling is made worse by removable boots, non weight bearing, pain, improper compression, so there are a lot of normal things that can be making the swelling linger too long. I am always fighting getting the swelling under control. Swelling is our enemy, it definitely slows healing, and makes the pain in an injury last longer. So, perhaps a good physical therapist could review things for you and start a better program of combatting the swelling. 

 The swelling across the metatarsals on the bottom of my foot, the tension and strain through my first 3 toes, can't bend toes, etc. still a problem. And the head of the fifth metatarsal bone is very painful. They haven't checked to see if there are stress fractures in any of my toes or the other metatarsal bones. Every time I bring up the issue of my toes not being able to bend and the stress and tension through my toes, he tells me there's nothing wrong and there's no soft tissue injury because the MRI would have shown it. Of course, he won't physically touch my foot to check for himself.  I've been dealing with this since March 18th and have been non-weight bearing for over 3 months now using the bone stim. 
Dr Blake's comment: I have many patients leave me for various reasons, some I am very sad about. I probably order more second opinions on my own patients than any doctor in my practice. Why are you staying with this group? Why not at least get another opinion? I would have had at least 2 by now. 

I have no idea if the fracture(s) is healing and no idea how much longer he plans on keeping me non-weight bearing. If he has a "plan" he's not sharing it with me. Like the 1st doctor in his office, they have tunnel vision about the base of the 5th metatarsal fracture and are blind to what else is going on with my foot and ankle. I'm a prisoner in my house because I can't walk or drive. I can't be up using the crutches more than 5 minutes because my left hip now gives out on me.  This seems really crazy and not normal.  I would truly appreciate any suggestions you might have. I have the digital x-rays that were taken and would be happy to e-mail them to you if you would like to take a look.  Again, any help would be greatly appreciated to stop this insanity.  Thank you. 
Dr Blake's comment: I would look at the AAPSM website, go under membership, and find someone in your area. I will be happy to look at the MRI, but you need someone local. This is not normal. You need several opinions. The doctor patient trust is broken. Once broken, it can not be fixed easily. So, start a new. The new person can get ahold of old x rays and MRIs. You need a new foot person, a physical therapist, a pain management specialist, and, in California, a sports psychologist. If you want to send me the MRI, send to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109. I hope this helps some. Rich

Accessory Navicular Pain: Email Advice

Dear Dr. Blake,

     I was wondering if you would be able to clarify some information to help us make some smart treatment decisions.

     My 13 year old daughter is a high level soccer player. She started to complain of pain in her foot last spring during the time she played soccer and ran track. She also played in 14 games of soccer without ever coming out. A significant increase in activity.

     The pain was located on a bump that has been recently identified as an accessory navicular.  She was first treated with rest and 4 weeks of physical therapy and orthotics. After returning to sport the pain returned but was slightly higher above the ankle.  MRI shows no fracture but edema indicative of stress changes os naviculare. 
Dr Blake's comment: The edema/swelling seen within the os navicularis/os tibial externum/accessory navicular can take months and months to resolve after the initial injury, so not an indication that things are not healing. The pain above the ankle was one of the tendons trying to help out the injury: FDL, PT, FHL, or AT. When one area is injured, the surrounding muscles/tendons help out and do some extra work. That can make them hurt also. A Rule of Three tends to occur until the body re-establishes equilibrium---original problem, compensatory problem #1, and compensatory problem #2. The true injury is at the bump with the accessory bone however. 


     Current treatment is 6 weeks non weight bearing air cast, then progression back to activity. She has so far missed 4 months of training. Everything we seem to read is confusing relating to surgery vs conservative treatment. For a high level athlete looking at missing another 3-4 months is devastating. We are wondering if surgery would be a better option as everything we seem to read indicates non surgical treatments are not effective.
Dr Blake's comment: I am sorry the literature is so poor on this subject. Yes, some patients need surgery. Doctors have a hard time deciding on surgery on someone that age, so feet get dragged. It is an impossible decision for a parent to make, since surgeries can have problems, and the patient can be worse (less than 10%). When they are worse, there is usually an explanation, but a second surgery is often needed after months and months of unsuccessful rehabilitation. For a professional athlete, paid big bucks, they have surgeries for speed of rehabilitation. Every second they miss playing cost the team money. But, in the non professional, and at a young age, you want to be very very sure that surgery is needed. I have treated 100s with this condition with less than 1% having surgery (and perhaps another 9-10% just stopping their activities to avoid surgery). So, 90% get better without surgery and can continue with their sport of choice at a high level, will your daughter be one of those? 

     Our doctor indicates feels that the literature supports good outcomes with nonsurgical treatment and that is what she recommends. Any information you can share to help us would be great. We just want to make sure that whatever treatment she receives it limits the time out of sport and reduces the chance of recurrence.
Dr Blake's comment: The approach to getting this better, and keeping it better, is a multi-discipline approach. The podiatrist/therapist/orthotist must make great orthotic devices to stabilize the injured arch/accessory bone. The physical therapist/trainer must develop a strengthening program, pain free, that gets the posterior tibial tendon, and the surrounding muscles/tendons, and the quads/core strong as the other side. Your daughter should be icing twice daily and contrast bathing for the bone edema once daily to remove the inflammation. She should be on a stationary bike, etc, pain free, up to one hour per day to get the legs strong for her return to activity. She needs to learn the best way to tape the area which gives her the best pain relief, since taping in soccer games/practices is crucial and more protective than orthotics. She should be in the deepest soccer shoe she can find. It is when the orthotics, tape, strength, pain level are right, she can go back to activity. The coach is probably the most vital part to this team. She/he must be protective of your daughter, be vigilant for signs of limping, know when to rest her, when to play her, perhaps change positions temporarily to help the demands on that ankle/foot. If the coach can not do this, all our best plans are destroyed, and it gives conservative management a bad name. Make sure diet is very healthy, including at least (2) 4 ounce servings of red meat weekly, if she is not a red meat eater. And, as parents, you need to get rid of any time line right now as you read this. Honor her body tissue. Do not think about time lines, you will only get frustrated. 

Thank you so much

Regards,

Dr Blake's comment: So, in summary, here is your next 3 month assignment:

1. Wean from Non weight bearing to weight bearing without increased pain
2. Perfect the orthotics
3. Perfect the soccer cleats
4. Avoid barefoot at home if that bothers the area
5. Learn a variety of taping methods
6. Ice and Contrast Bath daily
7. Eat healthy
8. Talk to the coach about a gradual return to soccer, and any ideas on position change
9. Tell the physical therapist you want to learn a pain free gradual and progressive strengthening program so 6 months from now you have tendons of steel (at least 3 times stronger). 

 Good Luck!!

And the response: 

Dr. Blake,

Thank you so much for your information. As a result of the info you provided we decided to seek a second opinion from an orthopedic surgeon. His diagnosis correlated with your info. He recommended casting in a walking boot for the next 3 weeks but did not feel NWB was necessary or appropriate. This is great news for us as this is not a stress fracture of the navicular as we were being told was a possibility as well . She is allowed to walk in the boot and swim which will decrease unnecessary  deconditioning and ankle stiffness. He also said surgery may be an option using a modified kidner only if conservative measures fail. He recommended physical therapy and orthotics.

Thank you again. It is nice to finally have a clear diagnosis and logical treatment options backed by two professionals.

Front of the Foot Pain: Email Advice

Hi

I've getting very desperate, because nobody is able to tell me what is wrong with my foot!

One doctor said it was a neuroma, so he gave me 3 cortisone shots, and it didn't work. Another was honest enough to say he has no idea, so he sent me to therapy.

What I've noticed is that on my left foot, I seem to land on the outside of my foot when I'm walking. However, it only seems to happen when I am wearing foot wear. ANY footwear. Tennis shoes, flip flops, or ballet flats.

When I'm barefoot, it seems to not be a problem.

This seems like supination from what I've read in your blog. But why is it only an issue if I'm wearing shoes?

Thank you so much in advance for the answer. I've had this problem for at least 6 months, and it seems to be getting worse :(

Regards,

Dr Blake's Response:

     Thank you for the email. Shoes typically take you more a more flat footed position to a more supinated position in a normal to pronated patient, and the opposite for supinators. Of course, if shoes place you right on where you are sore, you need an orthotic interface between the foot and shoe to make off weighting changes. That is normally attempted in athletic shoes first, dress second, sandals with removable inserts third. Flip flops if they are causing you problems need to be avoided until the inflammation is calmed down. 

     What to do now? It seems like you need some testing, like xrays and MRI, to analyze the problem. A second opinion may be good, but that does not mean you have to switch. Try to create your own pain free environment analyzing the best foot wear at this point. Experiment with various OTC inserts to see if you can discover what protects your foot the best. Ice your foot for 10 minutes 3 times daily to reduce any inflammation. 

     You can send photos pointing to where the pain is. Try to send me 10 bullet points on the type of pain you have. Am only? Sharp? Aching? Radiating? What helps? What hurts? etc, etc. Hope this points you somewhat in the right direction. Rich

Big Toe Pain: Inter-Phalangeal Joint---Email Advice

Hi Dr. Blake! 

     I am a 32 year old female whom recently started getting sharp stabbing pain under my big toe (not the large joint but the one in the first bend of the toe).

     I was diagnosed with an elevated first ray in my left foot and slight elevation in my right. I have some Hallux Limitus in the left so far, along with Hallux Valgus.
Dr Blake's comment: When the big toe joint has some limitation, then movement may be increased in the joint in front of (your painful area) or in back of (in the arch). 

Here are some of my questions:

1.  I am wondering what you would recommend for my particular condition?
Dr Blake's comment: You need to experiment with circumferential taping of the toe across the sore joint 24/7, padding either below (to bring the ground up), or to the side (classic dancer's pads), icing 2-3 times a day, figuring out if there are shoes that make it feel better (more padding, less flexibility, or more flexibility, etc), and cut out for the next several months activities that irritate it. I would at least get xrays to evaluate the area. 

2 Should I have surgery to avoid getting arthritis in the joint? (this has not happened yet)
Dr Blake's comment: I hear about preventive surgery, but I personally think that is mainly an oxymoron.

3. What brands of shoe would you recommend? 
Dr Blake's comment: You really have to play with this one. You have 5 parameters to deal with in a shoe, and some combinations will be the best. Set no preconceived notions. The 5 parameters are: padding, flexibility, width, toe box space and length. 

4.Can I still wear sandals so long as they have a back strap? 
Dr Blake's comment: Sandals, like any footwear, are fine if they do not increase the symptoms. Listen to your foot. 

5.I did stop trail running, as I don't want to end up crippled in my old age. I really appreciated coming across your site. No one seems to pay attention to this problem and it is terribly life-altering. I am devastated and having a hard time coping. I used to love running and being very active, so this is quite the blow, esp at such a young age. I appreciate any help you can offer. The doc hasn't told me how severe my condition could get. I do have my x-rays. Could I send those to you and get your opinion?
Dr Blake's comment: I would be happy to look at your films. Send to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. This problem does not tend to be that difficult to treat, so I guess I need more information from you. Try to send me 20 historical bullet points to review: How long, swelling, redness, duration after stop working out, etc, etc. Hope this helps some. Rich

Best,

Ankle Reconstruction followed by Posterior Tibial Tendon Dysfunction: Email Advice

Dr. Blake,

I had Bromstrom procedure October 2012, and in March 2013 was diagnosed with PTTD.

Dr Blake's comment: Bromstrom is a lateral ankle reconstruction for torn ankle ligaments.

 The posterior tibialis tendon is thickened consistent with tendinosis.  There is a longitudinal tear of the posterior tibialis beginning at the level of the distal tibia and extending to the mid aspect of the talus.  The longitudinal split tear measures 2.5 cm in length.  There is moderate fluid within the posterior tibialis tendon sheath.  There is no tendon rupture identified. 

The orthopedic surgeons are saying it will not get better, when I resume my activity it will come back, until; I have surgery.  They are saying I need FDL transfer, posterior tib debridement, spring ligament repair, and medical displacement calcaneal osteotomy. 

 I have done physical therapy, and ice, medication, now use pain cream.  It seems to feel better after stretching, and strengthening, I am wearing a brace, and prescribed orthotics.  I am a flight attendant and am on my feet for long periods of time.  I know surgery will put me down for 4 to 6 months, and would rather not go through another long painful surgery and recovery.  

DO you have any suggestions as to what I can do that I am not doing currently?

Dr Blake's comment: 

     Thank you so very much for the email. Most of my patients considering such a surgery take years to make such a big decision, so you can always do that. MRI findings such as yours are common, and I am happy that no tendon rupture occurred. I am assuming that the lateral ankle surgery placed too much stress on the medial structures causing them to start barking at you. 

     Without a rupture, you have the possibility of completely healing this without surgery. It is really based on prolonged protection of the posterior tibial tendon while you go through pain free strengthening. The strengthening of the posterior tibial tendon should include all of the other foot and ankle muscles/tendons, and the rest of the leg and core. 

     The next 3 months will tell a lot about your course. Each month the tendon should gradually get stronger as you advance from active range of motion, to isometric, to progressive resistance, to functional restorative exercises. It takes a good physical therapist out there to lead you through this. You will have ups and downs. And the downs, as you attempt to push the course too fast, is psychologically demoralizing. 

     Please keep me in the loop, and I will help as I can. I will place further correspondence on this same blog post. Hope this gets the process going. You already have achieved pain free function by the sounds of things, and that is a huge step forward!!! Rich

Move It Sister/Brother-This Ain't No Parking Lot!!-fitness tidbits from Lisa Tonra

"Move It Sister - This Ain't No Parking Lot!" 
by Lisa Tonra, Personal Trainer

I'm old, out of shape and everything hurts - why start exercising now? Because exercise really IS the fountain of youth!

Let's start by getting some common myths out of the way…

1. I'm (getting) old anyway. 
As the saying goes, age is just a number. Exercise, both cardiovascular and strength training, helps you look and feel younger and stay active longer. Equally as important,  regular physical activity lowers your risk for a variety of serious conditions, including Type II diabetes (diabetes mellitus), cardiovascular diseases, high blood pressure, obesity, colon cancer, Alzheimer's Disease and dementia. Much research has shown that inactivity often causes older adults to lose the ability to live independently. Being sedentary can lead to more doctors' visits (or worse, hospitalizations) and increased use of medications for largely preventable illnesses. Exercise is the key to staying strong, energetic and healthy, and delaying or reversing common conditions of the aging process.

2. Exercise will put me at risk for falling down. 
Not true! Regular exercise builds strength and stamina, which prevents loss of bone mass and improves balance, thus REDUCING your risk of falling! Muscle weakness has been shown to be the biggest risk factor for falls. Although we do lose some muscle mass with age, exercise can slow this rate of loss and even reverse it.

3. I've never exercised before. 
No problem - it's NEVER too late to start exercising! Physical movement and sports skills can be learned at ANY age (you may not become an Olympic contender, but I can guarantee that climbing stairs, walking the dog and carrying groceries will become MUCH easier). The advice of a well-qualified personal trainer and/or physical therapist can be invaluable as you begin your journey towards greater health.

4. My joints ache and it hurts to move. 
Motion is lotion for aging joints! Most adults over 50 suffer from osteoarthritis (degenerative joint disease) at one or more joints. Exercise will improve strength, flexibility and posture, helping to alleviate its common symptoms which include stiffness, pain and loss of functional movement and mobility. One of the greatest 'at-risk' joints is your knee. The odds of developing knee osteoarthritis (OA) rises hugely after age 50. By age 80, about one-third of men and half of all women will have OA of the knee. As knee OA progresses, it can cause debilitating pain, reduce your mobility and increase difficulty in performing daily activities. Add it all up and your quality of life is greatly reduced (and who wants that?) But adding exercise to your life can significantly reduce your risk for developing symptomatic OA. If you already have an arthritic knee, hip, or shoulder exercise can greatly improve your mobility and will reduce discomfort. More mobility and less pain? Let's GO!

5. I'm forgetful and get distracted easily - I can't manage an exercise program.
Not so fast! There is much research to support the value of exercise in shoring up memory and brain function. Both cardiovascular and strength training exercise can actually help to 'bulk up' the brain by creating more cells in the brain areas responsible for memory, learning. and critical decision making. More blood flow to the brain = sharper thinking AND reduced risk of Alzheimer's Disease and dementia. 

Knowing that regular exercise can improve bone mass, strength, flexibility, agility, ability to carry out daily activities, memory and brain function (WHEW!) what are you waiting for? 

Here are some tips to getting started safely:

1. Get medical clearance from your doctor. Ask if there are any activities that you should avoid.

2. Consider your existing health concerns. For example, if you have diabetes you may need to coordinate your meals and medications with your exercise schedule. If you have hip or knee OA, water exercise may initially be the best choice for you.

3. START SLOWLY! The usual aches and pains that accompany OA can be circumvented by adding activity in small 5-10 minute increments. Try a ten minute walk around your neighborhood at a leisurely pace each day for a week. As your fitness improves add a few extra minutes to the walk or challenge yourself with hilly terrain. Remember, motion is lotion for your joints!

4. Challenge yourself to commit to your new activity schedule for at least four weeks. After about a month your exercise schedule will become a habit that you will miss if you skip!

5. Stay focused on short-term goals such as improving your mood and energy levels.

6. Listen to your body. Exercise should not be painful or make you feel lousy (but do expect a small amount of typical muscle soreness after unaccustomed activity or more intense exercise). Stop immediately if you have chest pain, feel short of breath, feel dizzy or nauseous. Stop the activity also if a joint is red, swollen or feels tender.

7. Get expert help. If you've never exercised before, have been 'out of the game' for a while, or simply feel unmotivated enlisting the services of a professional is a wise choice. A well-qualified fitness trainer or physical therapist can help ease you into a routine that is best suited to your body type, interests and activity limitations. Lifestyle changes, including exercise routines, are most effective when you have a personalized program, preferably with a professional who works directly with you. It can indeed be intimidating to work with a trainer in a gym setting, but there are many options today! Exercise experts can meet you at your home, office, or community center and can arrange small group training sessions or classes. What better way to get fit AND catch up with friends than a buddy workout or class that is tailored to exercisers just like you? A pro can also make sure you cover all components of a well-designed activity program: cardiovascular exercise, strength training, flexibility and balance exercises.

So If you dread working out, it’s time for a mental makeover! Consider physical activity that is tailored to you as part of your new lifestyle, instead of a tedious chore that must be done. The best thing about exercising is that it gives you energy for more activities. When it becomes habit, you’ll never want to give it up. And exercising with others, either as part of a formal program or with your neighbors and friends, can add to the enjoyment of becoming physically active. Done safely, and under the guidance of a therapist or trainer, it’s NEVER too late to start. Once you add EXERCISE to your life you'll add LIFE to your years!

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

Basketball Shot wins Free Tuition

I am sure he was in very stable orthotics to be able to make this impossible shot! LOL Congratulations!! 

Severe Ball of the Foot Pain: Some Points to Consider

Posterior Tibial Tendinitis: Some Key Points

Algorithm of Treatment for Posterior Tibial Tendinitis from diagnosis to immobilization to re-strengthening to return to activity. 

Posterior Tibial Tendinitis: Some Key Points

 Posterior Tibial Tendinitis: Key Points

 ■ This tendon moves the ankle, prevents over pronation, and supports the arch
 ■ Treatment of this tendon at times requires stabilization of all 3 areas with ankle bracing, inverted orthotic support, and arch support
 ■ As soon as treatment is started to immobilize the injured tendon, both anti-inflammatory and some form of strengthening should begin
 ■ MRI should be used initially to rule out an actual tear, or if the treatment seems to hit an impasse

Walk In My Shoes: A Powerful Short Video!!

We daily envy the good fortunes of others which brings our spirits down. We are all incredible gifts, and I realize that life is unfair! This short but powerful video will be analyzed by everyone differently, but it's point is to get us thinking. We need to have a heightened appreciation of our gifts, not failures, our successes, not shortcomings. We do need to walk in another's shoes to really understand them. We will never understand them if we are only thinking about ourselves all the time. I think I could watch this video 10 times, in 10 different emotional places, and get 10 different responses because it is that powerful. 

Walking Stairs: A Great and Natural Exercise, and very underrated!!

Walking is one of the safest and natural activities that produces great health benefits. It is very underrated. If you build up your walking legs, look at some of the adventures you may have!!

Wurzburg , Germany

Pailon del Diablo, Equador


Chand Baori fountain in India.
These steps lead to a huge fountain built in the tenth century to collect rain in the region and accumulate them in temporary lakes.
The structure has a total of 3,500 steps and down to a depth of 30 meters.

Elbsandsteingebirge stairs in Schsische Schweiz, Germany.
Some steps are cut directly into the rock of these mountains.
Dating from the thirteenth century and were eroded by wind and water, but it remained being used daily by tourists. 487 steps, which have been restored in the eighteenth century to facilitate transit.

Crack of Guatape in Antioquia, Colombia.
Corner stone is a genuine monolith with a height of 220 meters.
Cement stairs were built directly on the rock, filling the crack where the sides support the structure.  To reach the top, you must climb the 702 steps.

Haiku scale in Oahu, Hawaii.
This extraordinary scale spanning 3922 steps, climbing and descending a hill of 850 meters. It was created to facilitate the installation of antennas in 1942. Largely made of wood, was modernized in 1950 with metal, but closed to the public since 1987.

The Inca road in Peru.
An ancient trade route that connects Cuzco to Machu Picchu town.
There are miles and miles of stairs in some very unsafe places, such as for example the famous floating stage.

Wayna Pichu at Machu Pichu, Peru.
Some steps cut into the rock which crown an ascent of 360 feet above the main city of Machu Pichu. In some sectors, the ascent is complicated, passing through narrow portions with small eroded steps.   They allow only 400 tourists to climb daily, and shuts down access at 1 p.m.

Cross Road ladder in Bermeo, Basque Country, Spain.
This network connects with endless steps where Rocky is a small church dating from the tenth century, it seems to be of Templar origin. To reach the hermitage of San Juan de Gaztelugatze must climb 231 steps and there are gaps between steps are identified to be the footprints of St. John, which are assigned certain curative powers. For example, sit on them for healing, or touch the hat to cure headaches.

Scale worm Taihang Mountains on the border between
Shanxi and Henan provinces in China.
This scale worm of approximately 100 meters was recently installed with the intention of attracting thousands of tourists to the beautiful Taihang mountains. Before climbing visitors are asked to sign a form assuring that are no heart or lung problems.

Fractured Sesamoid with Surgical Complications: Email Advice

Hi Dr. Blake,

I have been reading emails after emails on your site trying to find a similar situation to mine. I have been through 6 doctors in the last 5 years and I have hit a wall. I will tell you I am only 26 years old.

I fractured my  lateral sesamoid in 2008 of my left foot. I was casted multiple times,placed in a boot, fitted for orthotics, and had many cortisone shots. After 3 doctors I had my Lateral sesamoid removed in 2011. I got pregnant in between so I had to wait the year. My foot didn't hurt when I was pregnant but the moment my foot unswelled it was back.  The doctor who removed my sesamoid used porcine graph without my permission, I was allergic and it caused a HUGE mess. The doctor vanished on me. I found another doctor and she went in and cleaned out what the prior guy did 1 month later. My incision was infected, I had a hole in my foot. I got it cleaned out and now there is a thin layer between my bone of the foot and skin on the side from incisions. You can literally feel the bone. They say if i every get cut there it would be directly on the bone.  If anything touches it, it hurts right away and even makes my nerves crazy sending shocking sensations up my toe. That is the least of my problems.

Dr Blake's comment: I am so sorry.

Since that seaamoid was removed the pain had not improved. I was still unable to walk correctly or pain free. Over the course of 1 year my big toe starting turning in and the pain was increasing.

Dr Blake's comment: It is hard sometimes to know if the pain is coming from the sesamoid which is in the joint vs some other arthritic process within the joint like Hallux Rigidus (although you are quite young for that). 

My doctor suggested transferring the tendon and fusing my big toe. She said this would alleviate all my problems. I had that surgery in Jan-13. I have had nothing but more problems. Pain in my arch, above my toe joint, ball of my foot and now my toe hurts from the screw. I got orthotics and more cortisone shots. The shots no longer work.  Her next step is to lengthen the tendon. I would rather not have surgery on my foot again so I decided to get another opinion and changed doctors.

Dr Blake's comment: When they fuse the big toe joint, they typically fuse for a slight heel. The bend in the toe produced forces more pressure on the sesamoid area underneath. 
My new doctor did an MRI and x-rays. My medial seasmoid is fractured now and I have fluid in my tendon as well as chronic edema and arthritis in the joint.  This doctor casted me for 2 weeks after finding that out. If anything, this increased the ball of my foot pain drastically but the pain directly over the sesamoid is gone. I had NO pain when I was casted. With every step now I hear a cracking noise. This doctor says the tendon is not healing around the sesamoid. (That entire tendon hurts all the way up my calf, ankle. I saw a physical therapist and she had me in tears just from barely pushing on it). He is out of options on what to do other than remove the remaining sesamoid. He feels a Plasma Rich Platelet injection may do the job and heal everything in my foot. Well, my insurance denied that and I can't afford it right now. I am frustrated and extremely upset that I will never be able to walk normally without having pain. I can't hold a job that requires standing or walking. I can hardly go grocery shopping. The zoo? Mall? no way! I am in tears in the middle of it and at the end my foot is very swollen and I can not bear weight, it feels like my entire foot is broke. I am out of options and do not know what to do. I have been rubbing the essential oil lemongrass on the ball of my foot and arch and toe for 4 days now hoping it will work. Please help me! What can I do? What is your advice or opinion on this situation?

Thank You!

Dr Blake's comment: 

     Thank you so very much for your email, and I am so sorry for the problems. I have more questions, then answers, so while we try to get some direction, place yourself into as pain free environment as possible. This is probably with a removable boot with accommodative floating of the big toe joint with an EvenUp on the other side. 

Sesamoid fractures take minimum of 3 months of casting and the cam walker should do that. We need to protect the other sesamoid as well as possible. I am sorry that I have no experience with PRP to help you with that decision.
     The fusion should have taken care of 2 of the 3 sources of pain in a bad big toe joint: the pain produced by pressure in the joint and the bend produced by bending the joint. This leaves the 3rd source or the pain produced by weight bearing on the area. This is where temporarily (2-3 years with your problem) you need to off weight the area with various forms of arch support and dancer's pads.
     If you are working on the mechanical aspects of pain, you have 2 other areas to deal with: inflammatory pain and neurological (neuro-pathic) pain. For the inflammation I would be icing every several hours for 10 minutes placing an ice pack on the bottom of your foot. For the neuropathic pain, I would see a pain specialist. It can take you 2 or 3 to find one that really gets it for you. But, I would start working on that right now. 
     The nerve person, pain specialist, will have topicals, patches, oral meds, and other tricks. If you read some of my posts on "Complex Regional Pain Syndrome" you can get a feel for what that speciality has to offer. You will also read that is it important to be touching the area gently AMAP as long as it does not hurt to desensitize the area. 
     I am sure hope this starts pointing you in the right direction. You may have to have the metal removed, since that could be a source of irritation and only needed until the joint fuses at 12-15 weeks post surgery. Typically, they wait 1 year to let the area calm down after surgery before removing the hardware. Rich 

Hi Dr. Blake,

Thank you for writing me back. I never thought about visiting a pain specialist as the pain is bearable when sitting but once I step on my foot it sky rockets and doctors pretty much just cross me off the list and are unable to help me any longer.  I guess I dont understand why my foot is unfixable. My body has automatically compensated so I walk on the side of my foot. My physical therapist says its the weirdest thing. I can only do that barefoot or in flip flops though, but being barefoot hurts as well on the side all my weight is on. When I wear a shoe it no longer allows me to walk like that, which is why the doctor gave me orthotics but those still cause pain at the ball of my foot and arch. I seriously can't wear a shoe to walk, it hurts the worst! I know its bad to wear flip flops but it is the only way I can get around. I have done a dancer pad in the past ( first sesamoid injury) and it did not heal it. I can do one this time to see if it helps again. I did read about lipstick on the ball of my foot, I will try to do that as well. I do apply ice and apply heat, I do not feel it helps. It brings down the swelling temporarily but then when I walk it swells right back up. I have been using Voltaren gel 2-3 times a day and I am unsure if that helps either. I continue using it in hopes one day it will. 

Dr Blake's comment: Orthotic devices can be designed to put your weight on the outside of your foot with some inversion force. Many orthotic lab offer various techniques to start, and then the podiatrist/physical therapist has to do some in office tinkering. But, it can be done to get you into shoes. You can also invert/varus cant the outersole of a shoe to get your to the outside of your foot. This is so much better (for the next 4-6 months) than having you have to do it with gait changes and abnormal muscle contractions. Nothing will cure this in the short term. You need to use 8-10 things that each seem to make some difference. By putting them all together, you may get at least 50-60% better. 

To be more specific my most recent surgery in January was: Hallux Interphalangeal Joint Fusion with Screw Fixation with Jones Tenosuspension of the Left Foot.  She said I had first metatarsophalangeal joint capsulitis as well.  The pain is a lot worse after this surgery than with the first. I wish I would have never got it done!

Dr Blake's comment: I am so happy they did not fuse the big toe joint, best news you told me all day!!! The Jones tenosuspension I never see, so what did they do? Please make it as clear as you can. Even a copy of that paragraph from the op report. 

My MRI findings say: Postoperative changes. Moderate osteoarthritic changes and moderate disc space narrowing involving first metatarsophalangeal joint. Mild T-2 weighted increased signal involving the lateral sesamoid at the plantar aspect of the distal first metatarsal. Flexor Hallucis longus tenosynovitis. Fluid within distal flexor hallucis longus tendon sheath

Dr Blake's comment: Definitely want you to send me a disc of the MRI so I can see. Send to Dr Rich Blake 900 Hyde Street, San Francisco, California, 94109. Sounds like some arthritis in the big toe joint which has not been addressed yet, and maybe why you continue to hurt!!?? Hope??

The MRI is my most recent diagnosis. After that I was casted and now I am still in pain unable to bear weight if not it worse after casting which he thinks is from tearing the tendon now... Did I say this already? 

Dr Blake's comment: The MRI did not talk about torn tendons, so that is good. Alot of patients hurt so much worse after casting since the immobilization allows for stiffness, weakness, fluid retention, bone demineralization,etc. Get into the removable boot with accommodation and start putting some weight on it gradually. Massage as painlessly as possible, and as often as possible. You need protected weight bearing and mobilization, and anti-inflammatory for the next 4-6 months. 

I just realized I was backwards on my sesamoids-sorry- I had the medial removed and I still have my lateral?   I just know my outer seasmoid closest to the right foot was taken out and I still have my inner sesmoid closest to the left pinky. 

Any other advice? Does that added info help you any?

Have you seen improvement in ultrasound therapy or the electronic shock therapy? My doctor also mentioned a bone growth simulator, but thinks that is a 1-5 chance of working. 

Dr Blake's comment: These toys are all about timing, and it is really hard for me to assess that right now. 

I feel like I just need cushion at the ball of my foot, can they do implants or anything of that nature? I know, that may be a crazy thought. 

Dr Blake's comment: Have your doctor look at the Hannaford orthotic design on my blog, perhaps his lab can make something similiar. Dr Suzanne Levine in New York is injecting collagen for cushion into feet. She can advise if possible in your case. 

Did I read that you suggest wearing a boot for 2-3 years? Maybe I interpreted that wrong? 

Dr Blake's comment: The goal is to create a pain free environment and then gradually wean from it. If that requires a removable boot for 2-3 years, then that is what you do. Hopefully not, for that would rack havoc on the rest of your body. 

Also I can still move my big first big toe joint which is painful at the joint and ball of the foot. I have limited motion of that joint. When I move my big toe down my entire foot shakes.  My big toe is also up like a hitchhikers toe but not as drastic.  I have used a JAS system to regain motion but it really aggravates things and makes it worse as does Physical Therapy.

Dr Blake's comment: You really sound like some arthritis is in the joint causing a severe pain syndrome. The MRI will help me understand you better. You need to move the toe, but painlessly. Get small gains very week. Only a few physical therapists can do this. See my video on Self Mob for Hallux Limitus. Thanks for all your clarifications. 

Thank you for taking the time to read this.