Sesamoid Fracture: Email Advice

Dear Dr. Blake,

First, thank you so much for being available for patients and allowing patients to contact you with all their concerns. I feel so much at ease simply knowing the fact that I will be heard! 

Here's a brief history of my sesamoid injury.

Last year in May 2012, I had missed a step while climbing up a staircase and because of that I hit my right foot on the edge of this sharp step. However, that entire day I walked around bearing the pain and only a day later I found out about the fracture on my sesamoid bone. Photo-1 (attached) shows my fracture.

The fracture line is clearly seen in the medial or tibial sesamoid. 

 My doctor asked me to take care and wear good shoes and also gave me some oral medication. I went regularly..And by August 2012, he said I am all good now since I experienced no more pain on the area under my foot.

So I got back to wearing slippers, trendy sandals n high-heeled shoes, walking barefoot at home, gym-ing, running etc. However, there were sometimes when I noticed some discomfort but it didn't last too long and so I forgot all about it.

It was only two days back (Sept-2013, a year later) that I noticed some weird pain and I got concerned since its been a year and I still notice discomfort there. So i got an Xray done (Attached: Photo-2) and I was taken aback when I saw that the sesamoid bone is in two separate pieces now. I went to the same doctor and he said he'd have to put me on a 3-week medication (since i'm leaving for a trip next tuesday) and he said we'll check how you are once you get back. Else we'll have to get it operated (removed).

Here the sesamoid fracture appears widened. The first and second x rays are 15 months or so apart and there has been relatively little pain in this. 

-

Now Dr. Blake, I'm concerned. I don't feel good knowing the fact that I'm going to be walking around with a broken bone in my foot. What do i do? Can the bone ever get healed without having to remove it? And am i placed with a certain level of disability for life?

Please give me your advise on this since I'm leaving on a trip as well and I'd be exploring places on foot! Now I'm very worried about having a fun trip and a walk-stress-free life ahead!

Awaiting your reply.

Thanks and kind regards,

Paula (name changed)

Dr Blake's comments:

     First of all, x rays are the worse form of followup on these problems. The bone can look irregular due to increased water content across the fracture, but internally can be really solid. So, relax for now. If you read all my blog posts on sesamoid injuries you will realize you have a lot you can do to help your self. Here are my suggestions to work on over the next 4 months. 

#1 Get a baseline MRI
#2 Make sure bone density is good
#3 Make sure Vit D3 levels are good
#4 Make sure your diet is good with daily 1500 mg Calcium and 1000 units VitD
#5 Ice pack bottom of foot for 15 minutes once daily and also as needed
#6. Learn to spica tape of increased activities
#7 Learn to make dancer's pads to off weight the sesamoids even in heels
#8 Have custom orthotics designed to off weight the area
#9 Use common sense in avoiding activities you know will bother you. 

I hope this helps you get moving in the right direction. Do not be concerned over your new x ray for it does not tell how strong the bone actually is. Rich

The Patient's initial response:

Thank you so much, Dr. Blake!

Your responses have helped me understand my situation better! In fact I feel a lot better, too. I will keep all those points in check. As of this Tuesday, I'm leaving for Europe and I plan to get myself good shoes first and get regular with all the other points.

Thank you again!

Much regards,

Nerve Pain: Email Advice

Hi Dr. Blake,

I have been following your posts for months now.  Hope you can help in even giving me direction and whether seeing you or a different kind of doc would be best next step.

Out of the blue in Jan., I noticed a constant nagging sensation like my sock was uneven on bottom of left foot/big toe and irritating it.  When I took off sock, the foot was bright red, swollen and painful to touch esp. in the metatarsal area and more so on middle joint of big toe.  There also seem to be a lump on that joint and when I even lightly touched it, would send a radiating pain up my leg, into my back and up the right side into my neck.
Dr Blake's comment: You are talking about the femoral nerve which has a branch to the big toe and can radiate like that. I am assuming that something from that joint irritated the nerve causing the nervous system breakdown. 

And once the pain was activated, my entire central nervous system went into hyper gear and it was impossible for me to bring it down -- with many different supplements, topicals, even meditation, etc.  The other piece that went hand in hand were areas on ball of foot and around the big and second toe that were blue and even pieces of vein protruding that were the most painful areas.
Dr Blake's comment: This is sounding like RSD, which stands for Reflex Sympathetic Dystrophy.

Most of the acute symptoms have improved or disappeared since then although still some lingering issues that prevent me from going on a walk or doing even simple activities.
Dr Blake's comment: Sounds like you managed to create a nice pain free healing environment that is so important when the nervous system is barking soooo much!!

Since Jan. I have gone to a couple of different chiropractors who not only use activator, they also use techniques to break down fascia issues.  One thought that the major issue on big toe might have been capsulitis which also might be putting pressure on nerve.  I also went to osteopath.  He thought it was bursitis on big toe creating all the problems.  Also went to 2 different individuals that specialize in chiropractor neurology.  Their exam showed that the constant radiating pain had to do with pain center in brain not shutting off pain signals and my central nervous system had a hard time shifting to parasympathetic system.  Also X-ray of foot and back where taken.  No fractures in foot.  I have spinal stenosis I believe at L4/5 which I understand can trigger pain in first/second toe(???).  Also I do have a flat arch in the problem (left) foot.
Dr Blake's comment: This is helping with the whole picture. The L4 nerve root goes to the big toe. If this nerve is irritated at the back, and then irritated at the foot, a "double crush syndrome" occurs and the nervous system is very unhappy.

Practicing natural healing for decades, I have also done lots of remedies -- including vit. c, msm, an anti-inflammatory supplement with proteolitic enzymes, vit. B, B12, lion's man (medicinal mushroom for regrowing nerves), calc/mag + magnesium chloride (liquid and gel), comfrey compresses, castor oil compresses and the list goes on. I have also worked with feldenkrais practitioner and also try to stretch when id does not aggravate pain.
Dr Blake's comment: Neural Flossing or Gliding is great and relatively new to physical therapy world. It is a gentle way to stretch the involved nerves, not allowing scar tissue or swelling to collect around them. On my blog I have a video of one sciatic nerve flossing technique. 

Since Jan. I have not been able to use my customized orthotics, as areas where raised, trigger pain so I have gotten a cushy "not customized" orthotic from Walking Shoe Company that molds to foot and provides arch support.  That seems to work for now and does not trigger pain.
Dr Blake's comment: This a great idea, you have to remove any abnormal nerve stimulation.

I tried walking about 12 min. on dirt on Sunday (first time I tried to go for short walk) and couples of hours later I felt increased pain sensitivity.  Not unbearable,  rather a reminder something is still going on and simple activities still problematic. In Jan. pain level and intensity were probably a solid 10. now about 2-3 as long as I keep walking to minimum and not engage any other activities to aggravate it.

Sorry about long email.  Final comment .... being self employed, I have a very high deductible which essential means all of my medical expenses are paid out of my pocket.  Unfortunately, that piece does enter the equation of what I can do.

Thanks,
Deb (name changed)

Dear Deb,

     Thank you so very much for the email. You sound like you are at where one of my patients is right now: Wanting to remove the source since it could trigger it all over again. I do not blame you. You may have to save up your money so when you feel free to spend through your deductible (next year???) you can get the MRI or CT scan to identify the lump in your foot, and treat it. At the same time, you need to work on your back to get that as stable as possible (less chance irritating the L4 nerve root. All this can easily max a high deductible quickly, leaving 11 months to have the insurance doing the rest of the paying. I am so proud of how you dealt with the initial flare of RSD. Please send me 5-10 bullet points on the key things you felt were crucial getting this to 0-2 pain. Rich

Orthotic Designs: Vertical Heel Correction Variations

I am working on a lecture for podiatrists on the cast corrections of a patient that you want the heel to be placed at a vertical position. The orthotic laboratory will be given instructions on the amount of correction to be placed in the forefoot, midfoot and heel. This image is meant to start a conversation. These are the standard corrections I perform in making my orthotic devices on a weekly basis. My goal is to gradually teach the purpose for these, when to use, when to combine techniques. 

Removable Boots and EvenUps: Email Advice

Dear Dr. Blake,

I saw the image of one of your braces on line and wanted to write you about my mother.  She's 75 and has had RA since she was 40; she's 5'8" and weighs 140lbs.  Last year she had a stress fracture in her right heel and had to wear a knee-high brace for three months; this threw her back out of whack and she incurred a compression fracture in one vertebrae due to the different heights of the walking shoe and the boot.  

Having finally recovered from that injury and started an exercise and weight-lifting program (very gentle and minimal), she is now facing another stress fracture in her left heel.  Does she have any other options than the full-height boot?

Thank you for any information you have,

Dr Blake's comment: Thanks for the email. The older the patient, the harder the higher boots are to wear and not cause problems. She should try the lower to the ground, and more natural moving, cam walker from Ovation Medical. Also, she should have an EvenUp on the other side. I hope this helps her. Rich

http://www.braceshop.com/ovation-medical-pneumatic-short-walker.htm?gclid=CMqLoIunvbkCFaNxQgodUEMA0w

http://www.evenupcorp.com/

Analyzing the Mechanics of an Injury

When analyzing how an injury occurs in most overuse injuries, a podiatrist will look at gait, muscle and tendon issues, and the specifics of an injury. 

9/11 Tribute: The Great Boat Lift

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