Big Toe Joint Injury with Hallux Rigidus: Email Advice

Dear Dr Blake

I am emailing to say thanks so much for your blog - it is the clearest, most thorough and most practical site I've come across in all my web searching and I really appreciate it.

I can only imagine how busy you are already answering all the questions on your blog, but I'm also emailing to ask if you could possibly give me some advice.  I have had pain in the ball of my foot for the last 5 1/2 months. At first it was intermittent pain, which felt like a stone bruise under the ball of my foot, but gradually it became more persistent and more painful. Now it is painful all the time and feels like a hot needle in the joint.  Originally I was walking to and from work each day, but had to reduce the amount of walking I was doing, and then reduce it again, and then stop altogether. Despite this, the pain continued to get worse.

It has taken 5 months of various misdiagnoses and so incorrect treatment before I finally got an MRI and was diagnosed with grade 4 osteoarthritis of the lateral sesamoid-metatarsal, with cartilage loss, bone marrow oedema and some osteophyte formation.  (The exact wording of the MRI report is "There is a bone marrow oedema pattern elicited from the lateral sesamoid.  There is no sesamoid fracture or osteonecrosis.  There is lateral sesamoid metatarsal osteoarthritis, with high-grade partial thickness cartilage loss over both sides of the joint and focal exposed bone laterally.  Marginal osteophytes arise off the lateral sesamoid-metartarsal articulation. There is degeneration of the lateral sesamoidal phalangeal ligament which is hyperintense but is not torn.... There is a moderate reactive joint effusion at the MP joint.  Mild reactive bone marrow oedema patter is elicited from the central plantar aspect of the metatarsal head.")
Dr Blake's comment: Okay, you have Hallux Limitus Rigidus/Limitus with degenerative arthritis in the big toe joint. The pain you get is that the joint between the lateral sesamoid and first metatarsal head is inflamed, and everytime you put pressure on the lateral sesamoid it pushes against the sore inflamed first metatarsal head. 

I know you've already answered some questions on sesamoids, all of which I've read, and that has been really helpful.  However, I still am at a loss as to how I should proceed with my own sesamoid problem, and I have received a lot of clearly conflicting (at at times plain wrong) advice so far.
Dr Blake's comment: First of all, you have had this process for years slowly developing, so why does it start hurting now? You can take 2 approaches: remove the lateral sesamoid (not my first choice but probably helpful), or go 3 months in a removable boot with off loading padding and bone stimulator to see if that really calms the joint down. Following the 3 months of boot is a 3 month weaning process off the boot developing protective weight bearing orthotics, shoe selection issues, and foot re-strengthening.

Since my diagnosis I have been frantically googling to try to find out more, but most of what I read is about stress fracture (rather than chronic inflammation).  What I have read online about sesamoiditis is about the tibial sesamoid, with very little written about the lateral sesamoid.

I'm really surprised by the diagnosis because I'm only 45 and I don't fall into any of the usual risk groups - i.e. I've never had an injury to the foot, I never wear high heels, I've got no family history of arthritis, I've never been overweight, I've never had a job where I had to carry heavy loads, and I've never been an athlete and have never been a jogger or done any high impact sports.  I don't have lupus, and I've only got this in one joint, so I understand that means I don't have rheumatoid arthritis.
Dr Blake's comment: Unfortunately, simple mechanical issues like a long first metatarsal and big toe, and/or over pronation can slowly breakdown the joint (along with other issues). The process could have started 30 years ago, and been quite glacial in developing. Do you have a toe first toe? Do you over pronate? How is you bone density and Vit D levels? 

The orthopaedic surgeon I saw said that what I had was extremely difficult to treat, that surgery was not an option he would recommend (or do), and suggested an orthotic cut out.

He referred me on to get a steroid injection, which I'm getting in two days time. He seemed a little non-plussed when I asked him about follow up, and when pushed, suggested I see him again in three month's time.  I've decided I need to rest my foot more to give the cortisone injections the best chance of success so I've arranged for one and half weeks off work after my steroid injections this week, and I've arranged non-teaching duties for the next half a week after that.
Dr Blake's comment: Please avoid the cortisone, unless it is short acting. The long acting can make you feel great for 9 months while you are continuing to do damage. At least think it through as well as you can. I tend to recommend cortisone shots in these situations when surgery is the only other option. I personally think you have many options. 

The orthopaedic surgeon said that there is no exercise I can do that will make it better or worse - I find this hard to believe as although I understand that osteoarthritis is a long term degenerative condition, in my experience there is always some kind of exercise that can have a good or bad effect.  I'm contemplating seeing a sports medicine doctor for a second opinion in the hope that someone like that would be more interested in rehabilitation options.
Dr Blake's comment: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). 

So, what makes the pain worse are standing, walking and balance exercises.
Dr Blake's comment: You need to develop orthotics that off load enough to allow for standing and flat foot walking. You can balance in the middle of books arranged where their is a hole for the big toe joint to sit in to off weight. You really need to be placed in the Immobilization phase however for right now. If you use an Anklizer boot with float to off weight and then ice pack 20 minutes 3-4 times a day to bring the inflammation down. 

And what I've tried so far in terms of treatment:

Foot exercises (toe spread, metatarsal lift, theraband around toe) - but these made it worse, especially the theraband, so I stopped.
Dr Blake's comment: This is because you are in the Immobilization/Anti-Inflammatory Phase of Rehabilitation. These exercises will be great 4-5 months from now. 

Calf muscle release - didn't seem to make any difference so I stopped.

Anti-inflammatories (causing stomach problems but I'm persevering) and fish oil
Dr Blake's comments: I would save the pills, and go to direct icing, and perhaps once a day contrast bathing with one minute heat/one minute ice repeated for 20 minutes. It may be too early however for any heat. 

Cushioning - originally metatarsal pad (given to me by podiatrist), then a metatarsal pad that I cut a hole in for the sesamoid, but now after online research, I've fashioned a type of dancer's pad made of 1/4 inch foam.
Dr Blake's comment: Great, I love my dancer's pads!!!!

Arch support - through taping and through a store bought with arch support.  Have since been told (by orthopaedic surgeon) not to bother with arch support.
Dr Blake's comment: I love the red Sole insert which is in stores all over (like REI). You can adjust them endlessly since there is no plastic. Sometimes, a shoe repair store, which their handy dandy grinders can help if you need to remove an edge. The role of the arch support is two fold--shift weight into the arch and shift movement towards the center of your foot if you pronate as you roll through your foot into push off. 

Toe taping - I'm also now taping my big toe to restrict upward movement.
Dr Blake's comment: Yes, I love Spica taping!!!

Icing - Generally my foot hasn't looked obviously red or puffy but I've been icing it one to two times a day.  However, I went back to one of the many physios I've seen last week and he noted that the tendon area looked puffy.
Dr Blake's comment: Ice, ice and ice. At least with icing you can multi task. You can ice the bottom of your foot while brushing your teeth, checking emails, eating breakfast lunch and dinner. 5 minutes minimum and 20 minutes maximum. 

Cam boot - At no stage has any of the physios, podiatrist, doctor or orthopaedic surgeon suggested immoblisation of my foot (despite the problem previously being misdiagnosed as a stress fracture).  However, I've decided to give immobilizing it a try, and have rented a cam boot which I've been wearing (with my foam dancer's pad and toe taping) for the last 5 days.
Dr Blake's comment: Yes, minimum of 3 months!!!! 

Up until this point, I've been continuing to go to work, and to my weekly pilates class, but I have cut out all other exercise except that which I can do at home on a mat.
Dr Blake's comment: You need to create a pain free environment. Try to keep the pain level between 0-2, no matter what you are doing. 

I've asked my usual physio to help me put together an exercise programme for the future that replaces the daily walking I used to do with something else, but think for the short term I really need to stop using my foot. This is a problem for me as I have nerve pain down my back that I usually manage through various forms of exercise, the main one being walking (and making sure I don't spend too much time seated). I also have a job where I'm on my feet a lot (teaching).
Dr Blake's comment: Make sure you purchase an EvenUp for the side that does not have the boot. It will help protect your back. 

So my questions are:

I've read that usually you only immobilise a fracture or break, but is it ok for me to use the cam walker? Yes
And if so, for how long? 3-6 months really, but we can talk when you have been 1 month straight in the removable boot and 0-2 pain level has been maintained. 
 Up till my steroid injection? And after my steroid injection? Please delay thoughts of cortisone for now, unless it is only short acting, but I would ice for a month first and wear the boot and see how the inflammation goes down. 
What is usual follow up after steroid injections into a joint - the orthopaedic surgeon said to see him in three months, but shouldn't I have a follow up appointment sooner than that? Isn't it common to need more than one steroid injection?
Do you have any recommended rehab exercises I should do after the injection?
What's the best shoe for someone with my problem? Are rocker type shoes worth the money? Is a stiff soled shoe the best, or a more cushioned type shoe better? Typically you go from removable boot to stiff soled shoe like a Hike and Bike or New Balance 928. While you are in the boot, you are getting a bone stimulator (Exogen) and getting your orthotics perfected with the right arch support and right amount of dancer's padding. 
Why is the lateral sesamoid less commonly a problem than the other sesamoid? Supposedly it bears less weight than the tibial, especially when you pronate or if you have any amount of bunion. Both off weight the lateral or fibular sesamoid and load more the tibial sesamoid. 
 Does this make it harder to treat?  Does this have any implications for treatment? Yes, but not really. Subtle padding issues, surgeons more prone to just remove. I think you have more Hallux Rigidus symptoms right now, and less sesamoid technically. The sesamoid and lateral first metatarsal head cartilage issues means a bone stimulator is crucial. 
Why have I got this and will it continue to get worse? Sounds degenerative which is somewhat luck of the draw. For me it is my back, another the hips, another the ankle, etc. Yes, but learning to live with a problem like this is what sports medicine is all about. Do not feel alone, the world is with you!! And one of my Golden Rules of Foot: Teach the patient, not the imaging results. Another Golden Rule of Foot: Listen to your Body and let it help you create a healing environment. 

(I know you probably can't answer that, but it is really playing on my mind!).  I'm very worried about the long term prognosis for my foot because I'm quite shocked at how quickly it has deteriorated. The pain came on quickly, called a flareup (your first one, which is also the most disconcerting one!!), but the process is very slow in general. You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!

As I said before, I'm sure you are very busy, but if you can shed any light at all on any of the above, I would really, really appreciate it.

Kind regards

Cindy (name changed)

Dr Blake's comment: I hope my above comments start you towards healing, but you sound like you are already figuring it out. Rich

Here is the patient's response to this post:

Dear Doctor Blake

Thanks very much for taking the time to answer my email.  I'm going to do some reading up about Hallux Rigidus, as suggested.  And don't apologise for disagreeing with previous advice about the steroid injections - I know everyone has a different take and in the end I will have to make my own decision.  My GP has, like you, said that I’ve probably had arthritis for a long time, but only noticed it because it got inflamed and didn’t settle down. She seems to think if I can calm the inflammation down, it should improve, so she's supported the idea of the injections, but honestly, I not sure what I'm going to do.

Dr Blake's comment: You can also consider an 8 day Prednisone (oral cortisone) Burst or 5 PT visits using topical cortisone with Iontophoresis. 

  I think she's probably influenced (as I'm sure I am) by the fact that I need to keep active to manage the other ongoing muscular skeletal problems I have. I am tempted to do the injections and do the immobilisation and all the icing, contrast baths, supplements etc that I can, basically blitz it with everything I can.  Anyway, I've ordered an 'evenup' and am going to keep going with my gut (and your advice!!!) in the meantime and keep on immobilising my foot.  I'm interested in the EXOGON device you recommend - I read about this in a post on your blog from another person in Australia (that's where I live), and he mentioned renting one.  I'm going to investigate it further.   How long do people use these for - is it for long term maintenance of joint cartilage or just for acute stages? 

Dr Blake's comment: It is for the next 9 months to see if the cartilage under the first metatarsal head and the injured sesamoid can strengthen themselves.

In regard to your questions: . Do you have a long first toe? .Do you over pronate? How is you bone density and Vit D levels? No other problems with any other toes.  No real biomechanical problems (according to a couple of podiatrists in the past about other issues), bone density fine (got it checked after I was initially told my foot problems was a stress fracture) and I'm guessing my Vit D levels are fine as I live in a sunny place!

When you said: Sure, you want to avoid exercises that emphasize bending the toe at push off, but elliptical and cycling, and swimming can normally be done safely (perhaps with a slight modification). does that mean after 1-3 months in a boot, or during the same period?  One physio has suggested to me deep water walking as a possible exercise.  Does that sound like too much foot bending to you?  (She's suggested it because I can't do much bike riding because of knee problem - bout 10 minutes is tops, and can't swim because of shoulder problem - yep, I'm a complicated case ) 

Dr Blake's comment: There are 3 phases of Injury Rehabilitation--Immobilization, Re-Strengthening, and Return to Activity. You definitely need to be in the Immobilization Phase. The Removable Boot and Anti-Inflammatory measures should really calm your foot down. However, some foot strengthening and some cardio/core workouts are not only fine but crucial to a faster rehabilitation. You have to see the post entitled Good vs Bad Pain and memorize it. Keep the pain level between 0-2. Swim in the deep end of the pool if you can control the pain level, cycle 100 miles if the shoe or pedal position can be modified to avoid irritating the area consistently. 

 And finally, in response to your comment: You will learn this next year how to minimize the time of flareups, what activities pick on it the most (I purposely gave up golf with my back due to the torque, but have been able to play full court basketball with no problem), develop a relationship with a good orthotic maker, begin a lifetime of foot strengthening exercises, learn to select shoes that you do not pronate into, etc etc. A bunch of learning!!  Yes, I know what you mean, it is a life long project.  Unfotunately at times it feels like learning to adapt and compromise is neverending as I already have learned to manage chronic pain from ongoing back and shoulder problems.

Thanks very much for your advice and words of support in your reply on your blog.

Kind regards

Big Toe Swelling: Email Advice

Dear Dr Blake, 

     My big toe on my right foot is very swollen. It is about twice the size of a regular big toe. The swollen part is very warm, and very painful if I touch it .I can't wear a shoe on my right foot, it is very painful to even try to put a sock on my right foot. My toe and foot have been this way for over 2 weeks now. I'm still unable to wear a shoe. I can wear one of my husband's big socks. I do try to walk on my foot during the day, but the pain on the bottom and left side of my right foot is sometimes too painful to even try. I haven't been to a doctor, yet.....just like other people in  the USA, it's a money problem. I'm not asking for a 'hand out' or anything, like that. I would just like to know what's going on with my foot. Thanking u in advance for any help I can get from u for the diagnosis of my toe.

Regards,
Mari (name changed)

Dear Mari, 

     Pain and swelling in the big toe area is infection or gout until proven otherwise. There are also other more rare causes like fractures and sprains, but you would have had to know you did something to cause that. Please email back with answers to these questions:

1. Do you see any sign of an ingrown toenail that got infected? Did you cut your nails 4-5 days before the onset of pain? 
2. Do you have any infections in your body at this time or at the time of onset? Respiratory, urinary tract, etc.
3. Can you send a photo of both big toes?
4. Do you have any systemic signs of infection like fever, malaise, chills, or painful areas above your foot?
5. If you read about what causes gout dietary wise, is your diet high in purines? (see my post on foods that increase the chance of gout)
6. Do you tend to stay hydrated or not?
7. Is there a family history of gout or another systemic disease?
8. Could you have been exposed cold somehow?
9. How is your overall circulation in your feet and extremities?
10. Did anything happen in the 3-4 days prior to the onset of swelling like dropping something on your toe or starting a new exercise program or changing shoes?
11. Send me a close up on the nail itself please. 
12. What medications are you on for some can cause gout?

Hope this information gets us moving in the right direction. Rich

Multiple Problems: Email Advice

     I badly require some advice... Am located in Paris, France. Am 70 yrs of age and have multiple problems: hyper-laxity (Ehler-Danlos), cervical and lumbar stensosis, arthritis i=now in just about ever joint, jaw issues etc... I used to be sporty and highly active; some 5-6 yrs ago an accident and then immoblization and then don't ask. I have changed 20 podiatrists and even more insoles! My ankles and feet are now ruined. I am told that I may have to resort to shoes ofr diabetics !! I am not diabetic.

     Anyhow, would you know of a proprer well-trained podiatrist in Paris whom you could recommend? Failing this, perhaps we could have a more detailed chat? Amidst other thngs, my toes are so lax and weakened (sesmois atrophy and more) that I can give no push whatsoever off of them. And there is MUCH pain in toe and achilles tendons as well as "front enterior" tendohn... Let me know, though my explanation is more than partial and incomplete... THe result of all of this: beginngs if cervicak myelopathy and aching limbs and neuropathy and by now, alas! - 2 years of almost no movement (whereas I used to hime every Sunday from Paruis to Versaillesfrom the heart for any and all input.

Regards,
M

Dr Blake's comment:

     Hey M, I am so sorry for your problem. I do not know how to find someone in Paris for you, but you need a physio and physical med doc (we can them Psychiatrists here in the States). Definitely immobilization and rest, which may give temporary help to a sore area, will cause terrible de-conditioning of the muscles/tendons. With Ehler-Danlos, and other ligament problems, the muscles and tendons are vital to stabilize the joints and their weakening is what has put you somewhat in your dilemma. But, in that concept, is hope for the future. You need to understand when to honor the pain and when to push through the pain. It is a fine line that can change daily. But, moving the joints is the simplest form of strengthening, and then gradually adding resistance and other methods of making the exercises harder. I know some of our ED patients benefit greatly from prolotherapy (sugar water injections into the soft ligaments to tighten them up). The role of foot orthotics and shoes is to allow you to walk more, the basis of health. Walking is the foundation of you regaining your health, and even 1 minute 3 times a day can start you moving in the right direction. When you have multiple problems, you need to know clearly what you can push through, how to treat an area if you flare it up, and when you need to do something else. Can you share your benchmarks now? These are what you do 1, 2, 3 times per day both in exercises and activities. Hope this begins our discussion. Rich

M's response:

Thanks for your response.
Believe me, I push through so much pain that all it causes is MORE intense pain.
Two days ago I walked for 40 mns and from noon on onwards could no longer stand let alone walk. Yesterday, I did another 30 minutes, but to what avail?
The "nerve" pain is horrific and by now every joint from shoulders to ankles = arthritic and more.
Am scheduled for an MRI this pm for the "dorsal spine"; the cervical MRI revealed C5-C6 compression (myelopathy) and more.
So wish I had some orthotics I could imagine using... Out of my 30 odd pairs (!!) - it's a mess.
Will keep you posted to te best of my abilities and thanks for your aimiable assistance and prompt reply.
What a sad way to end after havinbg lead a "rich" life!
Best from
M

Dr Blake's comment:
     Nerve pain is true suffering M, and I am sorry. Even neural tension for your cervical area (neck), can lead to nerve hypersensitivity in the feet making it difficult to walk. Since Calmare Pain Therapy was invented in Europe, hopefully an opinion from them would be helpful. It works on the nerve pain only, but may help with the pain that is neuropathic in origin (typically the worse for us humans to deal with). Please see the links in my blog and other discussions of nerve pain treatment. Rich

Stand Up Testing: A Key to Longevity??

I am not sure if I want to live to 100, but I do want the end to be as graceful as possible. I realize I must do my part (it is only taken my 60 years to sort of figure that out!!) in easing the end. Take the advice of this article and exercise more, the benefits are more significant than you probably realize. 

http://health.yahoo.net/experts/dayinhealth/weird-test-predicts-longevity

Inverted Orthotic Technique: Email Advice

Hi Dr. Blake! 

     I am a Certified Pedorthist out of Fort Worth, Texas. I have the opportunity to 
speak to resident podiatrists/physical therapists regarding foot orthotics. I am 

writing to inqure about how I can present your technique for the inverted orthotics. 
What I am in the dark about is who qualifies for these orthoses?

Dr Blake's comment: Thank you so very much for inquiring. Most podiatrists will use it when their initial orthotic device does not bring about the symptom relief and the pronation control combined. When the patient is still pronating on the device originally made, the Inverted Technique may help. Typically, most orthotics designed set the heel vertical to slightly (1-2 degrees) inverted. A standard 25 degree Inverted Correction gives the heel about 5 degrees of correction, thus over 150-200% more support. Someone like you, and the students you teach, will begin to see patients that need the technique right from the get-go. Many patients with moderate to severe pronation are started at 35 degrees, equivalent to a 7 degree inversion correction. Runners, who typically needed 5 degrees correction (25 degree cant) in their stability shoes, now need 35 degrees cant in their neutral/transition/minimalist shoes since the shoes give less support for pronation. However, pronation control is not the only reason to use the Inverted Technique. The varus positioning you get with the Inverted Technique helps many patients with frontal plane problems like Tibial Varum and Genu Valgum. 

 What conditions are indicated and which are contraindications? 
     I understand the simple rigid vs. flexible deformity, but which diagnoses have you come 
across that can benefit from this, apart from PTTD, unless that's the only one? 

Dr Blake's comment: It is really an understanding of pain syndromes that lead you to know about what matches up. When you watch someone walk, you typically can tell if their pronation is mild, moderate, or severe. The Inverted Technique, which ranges from 15 degree cant to 50 degree canting with medial column corrections and medial Kirby Skives, is for the moderate to severe pronators. And these pronators get into problems in many ways affecting the weakest link in the chain. What problems are related to pronation that I treat (you may ask?!! LOL)?

1. Bunions are increased with over pronation
2. Hallux Limitus/Rigidus pain is increased with over pronation
3. Morton's Neuromas symptoms are worse with pronation
4. Arch Strain is worse with over pronation
5. Lisfranc's pain is worse with over pronation
6. Cuboid pain, and instability, is worse with over pronation
7. Anterior Tibial tendinitis, and shin splints, are worse with over pronation
8. Plantar Fasciitis is worse with over pronation
9. Lateral ankle and subtalar joint (sinus tarsi syndrome) impringement syndromes are worse with over pronation
10. Achilles Tendinitis and Hamstring strains are worse with over pronation
11. Tibial Stress Syndrome and Fibular Stress Fractures are sometimes related to over pronation
12. Iliotibial Band Syndrome is sometimes related to over pronation
13. Lateral Knee Compartment pain is sometimes related to over pronation
14. Chondromalacia Patellae is sometimes related to over pronation
15. Piriformis Syndrome and Ilio psoas strain can be related to over pronation
16. Some cases of Low Back Pain are related to overpronation

The contra-indications to this technique are two fold. Most patients do not need it, because they have mild pronation, or are supinators, or poor shock absorbers, or their symptoms are related to limb length discrepancies. But, secondly, a contra-indication has to be the ability for the lab to design it properly. I have reviewed at least 10 labs, and most can learn, or do it well. But some, just do not get it. They typically make a painful over-exaggerated arch which hurts. When done correctly, the Inverted Technique, which emphasized heel correction over arch correction, is very comfortable. 

Also, is there a chart maybe that could show the different correction angles compared to the 
eversion angles that you find or is it all the 5 to 1 rule?
Dr Blake's comment: If you understand the eversion angles, and your measurement of 0-3 degrees everted is mild pronation in gait, 4-7 degrees everted is moderate pronation in gait, and over 7 degrees severe pronation in gait, we probably measure the same and the 5 to 1 is appropriate. I will try to do a series of videos on it soon explaining the various anti-pronation cast corrections.  

You can see all the cast corrections for the over pronators

     Is there a rule about the arch height change other than to make sure it begins to make its descent distal to the 

medial cuneiform for the first ray drop? That is, do you increase the arch or measure it pre-modification and add to/take away from any of that height? 
Dr Blake's comment: I am attaching a couple of posts on arch height. The arch height gradually gets bigger with increasing inversions, or adding a medial column correction, but a 15 degree inverted cast probably has the same arch height as a Root Balanced with minimal arch fill. You will see in my cast corrections video over the next couple of weeks how the arch gets higher. I will try to do that video for you first. You hit the nail on the head perfectly by saying that the most important thing is to make sure the maximal arch height is at the medial cuneiform to insure first metatarsal plantar flexion in propulsion. 

http://www.drblakeshealingsole.com/2010/09/inverted-orthotic-technique-determining.html


If there is a clear/ to the point document that I could show them, that would be great. Otherwise, I'll direct 
them to your blog. By the way, I am becoming a fan of the technique as I just recently had 
a patient with severe PTTD who has not been comfortable in anything (Richie style, Arizona 
gauntlets, UCBLs etc.). I made him some orthotics using your technique, along with the 
use of work boots to give extra stability, and he loves them!  Sorry for so many questions, 
but I was so excited from seeing the outcomes in that patient that I want to spread the word 
about this in an accurate/appropriate way. 
Thank you sir! 
Dr Blake's comment: I am just ecstatic it helped. Most of the readers will not know how uncomfortable, or just big, these other devices are. Being able to take a patient that most who put in a AFO, Arizona Gauntlet or UCBL, and make an Inverted Orthotic device work, is a wonderful gift to that patient. The Inverted technique also allows the most normal function of all those techniques, thus the best chance for good strength to be re-established. 

Posterior Tibial Tendinitis with Accessory Navicular: Email Advice

Dear Dr. Blake,

     I have been following your site for a few months now and I am blown away by your kindness and generosity in answering the questions of strangers. It is an amazing blessing that you are giving to others and the sense of hope I have received from some of your entries is enormous.  I also read that you recently lost some people who are close to you and I wanted you to know that I'll be keeping you and your family in my prayers.  I was touched by the video you posted on June 1st and will certainly forward it to others.

Although I'm in Boston and can't come to CA to see you, I would be happy to pay you for email advice, so just let me know what your policy is. I would also be happy to send payment along with copies of x-rays, MRIs, etc. if you think it is necessary. I spent a few days writing and editing this to keep it concise and "calm" so I don't come off as a crazy patient! Although we distance runners ARE a bit crazy :) 

Dr Blake's comment: I can not thank you enough for your kind words. I have never charged for this service, but hope it is worth more than what you pay. I have to deal with crazy runners all the time, and because I am a crazy basketball player/athlete, we tend to get along just fine. I am needing time to review another patient's scans that she sent (sorry Sue, but I am slowly getting to yours), so I may not be able to review for a while. You can definitely send.  

     I am a 26 year old female runner - I absolutely love running half and full marathons, and this fall ran a full marathon that made my dream come true- qualifying for the 2015 Boston marathon. I have had no foot pain in my past 10 years of running about 35-40 miles a week, every week, except for some mild pain when I was about 16  which led me to get custom orthotics (they have been great for over a decade with zero signs of pain! BUT I've been wearing the same running orthotics for over a decade). Through my career I've had some minor problems that always resolved quickly with PT and cross-training (knee, hip), but never anything in my foot. I did once have a really bad sprain in my right ankle (not my currently affected side) that took over 6 months to heal. I do over-pronate and have somewhat low arches, but I'm certainly not flat-footed. I am petite at 5'2" and 103 lbs. (so I don't think I have much extra mass that is causing problems). 

     Mid-April while training for another marathon, I started getting some tightness/soreness in my left inner arch. I did a lot of icing, took days off of running here and there, but continued to train. I successfully ran my 20 mile training run on April 18th with some tightness, but not really pain. On April 25th, I took a short 4 miler and had a moment of sharp pain near my navicular, and limped the last 1/4 mile home. I put myself on a running hiatus for a full week. On the 8th day, I decided to "test" running again to determine if I needed to call off the marathon and cancel my travel and hotel. I successfully ran 10 miles with zero pain. However, that night my foot was stiff and sore.  Since then, I have not run a single mile - 40 days so far. Obviously I chose to sit out the marathon.  I wanted to be very cautious and not make my recovery any longer than it needed to be which is why I stopped running completely.

     The pain in mid April- early May was initially  at the accessory navicular, although I didn't know what that was at the time. I could produce pain when I pressed anywhere on it, with stiffness more generally around the arch. Further down in the email I'll give an update on where the pain is now. At no point did I have severe pain - I don't think it ever went beyond a 3 on the 1-10 scale. 

      I have iced in an ice bucket 2-3 times a day all 40 of those days that I have not run, and I have been cross-training with zero pain (bike, elliptical, etc.). Like many athletes,  I tend to run through A LOT of pain (including a stress fracture once!), but something in my heart and mind told me to STOP when it came to this particular injury. My heart is broken without running, although I'm trying to keep it in perspective. Lots of prayer!!  It has been emotional but I am grateful that I can at least cross-train but I'm living in fear of "will this ever heal?"

     I am a researcher by training, so of course I got onto PubMed and downloaded every medical journal article I could find. I diagnosed myself (haha) with an accessory navicular and posterior tibial tendonitis. 

     I saw a general sports doctor at Prominent Boston Hospital #1 in early May (omitting name out of respect for the doctor/hospital) who was largely dismissive of my injury and seemed totally un-sympathetic, but he told me my self-diagnosis was totally correct after looking at the x-rays (PTT and accessory navicular). He tested my feet and said my foot muscles were super weak so PT would be helpful. I had to basically get on my knees to BEG him for an MRI, because I knew I couldn't sleep until I got it. I had been making myself sick with worry.  He was frustrated with me but finally prescribed one (I was in tears at that point).

     I then saw a foot and ankle surgeon at Prominent Boston Hospital #2 yesterday, June 4th, 2014, who was kind, sympathetic, and seemed encouraging. He thought that it might be time for new orthotics since I've run in mine for so long, and having ones with a medial post would help with my overpronation, rather than only supporting the arch with a wedge. He prescribed PT and said we could meet again in 6 weeks to see how things were and re-evaluate if surgery is really necessary. The idea of surgery plus 6-8+ weeks in a cast, plus all that rehab, totally terrifies me, especially given that I'm not in severe pain.

Dr Blake's comment: The chance of you needing surgery is probably 2%. 

     At the same time, I so desperately want to be a "real athlete" again, and if the surgery afforded me that, I would do it. He definitely had limited experience with patients with this problem (he was in his fellowship in foot/ankle surgery, but I found him to be patient, understanding, and deeply caring) but his supervising surgeon had plenty and he would talk to him about it. He looked at my MRI and x-ray and said he didn't see much that was concerning, except for a tiny bit of fluid around the PTT. He was expecting to see much more irritation around the accessory navicular, but it didn't look bad at all.

Dr Blake's comment: This is a good sign. When the accessory navicular is a problem, there is more fluid around and/or in it. Hopefully, you have posterior tibial tendinitis mainly. 

     When I got home yesterday evening, my MRI report was finally in my mailbox- would have been helpful if I had it before I saw the surgeon! Maybe I'm reading into it too much, but the report from the radiologist seemed worse than what the surgeon told me today (he didn't think things looked too bad).

Imaging results: X-rays of foot and ankle showed accessory navicular. MRI report for the ankle said:

1. 11 mm multiloculated ganglion cyst between the spring ligament and talus

2. Mild tenosynovitis along mid to distal aspect of posterior tibialis tendon, with mild tenodonitis at its insertion on a type 2 os naviculare

3.  Mild degenerative changes along the articulation between the os naviculare and navicular bone

Dr Blake's comment: This mainly shows tendinitis. The treatment of tendinitis is very conservative--PT, orthotic devices, anti-inflammatory, taping, and strengthening. The ganglion cyst and degenerative changes make this interesting. 

     Other text on the report on foot and ankle: "normal alignment, joint spaces are preserved, no fracture is appreciated. The anterior ankle tendons are intact with normal signal intensity. Mild tenosynovitis along the mid to distal aspect of the posterior tibialis tendon. The tendon is normal in morphology and signal intensity, except at its attachment to a type 2 os navicularis where there is mild tendonosis. Normal fat signal seen within the sinus tarsi. The anterior and posterior talofibular ligaments are in tact. The anterior talofibular, posterior talofibular, and calcaneofibular ligaments are in tact, the deltoid ligament is intact. Deep to the spring ligament and overlying the talus there is a multiloculated ganglion that measures up to 11 X 6 mm in the axial plane. The subtalar joint is unremarkable. The articular cartilage throughout the midfoot is intact. The marrow signal is normal. There is no talar dome osteochondral defect. There is no acute dislocation, marrow edema, erosion, or cortical thickening. The flexor and extensor tendons about the foot are  intact, with normal signal intesity. No intermetatarsal bursitis is appreciated. No significant subcutaneous edema."

Dr Blake's comment: No significant change here. The ganglion is interesting if it is involved with your pain. 

     I'm thinking I might mail this report to the surgeon I saw yesterday so he can review it with the supervising physician (chief of foot and ankle surgery at the biggest Boston hospital) before my follow-up in 6 weeks. He reviewed the MRI and said nothing about the ganglion cyst, which I am in a complete panic attack about. I don't even know what this cyst is, but I assume it is horrible, terrible news. I'm avoiding googling it out of fear. 

Dr Blake's comment: Ganglion cysts arise from herniations of the ligaments from a joint. Sometimes they need to be removed. We always try injecting them and draining if possible. Some of them cause pain, most do not. 

     My pain these days: At no point since the initial onset of pain, up to today, have I been in incredible pain, thank God. I almost feel embarrassed that this has caused me so much distress, but I've been in very little pain this entire time. I can walk to and from work (about a mile each way), go about my daily activities, etc. with little or no pain. Cross training has been fine- no pain or stiffness during or after whatsoever.  The reason I have not run a single mile in 40 days is primarily because when I wake up in the morning, I have pain/stiffness in my foot for a few minutes. As an athlete, I take this as my body's message of "something is damaged," so I don't want to risk it. The  surgeon I saw yesterday said I could try some light running (but I refuse out of fear until I get my new orthotics). 

Dr Blake's comment: You are showing great wisdom at your young age. Definitely, this is an arch problem, and perfecting the orthotics first makes sense. Learn how to do some version of arch taping. I have the kinesio version and the low dye versions on my blog. These should be done with the orthotics for several months until your running is back up to normal. 

     The pain/stiffness upon waking is sort of difficult to localize and feels "deep" in my foot, but generally in the area of the navicular. Sometimes when I am sitting at my desk at work or get up after sitting for a while, there will be some stiffness in the arch, and there is often tenderness in the area of the PTT near the ankle  but more of an annoyance, not serious pain. As I mentioned, originally (in April/early May) I could produce pain on the accessory navicular when pressing it. Now, it is quite difficult for me to produce pain on the accessory navicular, and it almost never hurts. But the mild PTT tenderness, and particularly the tightness/pain in my arch upon waking, makes me worry. I am quite sure that if I went running, I'd spend the evening with a very stiff and sore foot. Right now, I mainly am limping during my first 3 or so  minutes out of bed, plus occasionally rubbing/flexing my foot during the day to test for stiffness/soreness. I'd say my pain on waking up in the morning is about a 3, the rest of the day I'm at a 0 or 1. Given this relatively low level of pain, it seems crazy to risk going through a major surgery. Honestly, if I were not a runner, I probably would not have even seen a doctor for this. But as an athlete, it consumes most of my thoughts, and makes me lose sleep! 

Dr Blake's comment: I have seen too many surgeries by great docs go wrong to say something but any thought of surgery  (if needed) should be 2 years from now. This means you do everything possible to avoid surgery. Again, the ganglion is a little unusual, and could be removed with minimal problem if we could prove it was your problem. Ganglion cyst are injected with cortisone all the time, but if placed too close to the posterior tibial tendon, could cause a rupture. If these things were easy a monkey could design a treatment plan. 

     I am scheduled to get casted for new Orthotics (the first appointment I could get for casting the orthotics is July 14, ugh!) and I will have my first PT session on June 16th (also the soonest I could get in).

So my question is... in your experience, do you really think there is a possibility of ridding myself of my PTT/accessory navicular pain with continuing rest, ice, and PT, even if 40 days off of running hasn't healed it?

Dr Blake's comment: Yes, orthotics with more support, a great strengthening program, icing, taping, activity modification, gradually increase running every other day with new orthotics (the new orthos should be more supportive and comfortable in the area of the accessory navicular), should all help. 

     Do tendons just sometimes take this long to heal? My concern is that if my accessory navicular is causing my PTT pain, how will I ever resolve it if I don't get the accessory navicular OUT of my foot? I guess I need to hear that other athletes out there in the world struggled with this for MONTHS but eventually returned to sport without surgery but plenty of PT and patience. The other part of me thinks "I had this bone for 26 years with NO pain, so what's to say I can't go back to being pain-free even if the bone is still in my foot?"  I dread a lifetime of just wondering when I'll need to have major surgery on this, and long for the days just a couple of months ago when I could easily run 40 miles a week, wear flip flops, go hiking, etc., without giving a single though to my feet. It seems like this came out of nowhere. I have been a serious runner for so long, with basically no change in what I was doing.  Do you think this very surprising finding of the ganglion cyst is related (a cause or a result?) of the navicular/PTT issues? Am I totally doomed?

Dr Blake's comment: 3% of the population have accessory naviculars. Our sports clinic which is geared more towards rehabilitation, does one of these removals every 2-3 years. Probably on 1% of the patients presenting like you. So, I feel comfortable that your chance of needing surgery for the accessory navicular over the next 40 years, with high level sports is probably around 2% at most. That being said, the ganglion cyst is more likely a cause of problems and needs long discussions with your docs. We really do not know where you are, so after you get the new orthos, and after you need that they give great support, along with taping, begin running every day with your foot taped, while you start PT. It sounds like it will take until September to get a great feel of where you are going with this. Keep me in the loop. 

     Second, is it bad that I'm still doing the ice baths, 40 days later? Should I also be doing heat baths of some sort on it? I just want to make sure there isn't the possibility that I'm over-icing, if that is a thing!

Dr Blake's comment: Definitely I would have you ice pack 10 minutes only 2 times a day, especially after exercise, and do one session of contrast bathing each evening. 

     Third, although I'm sure the Physical Therapist I'm going to see will be fine (I live in Boston with good access to medical professionals), my assumption is that PTT and accessory navicular issues are rare. I doubt they will know much about a ganglion cyst in the spring ligament.  Is there any information I should bring him/her about which specific areas I need to be strengthening? I don't want to make it worse with PT! Are there additional types of therapy, massage, medication I should be trying?

Dr Blake's comment: The ganglion is something for you and your doc to work on, and to decide if it is related to your pain. There is nothing that the PT does for this. The PT should painlessly strengthening the posterior tibial tendon in particular, the rest of your foot and ankle tendons in general, and work on your core strength, cardio, cross training. They will also do anti-inflammatory modalities. Definitely run while you have PT to get an honest feel of how you are doing no matter what they say to do. 

     I am totally dedicated to staying away from running as long as I need to in order to get through this without surgery (though praying I will be able to run the Boston Marathon in 10.5 months!) but you can be honest with me if you think surgery is going to be the only true option to "fix" me.

Dr Blake's comment: It is actually unfortunate that you have any running goals ahead of you. They sometimes get in the way to common sense. I am hopeful with the taping, PT, new orthotics, and return to running goes smoothly. We will see if there are any glitches over the next few months. Keep me in the loop. Rich

     The one blessing in this is that it has helped me re-evaluate my focus on faith, family, friends instead of just running, and it has encouraged me to cross-train and strength-train more (which I almost never did). I am an obedient PT patient and will follow my PT orders religiously. I want to come out of this healthy and strong, able to enjoy my feet and where they take me well into my nineties.

Thank you SO much for your kindness, I am praying for hope and perspective on this since it has been very tough to keep the tears back during the past 40 days.

Sybil (name changed)

Boston, MA - Age 26

Nerve Pain: What to do next?

Hey Dr. Blake, 

I keep up with your blog and I'm so sorry for your recent losses. Hope you are ok. I'm having trouble with my foot again and wanted to ask your advice, if you are up to it. If not, I understand. In case you ARE up to it, here's what's going on...

I can't get the pinched nerve (the Big X in the pics below) to calm down. I've had it padded a million ways (not sure I'm padding it properly either) and when I take the pads off and take a full step, it's zinging me just as strong as when it first started. I have been able to walk on the foot with the pads but I'm starting to get blisters and callouses on the side of my big toe from walking all weird from the padding and trying to avoid zinging myself by stepping on the pinched nerve. I did not and do not ice like you suggested (3x a day). I can but I don't because...I don't know why. Lazy, too busy, etc. So if that's what I need to do before anything else, I will make it happen. 

Thanks, 

Terry (name changed)

Dr Blake's response:

Hey Terry (you know who you are!! LOL),

     Thank you for the concern. I have been in a fog, but trying to help you and others does help get me centered. Thank you very much.

     First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time like you have. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves should be addressing 4 areas---mechanics (which you seem to have mastered), anti-inflammatory (and ice 3 times daily is the easiest), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc). 

Please email me back on what areas you have done and could do in each of these 4 areas. Rich

And the response:

Thanks for the response! Wow, I had no idea nerves could take so long to calm down. 

Mechanics - I think I am doing this right if that means not feeling the pinched nerve "activate" while I have the padding on. Most of the time I don't. This past week I feel it even with the padding on. For the last 3 weeks, I have been extra active and on my feet for much longer each day than normal. 

Anti-inflammatory - I am not doing any at all. So I can begin icing 3x per day. Any other ways?? 

Nerve hypersensitivity - not doing anything at all. What should I do?? 

Diagnostics -I never had the swelling or the level of pain for this nerve that I did for the original injury so I haven't done any new diagnostics. I just have the old MRI and X-rays that were done before this new pain started. I am not able to get a new MRI right now due to financial constraints and a super high deductible. 

Dr Blake's comments:

     Mechanics: So right now stay where you are at and avoid barefoot if that is irritating you. Some of my patients during flares will go into already tested removable boots or hike and bike shoes, or something that always works, and stay in it for a 2 week period.

     Anti-inflammatory: Definitely we need to see how 10 minute ice pack on the bottom of your foot works first 3 times a day. You can add 2 advil or 1 aleve occasionally. You can also massage into the area arnica or traumeel. 

     Nerve Hypersensitivity: Go online and purchase Neuro-Eze and massage into the area 3-4 times a day for one month. Also, look at the blog for the video on neural flossing  (aka neural gliding). Do that 3 times a day. 

     Diagnostics:Remind me what the old MRI showed since this is the best test. However, getting a neurological examination to look at the whole sciatic nerve (even the spine up to the neck) to have see if you are getting neural tension anywhere. Simply having a PT evaluate how you sit and lift, etc, to give you tips on posture and how to minimize the day to day stresses on the sciatic nerve can be helpful. 

     Please give me feedback. Thanks Rich

The patient's response:

Ok, thanks!! I will begin all of these suggestions ASAP. (I am icing as I type this!!) 

Here are the MRI results. The MRI was about 2 months before I started feeling this nerve pitch. Nothing particular happened that I am aware of that caused it. I was doing well and recovering from the original injury. But as you can see from the pics, this nerve pinching that's bothering me now seems to be right in a line up my foot from the original injury. 

MRI FINDINGS: Dorsally located subcutaneous nonspecific edema of the forefoot is noted. No stress fracture is currently noted. There are bursal effusions especially between the 2nd and 3rd, 3rd and 4th and to a lesser extent 4th and 5th metatarsal phalangeal joint. Subtle flexor tendon is noted third ray. These findings are compatible with bursitis, synovitis, and mild tenosynovitis without associated stress fracture. Phalangeal sesamoid ligaments appear unremarkable. 

IMPRESSION: 1. MULTIFOCAL BURSITIS, nonspecific soft tissue edema with no stress fracture noted. 

2. The Lis Franc ligament is intact. 

Dr Blake's response:

    All of the original MRI findings indicate inflammation, but does not rule out inflamed nerves (they can be hard to see, especially with the bursitis inflammation). If we get another MRI down the line, then the expensive one, the one with contrasts, should be done since it can give more information. Ask your doc about a 8 day Prednisone Burst to jump start the anti-inflammatory attack. Rich

Personal Reflection: God and me

In the last 2 months I lost 3 people very close to me. I have stared into the computer screen, but could not type for weeks on end. I was sent the below link from someone who believes in God as I do. Thank you Kenn. I have watched this and it brings me great peace. My sorrow seems a little less for now. You do not need to open if you do not want to, but it is one of the most beautiful videos about an interview with God. It made my sorrow softer. I pray it helps some of you. Rich

http://vimeo.com/8898059#at=0

Tips for Wearing High Heels to Minimize Problems

Here are some tips to create less problems for those of you that will be wearing high heels. 

http://www.idahostatejournal.com/vac/how_to/well-heeled-tips-for-picking-high-heels-that-are-better/article_8b8e6569-ce83-5aff-a7a2-5f063a31e450.html