Possible Sesamoid AVN: Email Advice

Hi Dr. Blake,

     I have been reading your blog for the last month and viewed several of your videos which has spurred a few questions. 

     My 14 year old daughter was diagnosed with AVN in the left tibial sesamoid (this means avascular necrosis or dying bone secondary to poor blood supply).  A bit of background; she is a competitive Irish dancer and sadly due to this injury just had to sit out on the World Championships.  Last fall she dealt with some sesamoiditis in the right foot which we treated and it resolved.  Both feet have bipartite sesamoids (naturally occurring sesamoids in 2 pieces), we know from X-rays.  The left foot started aching in late November and then was really bad in early January after she started back from Christmas break.  She went into a boot 1/15 for 3 weeks at the time the DPM was treating as sesamoiditis, when she started to work out of the boot in wk 4 the pain was the same so we had an MRI on 2/11 and the AVN was noted.
Dr Blake's comment: You can get an idea of AVN from MRI, but CT Scan denoting bone fragmentation is the best test, just more radiation.

   The DPM immediately tried to arrange for a bone stimulator and she wanted her immobilized again.  We also sought a second opinion from a pediatric orthopedic because teachers and family felt it was important.  She understood by the time we saw the orthopedic that Worlds was out, and we saw the MRI pic ourselves (clearly it was not normal to our untrained eyes).  She asked him what she needed to do to heal.  He said a cast for 3 wks non-weight bearing, then a boot for another 2 wks non-weight bearing and start an Exogen unit.  She was allowed to start weight-bearing last Thursday but we were traveling for Worlds so I had her continue with a scooter.  She is now walking in the boot and is not having pain.  In addition, she has seen a chiropractor during this time who has done some ART (Active Release Technique) for her left calf and arch and right hip and foot since it was getting the brunt with the crutches.  We were supposed to go back to the orthopedic this week, but knew he would not do any X-rays or MRI yet so I called and she is to start PT this week.  The PT can release her from the boot, and she’ll go into a carbon fiber plate and at some point back to activity.  She is chomping at the bit to get back, but very concerned she do it correctly so she doesn’t re-injure it.  My questions are:

1.      When should we expect to re-do an MRI to know if the AVN is turning around?  And why do you say, as did the orthopedic, MRIs, X-rays are delayed in showing healing?

Dr Blake's comment: The earliest for a new MRI is 5/11/15 or 3 months from the first. I personally like to wait as long as possible while following symptoms as I move the patient from non weight bearing to weight bearing with boot to weight bearing without boot to return to activity. The Exogen bone stimulator is a 9 month course, so you want typically 6 months before an MRI or CT scan is done. Do you have that patience? Most not, so use the 3 month rule for some idea of healing. X-rays only reflect the amount of calcium in an area. If that area is healing, the water content of the area dramatically increases bringing in nutrients, like calcium, making the area appear to have less calcium, thus poor healing, when actually there is more calcium with healing. It is just a percentage reader. You can increase calcium for healing, but with the increase water, the area looks like it has avascular necrosis or at least is not healing. 

2.      What % of your young patients heal from AVN?  Should we expect it will re-occur due to her intense foot pounding activity?

Dr Blake's comment: Young patients rarely have AVN problems due to their great bone metabolism. Unless you do not create a pain free environment (0-2 pain levels) as you progress her back to full dance, unless she has some dietary issues negatively influencing healing, unless you can not control the swelling with icing and contrasts, or forget to use the Exogen, she should do just fine. 

3.      We plan to have her use dancer pads when she goes back, though it will be difficult and change how her dance shoes fit.  Should we also do the spica taping, though I’m afraid it will impair her range of motion for dancing and possibly mess something else up? 

Dr Blake's comment: You have to just try. I love dancer's padding and spica taping for this problem. Remember every day she has had restricted mobility it takes two days to get that mobility/activity back. So, it is important to calculate for her the injury date to return to activity date starting date. If that takes 100 days, it will take 200 days from that point to get everything back. You go slow, conservative, and it typically does fine. With some tears for sure. 

4.      What type of shoe should she be wearing outside of dance?  Is barefoot walking bad?

Dr Blake's comment: Barefoot is the worse for the next year. You want a stylish shoe that she wants to wear, that has room for a dancer's pad, and allows for 0-2 pain levels. 

5.      How do we get her foot mechanics evaluated to see if she needs to learn different walking/running mechanics outside of dance to help minimize added stress?

Dr Blake's comment: I used to treat the entire SF Ballet. It took me a few years to really understand that what they did outside of class had a big influence on the pain during class. So, typically with sesamoid injuries, you are not just adding dancer's pads and arch supports to her dancing shoes, but all shoes and activities need to be evaluated. When you are talking about someone who is at the level of World Competitions, you need top sports medicine advice on all her shoes and activities. 

6.      Have you had any of your patients do dry needling for sesamoid/tendon issues?

Dr Blake's comment: I love dry needling for circulation and nerve hypersensitivity. If you can get it, do it twice weekly. Does it help more than contrast baths nightly, I am not sure. But, if you do both, and add the Exogen bone stimulator, you are doing your best to heal this. 

7.      In your opinion, when could she start riding a stationary bike?  She has not only lost lots of muscle in her calf but her hamstring and quad as well with the extended inactivity.

Dr Blake's comment: OMG, she should do this the day she injured herself for up to an hour daily. You can lower the seat of the bike a little, and place your weight of pedal in your arch. I hope this advice helps her. Rich

I do like the DPM we have seen though she does not see lots of high level athletes and the orthopedic is good too but we are rushed in and out - it’s difficult to get questions asked and answered.  So thank you so much for your blog and sharing your experience.

Kind regards,

Ollier's Disease and Calcaneal Apophysitis: Email Advice

From Wikipedia:

Ollier disease is a rare nonhereditary sporadic disorder where intraosseous benign cartilaginous tumors (enchondroma) develop close to growth plate cartilage. Prevalence is estimated at around 1 in 100,000. Normally, the disease consists of multiple enchondromas which usually develop in childhood. The growth of these enchondromas usually stops after skeletal maturation. The affected extremity is shortened (asymmetric dwarfism) and sometimes bowed due to epiphyseal fusion anomalies. Persons with Ollier disease are prone to breaking bones and normally have swollen, aching limbs.

Hi Dr. Blake,

I am truly at a loss for my son’s pain in his rt. Foot.  The pain is in his heel and it just isn’t getting any better.  A little history… my son has Ollier’s Disease and has had two surgeries on his Rt. Leg.  1^st surgery was May 2011 femur fracture, rod placement.  2^nd surgery was leg lengthening and corrective alignment of knee.  The leg lengthening wasn’t exactly a success as he was growing bone too quickly which forced us to double up on the amount of turns each day to avoid the bone from growing together.  This caused him to have severe nerve pain, that lasted about a year.  He was taking Neurontin to control this pain.  He also ended up with stress fractures once he could walk but it was the nerve pain in his foot that was the worst.  He ended up still being short in that leg and continues to be about an inch short.  During this time, his rt. Foot was 2 ½ sizes smaller than his left foot.  Today he is only about one size different. Rt. Shoe is a 3 left shoe is a 4.  He also has an internal lift in his rt shoe.  He still has trouble going down stairs, he takes them one at a time vs. a continue flow.  He recently had to have surgery on his left arm they actually did a salvage surgery to save his left forearm from amputation creating a one bone forearm in Sept. 2014. He again had nerve pain and was put on Neurontin which he is still taking.  

On March 15^th he was playing with friends being very active (which he really hasn’t been able to do) for about 4 hours.  He ended up coming in basically crawling because he couldn’t walk and started complaining that his heel really hurt with some pain on the top of his foot but mostly just his heel. There was no swelling, no redness, but it hurt to touch it and move it.  They were doing a lot of jumping as they were trying to make a big look out nest on top of a very large snow pile.  We took him to our local urgent care, they took x-rays and said they looked ok that it was most likely a deep, deep bruise and to stay off of it and rest it. 

  Three days went by and he wasn’t getting a lot of relief from the ibuprofen he was taking around the clock, icing it helped somewhat, but he was still pretty miserable.  I ended up taking him to Children’s in Boston where he is followed by two ortho doctors. He saw a Dr. on call, they took more xrays, and placed him in a boot.  He couldn’t stand the boot, he said it made the pain worse, he tried to wear it for short periods of time but it just wasn’t working.  The pain was still the same and not getting any better.  We went back to Children’s and this time they put him in a cast.  The cast was better but it still didn’t provide enough relief.  He was asking for pain medicine around the clock so I started thinking that it might be more nerve related.  We went back to Children’s yesterday and they took off the cast.  When they took the cast off he was in a ton of pain and said it felt better in the cast.  UGH!!!!   So, they ended up making a bi-valve cast so he can remove it and I can massage his foot.  He is absolutely miserable still, he keeps saying he just doesn’t know what to do and frankly neither do I.  We are going to be seen by the pain clinic at Children’s tomorrow and I’m hoping that you can give me your thoughts based on the xrays and my description.  Sometimes another set of eyes can bring something else to light.  This pain wakes him up at night, he has trouble falling asleep, he just wants to be a normal boy!!! 

PLEASE, PLEASE, PLEASE share your insight with me.  I would be beyond grateful for any advice and can be reached by phone or email.

Thank you & Warmest Regards,

Dr Blake's comment: Thank you so very much for the email. The heel looks normal on xray, but the pain from calcaneal apophysitis (yes, a normal injury) can be intense. The treatment is ice soaking 20 minutes (heel in the ice bucket only, not the entire foot) 3-4 times a day since the pain is primarily inflammatory. These growth plates stay open in boys until 14, so he could have a few episodes. You ice 3 days longer than you need to with each episode. After 5 days of icing, let me know what is happening. You should be aware of Calmare Pain Therapy for nerve pain. Go on their website, I am not sure if there are age restrictions, but it can be used on any part of the body, and it non-invasive. Hope this helps some. Rich

Hallux Limitus Discussion: Dancer's Padding or Reverse Morton's Extensions

​Dear Dr. Blake,

     I am a senior podiatry student. I was just reading one of your blog posts (Sesamoid Fractures: Advice when not healing well) and I have a couple of questions I was hoping you could clarify for me.

     My questions actually have to do more with hallux limitus. I have been trying to understand the difference between offloading the 1st MPJ with a dancer's pad for conditions such as sesamoiditis versus using a reverse mortons extension for a hallux limitus. Essentially they seem to be the same pad? But how could one be offloading and relieving pressure while the other one is increasing plantarflexion of the 1st MPJ (and I assume that would be increasing pressure) to decrease the elevatus?

Dr Blake's comment: Dancer's pads and Reverse Morton's Extensions are one and the same. I would rather give credit to the French who in the 1770s while studying their ballet dancers came up with this unique pad for big toe joint pain. It was the time of the French Revolution, but also the time of this unique pad that was not placed over the sore area, but designed to transfer weight. A truly revolutionary idea!! A dancer's pad should transfer weight from the first metatarsal to the second through 5th metatarsals at push off. When this works, normal push off occurs with the first metatarsal being free to plantarflex for an active push off. When there is too much weight on the first metatarsal (say from over pronation of the foot), then functional jamming and pain can occur as the first metatarsal tries to plantarflex at push off but is being restricted. So, at push off you want normal plantarflexion of the first metatarsal, with normal to slightly less than normal plantar pressures. This can help a pain syndrome produced by that jamming force. And, push off is only one third of stance. Dancer's pads do eliminate a lot of pressure on the first metatarsal during the contact and midstance phases. So, all 3 phases of stance have less pressure on the first metatarsal with a dancer's pad, and active push off should be less restricted and therefore more powerful. Now, a structural met primus elevatus is best helped by a Morton's Extension. It brings the ground up to the first metatarsal and allows it to function normally. A functional met primus elevatus, caused by over pronation, is only elevated by the pronation jamming it upward. It needs arch support to decelerate pronation, shifting the weight in midstance to the middle of the foot, with a dancer's pad to free up the jammed big toe joint. Besides Dr Root, Dr Langer first discussed this concept in the 1980s. Drs Wernick, Langer and Dannenberg introduced the kinetic wedge with first ray cut outs to free up the first metatarsal to achieve wonderful push off. The basic concept was that some arch support, and some first ray freedom, would help the first ray push off. This is achieved in various orthotic modifications. I love adequate over pronation correction from the orthotic device, along with some dancer's pad to give extra freedom. Dancer's pads have been crucial in pain syndromes, and less necessary when there is no pain (although always an option to add). 

Also, If someone has a hallux limitus and a plantar plate tear of the second, would you recommend doing a spica taping to the first and the second toe simultaneously? Your instructional video on Youtube for this is excellent. My mom actually has this issue and I have been trying to research different taping methods since she does not want surgery. I bought her a morton's extension innersole but she also doesn't wear sneakers very often as she is a dancer. She is hypermobile so perhaps using a reverse mortons extension may help the joint align. However, I am worried to add pressure to the sesamoids because she also states she has pain there (hence my confusion on padding). I have included a photo of her foot and x-ray just in case my rambling doesn't make sense.

Dr Blake's comment: Even though you are only a student, you are asking great critical questions. The main treatment for a plantar plate tear is a Budin splint or spica tape to the 2nd/3rd toes (typically buddy tape to share the pressure). Look at the Hapad products. Start with an Extra-Small Longitudinal Medial Arch for the Hallux Limitus to shift weight more central. Add a Budin splint for the 2nd/3rd toes (Single loop opened up for both toes). You can trim the Budin splint plantar padding as much as you like, and you can even add an extra small metatarsal pad to the splint. 

Dr Blake's comment: The xrays point to that long first metatarsal that gets jammed at push off. This is typically initially a functional jamming (functional hallux limitus), which can become osteoarthritis (structural limitus or rigidus). Since you can not load the second met head, you have to support the arch to transfer weight from first to central. 

 She also has a strange lump on the medial 2nd digit. She was told by a podiatrist that it was just bursitis but I am not convinced since it is a hard lump- feels almost like an extension of the medial condyle of the prox phalynx...the x-ray just looks like a bit of increased density in the soft tissue. Have you ever seen something like that before?

Dr Blake's comment: With plantar plate tears, the second toe can start to deviate to the the loss of plantar ligament stability. Here you see the second toe proximal phalanx deviating towards the first toe. She may need that fixed surgically some day. And, today definitely needs to live with a Single loop Budin splint with the loop opened up enough to cover both the second and third toes. I sure hope this helps her and good luck with your career. Rich

I am going to have her start doing the joint mobilization that you recommend in your other blog post.

So sorry for the long e-mail. I really appreciate you taking the time to read this. I am looking forward to your response. 

Best Regards,

Heel Pain: Email Advice

Hi,

Ive got a question I have been seeing a local doctor and he has gave me a series of 3 cortisone shots in the side of my heal no spreading it around just a prick and done. Now he is telling me that he needs to go in and cut the fascia. I am not comfortable about this. Is there any other options???

Limping in Illinois

Dr Blake's comment: 

     Hey Limping, thank you so very much for the email. And, sorry you are limping!! With perhaps less than 1% of all plantar fasciitis cases needing surgery, I look at this with a bit (a lot) of caution. The plantar fascia is the 3rd supporting structure for your arch (after the ligaments and muscles/tendons), and there are cases of arches collapsing following surgical release (very small percentage also). However, that means you should consider plantar fascia release only if all the stones are turned over. Definitely get some other opinions, but do not tell anyone about what this doc wants to do. Only tell them what you have had done that has not worked so far, and what are your options. Cortisone is part of the Immobilization/Anti-Inflammatory Phase where you are trying to achieve that coveted pain free environment (0-2 level pain). While you are getting the shots (or physical therapy, or a home program of icing and contrast bathing and NSAIDs, or a combination of these things), you should be getting protected weight bearing inserts like orthotics. You may need a removable boot like an Anklizer (purchase online), or need to tape every day (www.supportthefoot.com). Until the pain is under control, I would avoid stretching the achilles and plantar fascia since you may have a plantar fascial tear. An MRI would be wonderful to see what is really going on. If you can not get a referral, you can check the AAPSM website for sports medicine podiatrists. It typically is a good source. 
     You may need surgery, but I would step back, get some opinions, and see what people say. I hope this helps you some. Rich

Recent Sesamoid Fracture: Email Advice

Greetings Dr. Blake,

First off, your blog is amazing! I learned more here about treating my tibial sesamoid fracture than I have any other sources combined together. My question is primarily regarding getting the proper treatment and when it's time to seek a 2nd opinion. I fractured my tibial sesamoid back in January of this year. I'm not one to rush to the doctor, so I waited 5 weeks from when the pain started to get treatment. The DPM I went to took X-rays that clearly showed an acute fracture of the tibial sesamoid resulting in a bipartite sesamoid. He said that the bones may never unify, however most cases heal with a fibrous union between the fractured pieces. He put me in a cam boot and sent me on my way with instructions to come back in 6 weeks. He also said to ice 3 times daily and take ibuprofen for pain.  I’m on week  5.  At week 3 I had really bad heel pain due to the boot and added a gel insole. That greatly helped the heel pain. Once that calmed down, I realized that I still had light pressure on my sesamoids. I did a sesamoid accommodation myself and that’s help alleviate the pressure on the sesamoids while wearing the boot.

Dr Blake's comment: Bravo!!!!!!!

Since the boot is almost impossible to sleep in, I was sleeping barefoot and was waking up in a lot of pain. I had a muscle spasm that jerked my big toe one night and was in a lot of pain after that. I dug more into your blog and learned to spica tape. That’s allowed me to sleep and shower much better.  I only walk outside the boot for just a few steps on the side of my foot to get to the bathroom that’s right outside my bedroom. I can do that pain free for the most part. Do toe jerks and things like that re-break the bone if fibrous tissue is trying to grow?

Dr Blake's comment: No, you could not generate enough force to re-break the bone or the fibrosis junction.

How easy is it to re-fracture and set back the healing?

Dr Blake's comment: It is very hard to re-break after about 6 weeks in the cam walker, when most of the consolidation occurs. However, after 6 weeks, there is the worry about avascularization of the bone with boney fragmentation. That is why I push when possible for daily contrast bathing, Exogen Bone Stimulators, pain free environments (0-2 pain level), weight bearing to tolerance, good diet with calcium and Vit D3, and icing when aggravated, for about 6 months. 

I am taking calcium and vitamin D3.

My 6 week appointment is next week. I don’t know if he’ll want to keep me in the boot another 6 weeks for a total of 3 months in the boot, or if he’ll try to wean me out of the boot. I’ll need help getting a good insert for my shoes with a sesamoid cutout for that to be the case. Should he be doing this with me in the office?

Dr Blake's comment: I am so impressed by your knowledge and questions. Orthotics can be done by a doctor, physical therapist, pedorthist, running shoe store. Ask your doctor where to get the right insert that off weights the sesamoid appropriately. It is crucial to begin a successful wean out of the boot, and can take several weeks to make, and several visits to adjust. 

What if he recommends custom orthotics? I hear about as much bad about custom orthotics as I do good. Seeing as I feel he didn’t give me the type of useful information I’ve found through your blog to really allow me to be mostly pain free there’s a question of trust which is making me leary of going through the time and expense of getting custom orthotics and they not working due to his office just not seeing many of these cases. I don't want to be rude and question him, but I want to be sure I'm getting the treatment I need.

Dr Blake's comment: Time is never enough in a medical office, it is one of the personal reasons I started my blog for my patients, because I do not have enough time either to talk about everything. So, if he did not discuss everything, it was because the Immobilization phase is a relatively simple phase without the need to go over everything. Custom orthotics are my life, I see the unbelievable changes they can make in someone's life, but I sure do not understand everything about them. The secret to every part of your rehabilitation is in execution of the subtleties. Any doctor is good with some things, and okay or poor with others. Medicine is too complex. I have no idea about your doc, but I would not be worried at this stage. Just ask good questions, without putting a wall between the two of you. He may need to send you to a place that really specializes in orthotics, or for any aspect of the treatment. Does this sort of make sense?

How do I know for sure that if he tells me to wean out of the boot that it’s really time? I still have pain and swelling. In normal healing how long is dealing with a lot of swelling normal?

Dr Blake's comment: Golden Rule of Foot: Keep the Pain Level between 0-2 and you will know you are maintaining a Healing Environment. So, Listen to your Body. And swelling can be part of the overall healing for the next year, and you should continue to work with it with icing and contrasts bathing, while paying attention to the pain level utmost. 

No MRI was done initially. I have a $3000 deductible, so we’re being a bit conservative before really getting into high-cost items like MRI scans and bone stimulators. Having said that, I want to get this healed.  Can you help me with some indicators of judging healing progress as well as what my DPM should be doing at this stage that might let me know if he’s on the right track or if it’s time to seek a 2nd opinion?  What if he does X-rays and the bones are further apart? Does that mean the fibrous tissue will never grow to unify the fracture and that surgery is the only option? If I was your patient, what would you recommend be done? When's it time to start a bone stimulator? Most insurances wants to wait 3 months from what I'm hearing.

Dr Blake's comment: The following is my protocol if I was to take over your treatment right now:

• Not rely on x-rays at all, they are visually way behind the healing, and usually cloud the judgement rushing patients into surgery. But, not a reason to give up on a doc if this is what they are used to relying on.
• Ask the patient to self pay for an Forefoot MRI without contrast at some imaging center (typically $500 or so). It may be a crucial baseline in 3-6 months down the line. 
• Keep the patient in the cam walker for 3 total months (initial plan), and actively design inserts with dancer's pads and some arch support to off weight the sesamoid. It can be that by 8 weeks with the right off weighting insert, the weaning process can begin early.
• Request 2 times daily ice pack 10-15 minutes, and evening contrast bathing to control inflammation and flush out bone swelling.
• Make sure diet, calcium, Vit D3 are good. Consider Vit D3 blood test. 
• Make sure patient is getting core, cardio, and lower extremity strength and flexibility work close to daily.
• See if you can self pay for Exogen. If not, it is a judgement for the patient to wait and get another x ray 3 months from the first x ray documenting the delay healing for the insurance company. 
• Have the patient learn how to spica tape (takes a few times to get good at it)
• Look at their shoes and perhaps replace (how is the padding, flexibility, heel height, etc). It is at least good for the patients to look at Hoka One One, New Balance 928, carbon graphite plates from Otto Beck, etc.

Thanks for your time, I sincerely hope you can help guide me with an opinion of how to proceed.

Big Toe Joint Pain: Email Advice

Hi Dr Blake,

I've been a reader of your blog for a while now, just wanted to
thank you for putting all of this info out there, it is extremely
helpful.

So I'm hoping to get some feedback about a recent toe injury. About me:
I've been an avid tennis player for a few years (play 3-4 times a week)
and am currently 38.  

About 2 weeks ago, I noticed that after playing my left big toe felt a 
little tender, but the next day the tenderness was gone.  Then a few days 
later I played again and this time after playing this feeling came back 
but was worse, in addition to feeling tender now I noticed that there 
was some swelling/aching. When I pushed off on the left foot it was 
even a little painful. Not acute, just sort of a dull ache feeling.  Well 
this time the swelling didn't go away.  So I scheduled an appointment 
with my doctor (podiatrist) and he did some poking and prodding and 
said it seemed ok, that I should just rest. He even took some x-rays 
(from the top of the foot) and said nothing was broken, that the sesamoids 
were fine and the joint looked good, that I should just rest.

So for the past 1.5 weeks I haven't played tennis, I've just done swimming
and biking (biking I put the middle of my foot on the pedal so most of
the weight is near my arch).  I've also been icing 2-3 times a day and
really trying to immobilize the joint. The problem, is that the swelling /
tender feeling hasn't subsided. Not at all.  I especially notice an issue
when I put weight on the ball of my foot, it's not painful, but it feels
really tender.  It is even more obvious if I go up on my toes.  My toe
joint doesn't feel stiff, there is no bruising and I appear to have full
range of motion.  If I sit down and move the toe up and down without 
weight on it, no pain at all.

So given these symptoms, do you have any hunches about what the issue
might be?  Aside from continuing to ice and keep the joint immobile, is
there anything else I can do?  (I'm spica taping but that doesn't seem
to help much).

Regards,

Dr Blake's comment:

     Thank you so very much for your email. X-rays are poor indicators of anything serious within the joint, but it was the most appropriate test to do at that stage. You did well to get in to see someone so early. I love the 3 day rule: If pain does not go away after 3 days, you have to do something to try to change the course of the injury. Remember icing only controls swelling, never really gets rid of it. I love 2 times a day of 10 minute ice pack, but at least one time a day of straight contrast bathing to flush the tissue. 

You have to assume that you have a stress fracture because of the potential of overuse playing hard tennis 3-4 times a week, and how quickly this went from no pain to a lot of pain. Definitely check your shoes and make sure they are not worn out. Check the inserts in the shoes and see if there are holes in the area of pain. See if you can design a "dancer's pad" to take pressure off the area, probably will need it on both sides for balance as you start to go back to tennis. 

At this point in the injury typically more x-rays will not help. An MRI is normally recommended if 2-3 weeks pass with little or no improvement. Of course, if you were a Golden State Warrior, you probably would have already had 2 MRIs. So, if you are anxious, you can request it now. You can also treat the injury as a stress fracture, typically requiring a minimum of 6 weeks in an Anklizer Removable boot  (can be purchased online) with an accommodation for the big toe joint. 

http://www.drblakeshealingsole.com/2010/04/patient-footlight-1-possible-foot.html

So, make sure you are getting the calcium and Vit D3 you need. Avoid NSAIDs and cortisone shots if possible, since they can slow down bone healing. If you do not have custom orthotics, you may want to consider them to off weight the big toe joint, although some OTC inserts can be customized to do the same thing. 

I sure hope this helps point you in the right direction. It is never bad while you wait on a diagnosis (which you do not have), to continue to create a pain free (0-2 level pain) environment for proper healing whatever it takes. You are doing the correct thing with the bike pedal adjustment. Sometimes, you only need the boot for work when you do not want to think about it, and tennis shoes with dancer's pads for after work. Good luck, Rich

Heel Pain/Plantar Fasciitis: Email Advice

I came across your website trying to find any other options for the heel pain / fasciitis that I may have. I am from Tennessee. My problems have been going on for 2 years. Both feet.

 About 3 months ago the right heel pain resolved. The left has not. I am seeing my second podiatrist. I have the custom hard inserts I keep in my shoes.

Dr Blake's comment: This is the time to critically evaluate each treatment avenue/modality and possibly make changes. The orthotic goal for patients with heel pain is to transfer the weight into the arch and cushion/float the heel. Do you feel this is being accomplished? If not, see if they can be altered or remade. This is called protective weight bearing and every step you take can be used to make the heel better if done right. 

 I have had my heel injection 3 times by the second podiatrist this year. Helps some but seems to "wear" off and return to pain. 2 times the year before with absolutely no relief which is why it took me a year to finally go again. 
Dr Blake's comment: Cortisone shots can be crucial if there is heel bursitis, but it is a mixed bag with plantar fasciitis. You really do not want to inject the plantar fascia itself, so you have to inject under it (and gravity actually pulls the cortisone away from the fascia) limiting its effectiveness. 

Wears a night splint but not all time because I didn't feel like it was making a difference.
Dr Blake's comment: If you have the classic morning soreness from from plantar fasciitis, the night splints should do wonders if the plantar fascia is tight. When there is minimal results with the night splint, you either do not have plantar fasciitis, your fascia is just not tight, or it is the wrong type of splint (I like the ones where the heel is enclosed and the toes are not bent up). 

 Can't take antiinflammatory long. They hurt my stomach.
Dr Blake's comment: You can use celebrex which is milder on the stomach with or without cytotec. Or, you can use topical Voltaren 1.3% gel or flector patches. Any anti-inflammatory drug, no matter the application, should be done on a 5 day on 2 day off routine, or 10 day on 4 day off routine, to rest the body and prevent some of the side-effects. You typically have to ice more on the days you are not using the medication. 

 Oral steroids may help a little but I know I cant always take them.
Dr Blake's comment: I love an 8 day Prednisone burst to knock out inflammation. See my blog post on that. It is especially good in chronic situations, or acute flares. But, it can also be very diagnostic when it works or does not work. It is for inflammation, but does not help the mechanical or neuropathic aspects of the pain. 

 Have been in a walking boot for 6 weeks. That didn't help any.
Dr Blake's comment: This is where I would need more info. When you were in the boot, were you 100% pain free. Plantar fasciitis feels great in the boot, plantar heel bursitis may hurt more in the boot. The problem with boots and heel pain is that your heel stays down longer than normal walking, thus increasing the normal pressure on the heel. But, the boots allow you to roll through, not bending the toes at push off, and thus not irritating the plantar fascia. I guess you can see that success or failure with any of these treatments can help us fine tune what is going on and how to fix it. 

 Have used heel cups. Good shoes that are known for stability. Have heel Spurs to both feet. But as a nurse practitioner I understand it is not the spur itself causing the pain. I have wore straps around my ankles that allowed me to strap my foot.
Dr Blake's comment: Does the strapping help? Typically works well with plantar fasciitis. And yes, the spur does not cause pain!!! 

  I do work 6 days a week for the most part with one to two of those days 12 hours.
Dr Blake's comment: I do not have to tell you that working that much can decrease your immune system's ability to heal. Have you had a workup on your ability to heal? Are there other problems that have been slow at healing? Are you always fatigued or have other systemic signs/symptoms?

 I am so frustrated that I cannot make this resolve and wondered if you might have any suggestions on what to do. I would love to be able to walk from the time that I get up til bedtime with no pain. I want to be able to walk run and I cannot. My feet get so sore and it is difficult to walk. Once I get walking it will settle some but will be even worse when I sit or sleep. I am suppose to visit the podiatrist again Monday to consider a 4th injection. Thank you again for any comments you may can give
Dr Blake's comment: I would suggest no more shots until you get an MRI. You could have a slight tear in the plantar fascia that cortisone can make worse. Even if you have to self pay for a Rearfoot MRI without contrast, it would be worth it. Hope this helps you in some way. 

Helen (name changed)
Tennessee

Sesamoid Pain with Compensatory Symptoms: Email Advice

Dear Dr. Blake,

I’ve been reading your blog over the past month- thanks so much for all the information!  

I wanted to ask you some questions about my foot pain, because there are a few things I am confused about.  I apologize in advance for the length of the explanation.

In mid-February(it is now mid March), I started feeling a vague pain on the ball of my foot under my big toe on my right foot.  It came and went and I was still able to wear high heels to work, workout, and walk around normally. About 10 days later, I was no longer able to wear heels and switched to flats.  A few days later, I could not walk flat on my right foot and started to walk on the outside of that foot.  A few days after that, I was limping and went to see a doctor. 

Dr Blake's comment: Sounds like a sesamoid injury. The swelling within the bone builds up over the first 4 to 14 days after the injury making the symptoms more and more painful and limiting.

I visited an orthopaedic surgeon (the type of doctor covered under my insurance plan).  He bent my toe up and down and pressed on my bones- I didn’t feel any pain.  He took an x-ray to be sure and confirmed that there was no fracture.  He told me to take it easy to reduce possible inflammation of the tendons in that area.   I started icing, elevating, and minimized walking as much as possible. 

Dr Blake's comment: For sesamoid injuries, x-rays are typically a poor indicator of the problem because they may not show stress fractures or bone contusions. 

A week later, the pain became intense and I went for a second opinion with another orthopaedic surgeon.  The pain was now in both feet, in the exact same area with the exact same symptoms.  My feet were tingling and there was a constant sensation of pins and needles and electric shocks.  Additionally, my feet were getting very cold to the touch, even when I wasn’t icing.  There was a stretching/pulling pain in the web of my first two toes. 

Dr Blake's comment: When you injure the area, there can be the mechanical (orthopedic) cause of pain, the resultant inflammatory aspect of pain, and then secondary neuropathic pain for the body protecting itself. You sound like you have all 3.  

The second surgeon did more x-rays on my right foot (but not the left one), some blood tests, and an ultrasound.  The xrays were negative, the blood tests showed slight vitamin D deficiency, and the ultrasound showed tendonitis under the right toe but not the left one.  I was given a diagnosis of sesamoiditis and started taking vitamin D3: 10,000UI daily, 5 days a week. 

Dr Blake's comment: Vitamin D3 deficiency is proving to be a be killer for runners. One of my patients that I saw yesterday has not run for 2 years due to stress fractures from low Vitamin D3.  

The pins and needles/electric shocks sensation decreased in frequency and intensity but the other symptoms remained.  The way I was walking and standing to avoid stressing the sesamoid area led to sharp pain in my heel area in the fat pad directly under the heels (both feet but more on the right) and Achilles/calf pain in my right leg.  I started with a physiotherapist in mid-March to learn how to walk properly.  He found my symptoms tricky for the following reasons:

Dr Blake's comment: Glad the nerve hypersensitivity is calming, because that can become a problem on it's own. You typically have one injury and a bunch of secondary compensatory symptoms (tendinitis, nerve irritability, achilles tightness, etc. It is important to address these issues, but not to lose sight of the original issue. 

1)      There is absolutely no pain when my flexor tendon (the one supposedly affected by the sesamoiditis) is stretched or pushed in any direction

Dr Blake's comment: I am sure any flexor tendon problems is just secondary pain, not a true injury. 

2)      The pain is in both feet (which seems to be a rare occurrence) but it is not always in both feet at the same time

Dr Blake's comment: I have some many patients with sesamoid pain in both sides, knee pain both sides, achilles both sides, etc. It really depends on your weak spots.

3)      When walking, I feel like there are pebbles under my first metatarsals but when the area of the sesamoid bones is poked by hand, I don’t feel pain

Dr Blake's comment: This is highly usual for stress fracture, so sesamoiditis may be right. 

4)       Sometimes it feels like my foot is tightening up (possibly from swelling) and moving the foot upwards (without bending toes) causes pain that radiates from just below the web of the first two toes on the sole of my foot and ends just behind the ball of the foot under the sesamoids

Dr Blake's comment: This is definitely neuropathic pain with neural tension. See my blog posts on neural flossing and Neuro-Eze. 

5)      Laying flat on my back and moving my leg upwards in a straight line reproduces the pain described in #4 but only when the foot feels tight- when it doesn’t feel that tightness, nothing can reproduce that pain

Dr Blake's comment: The sesamoid injury can cause swelling, the swelling irritates the local nerves, the swelling can come and go due to anytime that affect swelling like the foods we eat, how hydrated we are, the temperature and humidity, etc. 

6)      I sometimes feel the whole ball of the foot swell up- but there is no pain to touch

Dr Blake's comment: Swelling means your body is trying to heal something. But, swelling itself is a bell shaped curve. Some people swell alot and others little with the same injury. It is hard to judge, and if you swell, the swelling shoud be treated on a daily basis. But, you may be swelling long after you are completely healed. 

After 2 sessions of physiotherapy, my feet feel much better when I take my first steps in the morning but are much worse when the burning starts (this is the only time there is pain when touching).  The pain I currently feel under the sesamoids is burning/stinging, sometimes very intense (the skin is not hot to the touch), tightness, and pebbles or ball under my feet when I walk along with a bruised feeling on the outside of the first metatarsal. 

Dr Blake's comment: These are all nerve hypersensitivity, protection, symptoms. They are real and are not treated by typical mechanical or anti-inflammatory measures. Try neural flossing, Neuro-Eze, tylenol, warm compresses. Review all the treatments on my blog for nerve pain including medication (started only at bedtime for these symptoms. 

 These symptoms come and go, sometimes there is more than one symptom, sometimes all of them, sometimes none.  

Dr Blake's comment: This is how compensatory pain goes, not the pain from an injure that is there from start to finish until the injury heals. 

The pain in my heels gets better with rest but comes back with pressure and standing/walking (but heels feel ok in shoes like Birkenstocks). The Achilles pain gets better with rest. I will go back to the doctor to try and get an MRI approved, maybe more blood tests to rule out any infections, and maybe take some time off work so that I can fully rest my feet.  At this point, I am reaching out for any advice and am hoping you can help- does this seem like sesamoiditis in both feet or might there be something else I need to look into?  

Dr Blake's comment: So, remember to not lose sight of the primary injury. You injured your sesamoid. You need to treat the mechanics with dancer's pads, possibly orthotics, spica taping, icing, an MRI, creating a protected weight bearing environment. Good luck. Rich

Thanks for taking the time to read this.

Regards,

Name Removed due to Witness Protection

San Francisco Bay to Breakers: 2015 Tip #1

Nerve Pain: Dr Danielle Rosenman

Hi Rich,

Steven was happy to see you today, and I am happy that his feet are well cared for!

We forgot to get you some flyers for the new groups I have starting February 23 and 24, A Change of Mind: Neuroplastic Tools for Healing.  Here is a short description from the syllabus:

These innovative experiential groups teach participants basic principles and practical applications of the neuroplastic ability of the brain to change, in order to reduce symptoms such as pain, discomfort related to illness, stress, anxiety, and depression.  Participants improve their quality of life by using a specific learning method to change brain pathways along with well-researched effective techniques such as meditation, imagery, journaling, expressive arts, and changes of thoughts and behaviors.

I developed the groups within the context of  the neuroplastic method developed by Dr. Michael Moskowitz, a psychiatrist and pain specialist who is profiled in the first chapter of “The Brain’s Way of Healing,” the new book by Dr. Norman Doidge (who wrote “The Brain that Changes Itself”).  By the way, it is a great book – even more exciting than his first book.

I’ve attached the flyer – if you want to refer people, you could print it in your office, or ask me to mail you copies, which I would be happy to do.  I’ve also attached a letter to colleagues and, for your interest, a piece I wrote about my process in getting from there to here.

By the way, I have had no foot pain since about 5 or 6 months after I started using the neuroplastic tools against pain.  I can now walk easily for an hour in the hills (mild up and down or flat), and up to 2 hours on occasion!  Steven and I went to Alaska in September, a trip I couldn’t imagine 2 years ago, and on the cruise part, we danced every night.  We hiked at every port.  Hurray!   My orthotics are still working well – thanks!

All the best,

Danielle

Danielle Rosenman, M.D.

MedicalCounseling

510-701-0134

www.medicalcounseling.net

drosenman@medicalcounseling.net

Blog: www.daniellerosenman.com 

Big Toe Joint Pain: Gel Products

Hi Dr. Blake,

Thanks for the heads up about the molds.

Can they be mailed to me?

If not, I think I will not keep them.  The orthotics never worked for my inflamed metatarsal/hammer big toe.  I have had good luck with

1. ‘gel socks’ from Dream Products:  http://www.dreamproducts.com/neuropathy-therapy-socks-6863.html

2.  gel inserts…the ones from gelunited.com…. http://gelunited.com/Gel-Shoe-Insoles_p_17.html

These two items have been miraculously helpful along with eliminating most of my shoes except those that are wide toe boxes.  I still do the taping you showed me, along with variations that I have developed to help the tendons in my foot.

Thanks for your kind assistance.  I guess the bottom line is that we just have to keep trying things.  I was very motivated to keep walking!