Possible Sesamoid AVN: Email Advice

Good morning Dr. Blake

I found your blog by searching help for my condition, I was just diagnosed with an avascular necrosis of the sesamoid bone. 

I have an increasing pain since last august, at the beginning that was nothing, just like small cramp when I was walking but it gets worse since November. I did X-Ray and MRI and my doc in France concluded a " contusion " of the sesamoid bone and I had some insoles to wear in my shoes, but it doesn't do any real difference and the pain continue to increase. 

Finally, I saw a doc here in the US and he told me that was a AVN after taking new X-ray and MRI where we can see more cyst in my bone. As I understood, that the worst case we can have for this bone, and I don't even remember any event in my life around last summer as a bad jump or a fall ! I don't smoke, I don't drink any alcohol except a glass of wine every two or three weeks.... 

My doc wants me to wear a walking boot for 6 weeks to try to ease the pain, and he will give me my options then... But he never talks about healing the bone, only release the pain ! 

Is there anything we can do to heal the bone ? Dis it happens to someone ? I'm only 24 years old, I never had any bad health problems before, I don't run, I'm normally active but doing low impact workouts for years... I'm getting very pessimistic, I will enter in one of my most important year for my career as I will graduate soon, and I'm afraid that this condition would ruin all my hopes ... 

Dr Blake's comment: 6-9 months of Exogen bone stimulator, along with some weight bearing with orthotics and dancer's pads can turn this around. I believe avascular necrosis can only be diagnosed on CT scan, so consider getting one. If the bone has fragmented, definitely consider surgical removal. 

Does the surgery help ?  My doc told me that if we remove the bone the other bone can get the same... Will I walk normally again someday ? :( 

Dr Blake's comment: Since you did not deserve this, is there any problem with bone density or Vit D deficiency?If you are a vegetarian or vegan, you may want to temporiarily change or at least get a dietician to consult.I have never seen the other bone have a problem, but sure it could. This is one of the reasons you try to save the injured one now, even if it seems alot of time. And it is never at a good time to injure this bone. 

And my other foot begins to be painful too, but the X-ray shows nothing abnormal ... 

I'm trying to walk less as possible, I'm wearing a " step " bracelet and I set the vibration at 5000 steps, and try let it vibe as late as possible in the day ! But i'm working in a lab and you always have to go get stuff in other buildings or just walk in you own building because your experiment requires to go to different rooms.

I also stopped to workout, I was doing occasional weight lifting (no squat or lunges) and some " horizontal " bike, a thing I can do without using the ball of the foot, but I don't have the feeling it helps my bone. Should I stop everything ? I stopped for 2 weeks now. 

Dr Blake's comment: We need circulation, leg strength, cardio, and weight bearing. This is a good time to test things out to see what does and does not bother you. Simply putting the pedal of a bike on the arch can off weight the area enough to help. 

Sorry for the tone of my email, I'm completely down by the news...

Dr Blake's comment: Send me a photo of the 3 xray views when you can to see what they are calling AVN. And ask about a CT scan.

If you have any advice to give me, I would be so grateful ! 

Best,

Sesamoid Injury with Possible Surgery:Email Advice

Hi Dr. Blake,

I just discovered your blog and wish I had found it when I first looked for information on sesamoiditis.  

Almost two years ago I slipped on wet pavement and fell.  My foot only hurt a little immediately after but by the next morning it was painful to walk.  However, I'm a  teacher it's so difficult to take a day off (especially last minute since it takes several hours to create good sub plans).  So I decided to see how it felt in a few days.  I wore tennis shoes most of the time and it started feeling better.  However, a few weeks later when it got worse, I ended up with an appointment at an urgent care clinic.  That doctor had x-rays taken and said it wasn't broken and gave me a "post-op" shoe which he told me to wear for two weeks.  After two weeks, it felt better but not healed.  I had planned to continue wearing the shoe but the sole cracked in half.  Since it was over the two weeks, I decided it should be fine.  I realize now I should have followed up with my regular doctor immediately, but I didn't until the pain was bad again.  She said to try the post-op shoe again since that worked before.  And the same thing happened (including the shoe breaking after a couple weeks).  At that point I made an appointment to see her and she contacted the podiatry department for my health plan who said that I needed custom orthotics for sesamoiditis.  They referred me to a doctor out of my health plan because none of the doctors within my health plan make them.  However, that doctor was on vacation for a month.  At that point I had been reading about sesamoiditis as a chronic injury.  So I asked to see a podiatrist within my health plan to confirm the diagnosis and get some suggestions for what to do in the next month.  That doctor just suggested over the counter shoe inserts and a sturdy shoe (which I was already wearing most of the time).  He also looked at my initial x-rays and said that there may be a fracture  but there was no way to get a better picture of that area to determine because if where it was, but that the treatment would be the same and I needed to get the custom orthotics when the other doctor was available.  (When I eventually met with the orthotics doctor, he said an MRI would tell and was surprised I was told that there was no way to tell if it was broken or not but also said that the treatment was the same so I didn't worry about it.  He also said that he thought I would be in more pain if it was broken--but I wasn't sure he knew how much pain I was in because every time he asked me to walk barefoot he expressed surprise that I was walking entirely on the side of that foot and not putting any pressure on the ball of my foot.)

So finally a couple months later (6months after the injury) I had the orthotics but no treatment plan was ever discussed other than "wear the orthotics."   And I wasn't sure who I was supposed to be asking since the one doctor was out of my health plan but the other one hadn't seemed very helpful.   So after a couple months when I was feeling better I figured even a broken bone was only 6-8weeks and started going barefoot in the house.  Of course the pain got worse and eventually I contacted the podiatrist within my health plan since follow-up visits with him would be covered by my insurance.  

He ordered a bunch of x-rays that he said showed that it was not broken.  He blamed me for stopping treatment early even though I had never been given a time frame for treatment and still had to ask him multiple times in that visit to get a straight answer on when he felt I could stop wearing the customer orthotics for everything except sleeping and showering.  (He finally said two weeks without pain and I could try without them.)  

He also gave me some stretching exercises to do and said that I was probably putting a lot of pressure on the ball of my foot when I walked and the stretches should help change the way I walked.  At that point he said surgery was a possibility but I should try stretching it and staying off of it for longer and that the stretching would help me have a better outcome if I did need surgery.  The problem was that several of the stretches required that I put my weight entirely on my right foot.  So the stretches were making it worse.  Thinking that he was the doctor so wouldn't have told me to do those if they weren't necessary, I kept trying to do them even though they hurt and some I could just never make myself do every day.  Finally, I went in to see him again and he said I should only be doing the ones that didn't hurt.  I was also about to go on a long-planned extended family vacation to an amusement park.  So I asked about precautions for the trip.  He gave me a boot that he suggested using.  My friend had also suggested asking about cortisone shots so he also gave me one of those (although I researched later and saw a lot of negatives on those and wish that I hadn't).  I ended up renting an electric scooter after a few hours using the boot because it hurt my legs and hips. 

I saw the podiatrist a few months later.  At that point I wasn't having pain during the day although it was often achy at night when I took my shoe off to go to bed.  He suggested icing it and also suggested I could try short walks in the house barefoot.  School was about to start again so I said that I would wait for a month to see how being on my feet more affected me.  Unfortunately, I made a poor choice to take my kids swimming just as school started.  I told myself I would be very careful and get out if I felt any pain.  But I didn't feel the pain until the next day.  I was embarrassed to admit to the podiatrist that I over-did it like that after insisting I was going to be extra cautious.  So I just went back to being very careful, icing it, etc and tried to heal it again.  I tried using the boot at school for a couple days but it felt worse when I did that so I went back to my regular shoes & orthotics.  It was slowly getting better.  But a few months after that we cleaned out our guest room so I was carrying stuff down the stairs to the garage and the next day it was very sore again.  It got a little better but was still a little sore at the end of the day.  Then last week I was walking and I stepped down and had a sudden sharp pain in the ball of my foot.  Since then it has been very painful even first thing in the morning.  

I've made an appointment to see the podiatrist again but I really think he's going to recommend surgery (which is another reason I haven't gone back to see him in several months).

I feel like I just told you my whole life story, but I know you've mentioned looking at the big picture on your blog.  You've also mentioned that you respond to comments that have a more general audience.  So I"ll sum and ask my question in a way that may be easier to respond to:

I am nearly 40 and have been dealing with sesamoiditis for almost two years.  It gets better but the pain returns if I try even a moderate level of activity (even when wearing custom orthotics).  I'm not very active.  I'm not a competitive/professional runner or dancer who needs to get back into shape.  I'm just a mom who wants to walk to the park and play with her kids again.  At this point, would I be better off just having surgery rather than continuing what seems like a losing battle to get my foot to heal?  

If you think there are measures I should still try to avoid surgery, then I have one other question.  My doctor has ordered x-rays but I see you recommend an MRI consistently.  Since my injury was almost 2yrs ago, would it be worth it to push for an MRI now or should I just go with what my doctor uses/expects.

Dr Blake's response: I am so sorry for your situation. You would have every right to have surgery due to the length of time you have been suffering. Surgery is every successful and you just want to make sure your surgeon has done these and knows the subtleties of the surgery and post op course. How much PT? What happens if the joint freezes up? How long in a removable boot afterwards? Etc, Etc. 

     That being said, surgery is done for a non-healing fracture, not sesamoiditis. This is why I would recommend an MRI to make sure everyone really knows why you hurt. I have seen situations where the original fracture had completely healed, but the metatarsal head developed arthritis, or a bursitis had developed, or excessive scarring. So, without an MRI to tell you that the only source of your pain is a non healing fracture, I could not at present recommend it. Also, non healing fractures can heal with 9 months of Exogen bone stimulation, rigid sole shoes, orthotics that do off weight the sesamoid, dancer's pads and spica taping, icing and contrast bathing, and making sure your bone density and Vitamin D levels are healthy. 

     So, step 1 MRI. Based on the MRI results, step 2 can be another smarter approach at conservative management if seems reasonable or surgical removal of the damaged bone. Keep me in the loop and I sure hope this helps you. Rich

Thanks for any help you can offer!

Fat Pad Atrophy Article

http://meeting.nesps.org/abstracts/2015/85.cgi

Someday it will be easy to get an injection to restore the fat pad when you need it. 

Hallux Valgus/Bunion: Email Advice

Thank you so much for taking the time to provide this advice! I am a 30 yo with hereditary hallux valgus. I rarely ever had bunion pain - even through 16 years as a ballet dancer and 4 years on pointe! About 6 months ago I took up two new hobbies: a Japanese martial art called katori and ballroom dancing and my MTP joints have started aching. These conservative options are exactly what I was looking for in hopes that I can slow the bunion progression. I'm especially grateful for your recommendation of a night splint. I spent hours reviewing these but could never decide which is best and which are bogus. 

http://www.drblakeshealingsole.com/2012/07/how-to-conservatively-treat-bunions.html

I have a few questions, if you’re still monitoring this thread and have the time to answer:
1. What is your opinion on menthol-containing products like Tiger Balm and Biofreeze? Would they be a good idea in conjunction with the massage? Definitely!!
2. I found one video you posted on bunion taping (incidentally, I have learned a lot on Lisa Howell’s site). Would that work with Rocktape? Definitely!! If not, might you recommend a method for bunion taping with Rocktape? There are so many options for taping that I have no idea where to start. 

http://www.drblakeshealingsole.com/2011/05/taping-with-kinesiotape-for-bunions.html

3. I also found the video you posted demonstrating metatarsal doming exercises, and I’m eager to start those. Are there any other exercises you recommend for strengthening the small muscles of the feet? (Besides the balancing one in another of your blog posts on bunion care – I can balance on each foot with my eyes closed, but I make sure to do that regularly!)

http://www.drblakeshealingsole.com/2015/07/bunion-and-general-foot-strengthening.html

I would really appreciate any advice. I’ve read through much of your blog and you seem like exactly the type of podiatrist I would like to find! I will, of course, go see a local podiatrist, but it will be a few months before I can see one on my HMO plan and I want to start as soon as possible to relieve pain and, most importantly, slow the progression of the deformity.

Dr Blake's comment: Thanks for your kind words. I hope this helps some. Rich

Severe Plantar Fasciitis and Oral Cortisone: Email Advice

Dear Dr. Blake.
Thank you so much for posting and blogging about Plantar Fasciitis /Bursitis.
It has been very helpful for me.
In my hospital in Amsterdam i had all the treatings. I do not
have to name it again.. I told my orthopedic doktor about oral cortisone and he was
at least suprised. He never heard of oral cortisone with Plantar Fasciitis.

http://www.drblakeshealingsole.com/2010/12/oral-cortisone-king-of-anti.html

He gave me a cortisone injection.
No pain relief. Yes for 4 day.s..

At the moment i.m in Marbella/Spain.
Also here i have had, Fysiotherapy, laser. insoles...
no happy end . Pain and pain.. of course I used also ibuprofen, paracetamol,
naproxen and so on and so on.
I.m desperate.. 

Reading your artikel about Oral Cortisone..
And the Prednisone Burst.
I want please to ask you.
You are working with sport men and woman.
I.m a fragil woman from 70 years old and my weight is 60 kg.

I think that for every person the quantity of oral prednisone can be different.
So in my case what do you advice me ?? How much is responsable for me, as an old fragil woman to take ?

Dr Blake's comment: Please ask a pharmacist  if age and weight are a factor. I have not come across that. 

Considering the fact that I also have a severe pulmonary fibrose IPF, and i.m on PIRFENIDONE.
Thats  a very heavy and strong medicin.
The regular dose of Pirfenicone = 9 pils a day, but I can only handle 6 pils a day.

https://en.wikipedia.org/wiki/Pirfenidone

Dr Blake's comment: Your doctor treating the fibrosis, and the pharmacist mixing the drugs, would be the best at commenting if a 8 day course of oral cortisone would be contra-indicated. 
 
I would be so happy to hear from you and listen to your advice.
Yesterday I started with 2 pils of 5 mg (togehter) and it was too strong already.
My body was shaking..and sweating and so on..
Dr Blake's comment: That is probably your answer not to take. Sorry.  If you can get an MRI or Ultrasound, see if you do not have a plantar fascial tear. The treatment would be a removable boot for 12 weeks but you do not need the medicine then. Good luck . Dr Rich Blake

Yes i hope you have a little time to answer me.
Thank you so much Dr. Blake and I wish you all the best..
LOve.

For Stephen Curry Fans to Enjoy!! Math Analysis

http://fivethirtyeight.com/features/stephen-curry-is-the-revolution/

Accessory Navicular: Email Advice

I am enjoying your website. It has helped me to understand my navicular syndrome.

I am 64 and didn't have any problems till 2 years ago, thought I had a fracture but 

Dr informed me of my extra navicular bone in each foot.  Got thru that episode on my right foot after 3 weeks of rest etc.

Now, I wake up in the night with Left ankle pain, can hardly walk till I take ibuprofen, ice my ankle, wear my boot shoe and elevate. By afternoon it subsides and I can get around pretty well. This has happened for 3 nights now.

I do put pillows around my foot at night, it feels good. I do have a bone that sticks out on each foot.

Dr Blake's comment: Does the left ankle hurt at the bone? Does it hurt to put weight down or to move the ankle in circles or both? Answer by commenting on this post and I will reply to your comment. You should be icing 10 minutes 3-5 times a day and try the kinesiotape circumferiential wrap. The taping for the posterior tibial tendon dysfunction problem is probably the best for you. 

Your videos on taping and exercise have been informative.

I started doing the first exercise gently.

Any tips on how not to aggravate it during the night. Am I just stretching it in my sleep enough to upset the tendon ?

Dr Blake's comment: Try the posterior sleeping splint for plantar fasciitis. Works well at night for this. 

I wear my ankle compression sock or ankle brace on some nights.

This is getting in the way of my daily gardening etc.

Dr Blake's comment: Use a removable boot anklizer type just for gardening (you can put your orthotic and tape inside the boot).

Okay, not that type of boot!! Good luck, and get an MRI soon if it is not turning the corner. 

I do wear arch supports in my shoes. Ive tried a number of different types. Some aggravate it even more. 

Thank You for any help. I would rather avoid surgery. 

I use to work in SF years ago. I live North of Portland in WA now.

Frozen Ankle post Sprain: Email Advice

Dr. Blake,

Good afternoon.  I just came across your blog and I just want to say thank you for taking your time to respond to so many people!  I would love any information you could provide me after I tell you about my injury. 

Ok, so here we go. March 16, 2015, I went to one of those wonderful trampoline places for a birthday party and badly sprained my left ankle.  I had to be carried off and my ankle swelled up instantly.  It took me about a month to get an appointment to see a podiatrist.  In the meantime, I kept it iced, elevated, wrapped with an ankle brace and I was using crutches/cane/knee walker to get around.  My first appointment with the doc,  after x-rays, I did not break anything.  He said it seemed like a 3rd degree sprain with a high ankle sprain and it was frozen, which does not happen very often after a sprain.  He said this happens maybe 1 in every 1,000 sprains. Just my luck, huh?

Dr Blake's Comment: High ankle sprains involve the ligaments between the two ankle bones (tibia and fibula). When those ligaments get sprained, you lose forward bend of the ankle, thus "a frozen ankle". The more common lower ankle inversion sprains have full mobility to bend, it is the side to side ligaments that were injured and have to be protected. So, everything makes sense so far. Rich
 
I was put in a knee-high air boot, weight bearing and sent to physical therapy and  to check back in 6 weeks later.  After about 2 weeks, we realized my ankle was not moving or going to start moving, so we moved my check up to be seen earlier.  I had an MRI, and my doc said it was a basically a frozen joint and still the high ankle sprain and 3rd degree sprain. 

Dr Blake's comment: This is good medicine to get an MRI early in the game to rule out cartilage or bone injury. So far, you have been in the Immobilization Phase, and you are not going to gain alot of motion at this point until you are out of the boot. So, everything still seems normal. 

 We tried numbing it in the office about 3 times and tried to manipulate it, but that did not work.  So, he wanted to try a manipulation under anesthesia, where I could not fight him, but my insurance didn't cover that.  We are also in June 2015 by this time.

Dr Blake's comment: So, since a high ankle sprain can take 12 months or so to gradually loosen up as you balance pain free protection with gradually more and more stress, why was there so much concern about your ankle. Was it totally locked? How much did it hurt? What was the range of motion with the knee straight bending the ankle and with the knee bent? Do you have an excessive scar formation problem? Are we 100% sure that there were no bone/cartilage injuries?

  I was supposed to have surgery right after 4th of July weekend and found out that my surgery was not approved less than 24 hours before my procedure.  They would only cover the scoping.  My doc didn't want to just cut into me, so we tried to appeal the surgery and 30 days in, we found out the appeal was never started, so 60 days total, it was denied again.  This is now September, and by this time I would have rather him do both, the manipulation and scope, to be safe because the joint has been frozen going on 6 months now.  So, we scheduled my surgery and after it being cancelled one more time, the big day was October 22nd.  I had my one week follow-up and he released me to start back up physical therapy.  My 2 week follow-up, he removed the stitches.  We wanted to be aggressive with the therapy so the joint did not freeze up again, but not too much so the body went into shock and froze up by being to forceful too soon.

 

My physical therapy doc wanted to start dry needling me, but we had to wait until I could do a good stretch.  By the beginning of November I was being dry needled twice a week and she started grastoning me as well.  She thought because I had such short movement from the knee down for so long, that my muscles were so tight and that is why my ankle could still not move up very well.  I went from PT 3x per week, to 2x about a month ago.  In January I had a follow-up with my foot doc and he released me to full physical activity like I used to before my injury.  I was pretty active, working out pretty much everyday, so not working out for about the last 10 months or so has been killing me.

 

Ok, so I've been going to pt since my first post op and doing all my home stretching and my ankle is still not moving very well.  The front is better, but I am super tight in the inside,  like I can feel it pulling when I try to move my foot upwards.  After many breakdowns at pt, my pt doc told me a frozen ankle can take 1-3 years to fully heal, called it "a thawing out period".  After accepting that a few weeks ago, I am still not convinced.  I am tired of everyone telling me this does not happen very often and not really sure what to do.  We get it to stretch pretty good while Im at pt, but then it freezes back up.  I want to know what to do to fix this.

Dr Blake's comment: You definitely want a new MRI, because a one year comparison can tell you what is wrong and if there is anything to do to fix it. But, what did the surgery find? Too much scarring? Scuffed cartilage? More info on this tight ankle is needed. Make a comment to this post and I will reply directly to the comment. Yes, these can take this long, but I agree something does not make sense. Something is missing. 

 

Last week, I went and got a second opinion from another podiatrist.  He took more x-rays and looked at my MRI from before the surgery and I had pics from my scoping.  He told me it looks like he only scoped the front of my joint and not the back.  He showed me my MRI and the notes, and  there was no evidence that it was a high ankle sprain.  He said I did a number on it, but in the lower bones, I banged both together in 2 spots and he showed the bruising.  From the x-rays, he said it looked cloudy in the back part and when he showed me that my heel doesn't move side to side, because he believes the scar tissue it still there.  That was a pretty hard pill to swallow.  He recommended getting a steroid shot and ordered a JAS splint for my ROM issues.  The doc said he had a similar patient and he did the scope of the ankle and then put a cushion in the back to help with movement and she is at 80% mobility.  Here I am 4 months post surgery and unless I am very warm and all my weight is stretching the joint, I am not where near that.  I didn't get the shot that day, but I have it scheduled for Monday, Feb. 22, and I am very nervous.

Dr Blake's comment: Okay, now we are getting somewhere. So, I am sorry I am answering this after that appt. Definitely opt for a new MRI. If the initial MRI was misread as no bone injury, no wonder you are not better. If you injury bones, they need to heal before you can begin to get mobility back. I did have a PT who could not work for 3 years waiting for her bone edema (swelling) to completely resolve. Exogen bone stimulators can definitely help, along with flushing with contrast bathing nightly. There is still hope. Can you send a snapshot of the MRI image or two that shows the one edema?

http://jointactivesystems.com/

 

I have a follow-up with my main doc on March 1st and I am going to ask if he scoped my whole ankle or just the front.  I am also going to ask about my MRI. 

Dr Blake's comment: Most docs just scope the front in these cases, the back being too hard to see. To access the back potentially can cause more tissue damage or scarring, so he probably erred on caution which makes sense. 

 

I guess my question to you is whether you think the shot is a good idea? 

Dr Blake's comment: If you had a shot on your visit fine, but keep them to a minimum until you know the bone/cartilage has completely healed. So get another MRI, get an Exogen bone stim if the bones still light up, get me some pictures. Hope this helps you somehow. Rich

 That is how I came upon your blog, looking up info about the steroid shots.  When they told me they would have to inject the shot into the ports where I was scoped, I freaked out because I am still in pain when my therapist tries to work on the scars.  I am only 31 and I just want to be able to be active again.  I thought after my surgery, I would be fine and now to find out that it is still frozen in the back, I am not sure what to do.  I asked the doc I had the second opinion with, was all this dry needling to get my foot to move basically a waste if the scar tissue is still there?  He said it isn't hurting anything, but I said it isn't really helping anything either and he said no.  I just spent the last 4 months going through some rough stuff and to find out my ankle it still messed up, I don't even know where to begin.  I have been reading reviews about these shots and I am reading more negative ones than positive.  I just want to make sure I am doing the right thing.  I really hope this and the JAS splint helps, because I really do not want to go through another surgery if possible. 

 

Any help would be greatly appreciated.  Thank you for taking the time to read this.

 

Very Respectfully,

Words to Live By

This was an email sent from a friend. I agree with everything said. It is always good to reflect alittle on how we are living on this earth. Love, Rich

As we grow older, and hence wiser,

we slowly realize that wearing a $300. or

$30.00 watch   - - - - - - -

they both tell the same time...

 

Whether we carry a $300 or
$30.00 wallet/handbag - - - - - - -

the amount of money inside is the same;

Whether we drink a bottle of $300 or $10 wine - - - - - - - - - -  - -

the hangover  is the same;

Whether the house we live in is 300

or 3000 sq. ft. - - - - - - - -

loneliness is the same.

 

You will realize,

your true inner happiness

does not come from

the material things of this world.

 

Whether you fly first or economy class,

if the plane goes down - - - - - - --

you go down with it...

 

Therefore.  I hope you realize,

when you have mates,

buddies and old friends,

brothers and sisters,

who you chat with, laugh with,

talk with, have sing alongs with,

talk about north-south-east-west or heaven & earth, ....

That is true happiness!!

 

 

FIVE UNDENIABLE FACTS OF LIFE:

1. Don't educate your children to be rich.
Educate them to be Happy.
So when they grow up they will know
the value of things not the price.

2. Best awarded words in London ...
"Eat your food as your medicines.
Otherwise you have to eat medicines as your food."

3. The One who loves you will never leave you
because even if there are 100 reasons to give up

he or she will find one reason to hold on.

 

4. There is a big difference between

a human being

and being human.

Only a few really understand it.

5. You are loved when you are born.
You will be loved when you die.
In between, You have to manage!

If you just want to Walk Fast,

Walk Alone!

But if you want to Walk Far,

Walk Together!

 

SIX BEST DOCTORS IN THE WORLD:
    1. Sunlight
    2. Rest
    3. Exercise
    4. Diet
    5. Self Confidence and
    6. Friends


Maintain them in all stages of Life and enjoy healthy life.

 

Sent with Smiles,
Affection and Love !!

Post Sesamoidectomy

Hello again dr Blake!

At 10 months after tibial sesamoidectomy I'm happy to report some progress. There has ben no severe flare-ups since November. I have been able to do all my daily activities pain free (working, even standing for up to eight hours in the OR, shopping, walking to the store etc) and have noticed that I've gained back my usual, quite fast walking pace. I've also started the walk-run program, and progressed up to 3 minutes of running but at that point there was some pain again so now I've got to start over at 2 minutes. Somehow, running seems a lot worse for me than walking, even though I have a thicker dancer's pad while doing that. The winter weather has been very crappy (pardon me) this year, and I've not tried cycling yet. It's a hobby I used to love and I'm anxious about not being able to do that again.
I'm happy about living pain free now, but still I long for the long hikes and cycle rides I used to do... Should I just forget about those now and find other hobbies? Can I still expect progress this long after the surgery?

Dr Blake's comment: Definitely, as you gradually stress the joint, the scar tissue will become more normal, and the body's own neurological protection will lessen (less sensitiivity). Hope you are continuing to ice twice daily to keep the inflammation down, even on relative non-exercise days. Making sure the biomechanical support and off weighting is correct is crucial in the Walk Run Program (link below). Thanks for inspiring others with a similar situation. It is typically a 2 year post op course. 
I'm contemplating about getting PT to analyze if my gait is stressing the sesamoids too much, and also to guide with some exercises for the foot. It's hard to find the time for rehabilitating the foot with my busy schedule and now that I'm pain free on 90% of the days, I just kind of forget about it...

Wishing you a lot of sunshine in the coming spring!

http://www.drblakeshealingsole.com/2010/03/walkrun-program-for-injury.html

Referral Source: AAPSM for quality sports medicine

Hello Dr. Blake,

I am a nurse, 66, very active (till recently) with hallux limitus. I had the issue a few years ago but it went away with shoes, rest and so forth.  I would like to see someone like you in the Austin Texas area (or fly to see you if necessary - this could be difficult but I would do it!) but cannot seem to figure out how to assess by websites.  I have seen one person so far but did not like his nonconservative approach as I think orthotics and PT could really help.  Short of learning how to tape and get shoes and orthotics from web reviews I feel kind of on my own.  Austin must have some good people but I cannot find.  I wonder if you have heard of anyone here from one of your professional meetings or so forth?  I know if you mentioned a name that would not mean you know they are good, but just that I would go see and assess for myself.

I really want to do the right things for myself.  I stopped jogging and don’t want my overall health to deteriorate because of pain but also don’t want to ignore the pain.  I just bought 2 pairs of Finn Comfort shoes with a sort of rocker bottom and I am feeling lots better after that.

Thank you for your time and being so great!


Thank you so very much for your email. I am past president of the AAPSM (link below), and the members in general are more into sports medicine and keeping their patients going than most podiatrists. This is where I would start. There are 4 podiatrists listed from Austin and I personally know Drs Valencia and Brace. Good luck!!
http://www.aapsm.org/members.html

Children's Health Article

With the rise in childhood obesity and diabetes, this article emphasizes the role of moderate to vigorous activity to improve health. 

"Physical activity seemed to be the main explanation for the differences in childrens’ adiposity. Every 10 minutes per day of moderate to vigorous physical activity was associated with 3.5 percent lower body fat at the end of the study, even after adjusting for fitness levels and the amount of screen time. This amount of exercise was also linked to a 4.8 percent increase in insulin sensitivity."

http://www.reuters.com/article/us-health-children-adiposity-diabetes-idUSKCN0VI24L

Exogen Bone Healing System recommended by Dr Blake

http://www.exogen.com/non-union/

     Over the last 10 years, Exogen has been the only bone stimulation system I have used. I am very pleased by the results. I have no financial connection with this company. My patients use 20 minutes once a day for 6 to 9 months. It has almost eliminated surgery for some injuries like sesamoid fractures. 

Post Op Sesamoid Removal: Email Advice

Hi Dr. Blake,

I'm not sure if this is the best thread to ask my question on, but I couldn't find exactly what I was looking for.
I just had my stitches taken out yesterday from having my sesamoid (tibial?) removed. I had the same procedure on my other foot 4 years ago by an awesome doctor in Monterey. Unfortunately, this time it was done by a Navy doctor and I had no choice. They don't seem to care all that much about recovery and follow up and the only instruction I was given yesterday was to grab my big toe at the base and push it as far forward and backward as I could for an hour a day. She said if after a month it's stiff, then I could do PT. Does that seem normal to you? Last time I did PT right away for a couple of weeks. 

It just seems really stiff and there is a lot of numbness. Nothing like last time. I just want to make sure that there isn't anything else that I can be doing since I've been left to my own devices for healing it.

Thank you so much for any info you can send my way for stretches or ice/heat therapy suggestions for 2 weeks post op!

Dr Blake's response:

Hey Amber, sorry for my delay in responding. I hope you are healing well. You should definitely get a referral for PT which is typically started between 2 and 6 weeks post op. Three times daily you should either just lay your foot on an ice pack for 15 minutes or do contrast bathing (as long as you are doing something three times daily to influence the joint swelling). I do not think you should just move the joint up and down (see my post on Hallux Self Mobilization). Do you have protective orthotic devices and/or can you make dancer's pads, but it is important to off weight the surgical area for the next year at least to some degree? You can definitely start doing metatarsal doming three times a day, and even flat footed balancing with the ball of the foot off the ground. Hope this helps you some. Rich

Photo of the Dancer's Pad Placement 

http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

http://www.drblakeshealingsole.com/2010/09/hallux-rigidushallux-limitus-self.html

Recurring Tendinitis (primarily peroneal): Email Advice

Hi Dr. Blake,
I have had recurring tendonitis diagnosed in various tendons in my lower leg and foot over the past 2 years. Started with overuse sesamoiditis, posterioal tendonitis and peroneal tendonitis. MRIs of foot, knee and even back after an EMG because of calf muscle atrophy. I am a climber so this constant injury is very frustrating to not be able to walk lain free, let alone climb. A podiatrist and now an orthopedic surgeon recommend a tendon sheath injection for the Peroneal tendon issues. I have pain at attachment under arch and at side of calf below knee. Weakness and increase pain wih movement. Also tendon pops at ankle. I have done pt and various therapies only to platue. Do you thimk the shot is best way to go? What questions do I need to be asking to make sure it is safe?
Thanks, Sarah 

Dr Blake's response:

Sarah, sorry for my delay in responding. I am assuming that the MRIs only came back with tendinitis and no tears. The PRP injections are gaining popularity, make some sense, but I just have no experience with it to recommend clearly. Definitely no cortisone into the muscle, tendon or sheath for fear of rupture due to transient weakness (which could last up to 9 months). Review the blog article on BRISS for tendinitis. See if there is anything missing in your treatment. Have you been adequately immobilizing in a below the knee removable boot for up to 3 months? Do you then to supinate excessively even with orthotic devices? When you return to activity, do you just go back to an overuse situation? Sounds like unless you can not get the tendon strong, it will be permanently the weak link for activities. How can it be made stronger? Or why haven't the PTs been able to make it strong? Sorry more questions than answers. Rich 

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Positive Link between Probiotics and Diabetes Improvement

http://www.newsmax.com/FastFeatures/diabetes-probiotics/2016/01/10/id/708878/

CRPS: National Study On Right Now: Participants Needed

http://www.studycrpsnow.com/

Calmare Pain Therapy for Foot Nerve Pain: Email from Patient

This email was Happy New Years to me. I have been working with this patient for many years. I recommended Calmare Pain Therapy several years ago. She had to drive to the doctor's office, stay 2 weeks at a hotel, and get the 10 required treatments to help her very severe left foot nerve pain. She may require some booster treatments in the future. Right now she is very gradually testing out her new left foot!! 

Happy New Year!!! 

I’m emailing you with fabulous news about the effects of the Calmare pain scrambling treatments that I received in December. 

After 10 sessions, the intensely debilitating nerve pain has drastically dissipated! Words can’t even touch the depth of gratitude I feel and the degree of excitement I have with this increased mobility in my life. Since Dec. 22nd, I’ve danced for 10 minutes at least 3x, have walked with a friend for 50 min, have gone window shopping with another friend, and even baked muffins! 

I’m taking things s l o w l y and steadily to ensure that I remain on this healing path. Wow, there’s nothing like an absence of nerve pain to bring out the giddy “kid in a candy store” and the “where do I want to travel to first” parts of me. I’m embracing this moment fully with glee and at the same time, am humbly moving forward to stay within the zone of diminished nerve pain. I am sooooo thrilled!!!! I still have joint, tendon, and ligament pain in the ball of my big toe joint and throughout the tendons and ligaments that connect to it. However, now that the nerve pain has diminished, I trust I’ll be able to tend to these mechanical issues with greater and more rapid success. Aho!

Thank you from the bottom of my heart for your prayers. I deeply appreciate you holding my healing journey within your heart and for your prayers during these treatments. I connected to the web of support many times while receiving these treatments  and want you to know how palpable and significant your prayers were … and are. Thank you. Truly, thank you.

(And, if there is anyone who didn't receive my prior email, please forgive me as I’m sorting through my 800+ contacts and I very possibly missed you.)

For those of you from the Bay Area dance community, I hope to see you soon - even if for 10 minutes at first - on the dance floor. I look forward to being with you within the non-verbal depth of our meditation practice and welcome connecting with you there. And for all of you from the Bay Area, I’m now available for walks in nature - as long as you’re open to sitting together at the midway point to rest and commune with the elements.

I wish you a year of rich and heartful connection with all that brings joy to your world. And, I wish for this planet and for all sentient beings who live upon it, that this is a year when the human race acts on greater behalf of this generous, amazing, abundant, stunning, and interdependent orb of life.

Love to you,

Swelling: Contrast Bathing to reduce swelling after injury

Contrast bathing is one of the best ways of reducing swelling. This is even true for deep swelling in the bone/soft tissue which is not visible to the eye. The normal routine involves:

• Obtain two containers large enough to accommodate the body part involved.
• Place the two containers side by side, one is filled with ice and cold tap water (approx. 55 degrees F), and the other filled with warm/hot water typical for a hot tub (approx. 100 degrees F). Use your fingers first to test that the warm water is not too hot.
•  Place the body part in the warm water first for 4 minutes, and then immediately into the cold water for 1 minute. This is a perfect technique for feet, ankles, and hands.
• Repeat this cycle for a total of 4 times totaling 20 minutes.
• You should also feel that you are looser and less swollen.
•  Attempt to do this once a day on work days, and twice daily on your days off.
•  Move the body part through a pain free range of motion while immersed in the warm water.
• Continue contrast bathing for 1 week longer than you think you would need based on your symptoms.

As long as you are using ice in the cold bath, it is not necessary to try to keep the warm container near 100 degrees F during the full 20 minute cycle. As long as there is a good difference in temperature, you will obtain the desired result. The warm water causes vasodilation increasing blood flow, while the cold water causes vasoconstriction decreasing blood flow. By going back and forth between the two water baths, you can create a mechanical pump for the swollen area. While immersed in the warm water for foot or ankle injuries, pretend your big toe is a paint brush. Gently move through the letters of the alphabet, using both big and small letters, then on to hieroglyphics, or Chinese lettering. While immersed in the cold water, keep the body part still.

This is an 80% heat to cold ratio with the goal of reducing swelling. Following the typical 3 days (72 hours) of ice after an acute injury, I find it helpful to slowly build up to this amount of heat/cold ratio. For 3 days, I will use a 1 minute heat alternating with 1 minute cold cycle (1hot/1cold ratio), repeating 10 times, for the same 20 minutes. If the body part is less swollen and the patient feels less stiff, I will advance the patient to 3 days of 2 hot 1 cold ratio repeating 6 times for 18 minutes. Again, if the swelling is reducing and the range of motion feels better, I will advance the patient to 3 minutes heat and 1 minute cold repeating 5 times for 20 minutes. After 3 days of further improvement, then on to 4 hot and 1 cold as described above. Normally, if the swelling has been around for 2 weeks or more following an injury, it is okay to start at the 4 to 1 ratio. If you aggravate your injury during the contrast bathing phase, just return to ice for 3 days or more until the symptoms have stabilized. Following the aggravation, normally the 4 to 1 ratio is fine to restart. Never use heat, only ice, immediately after an injury or with re-aggravation of an injury.  To summarize the above:

Days 1 to 3 Ice Alone
Days 4 to 6 Alternating 1min warm/1min cold cycles repeat 10 times
Day 7 to 9 Alternating 2min warm/1min cold cycles repeat 6 times
Day 10 to 12 Alternating 3min warm/1min cold cycles repeat 5 times
Day 13 and on Alternating 4min warm/1min cold cycles repeat 4 times



Contrast bathing should never make a patient feel more swollen and stiff. If so, you are using too much heat and must begin to experiment with less heat as mentioned above. However, it is worth the effort. Contrast bathing can produce incredible gains in range of motion, pain reduction, and lead to quicker returns to activity. A wonderful addition to contrast bathing is elevation. With the increased blood flow due to contrast bathing, immediately dry off, wrap the area with some form of compression, lie on the floor, and elevate the injury as high as possible for 20 minutes. You can gently move the ankle up and down to help the drainage process. For most foot and ankle injuries, lie on the floor and get the foot up on the wall or couch way above your heart level. I call this Super Elevation!!!

Since the typical ankle sprain leads to swelling for 3 to 4 months, and a bad ankle sprain can be swollen for over 1 year, you may be contrast bathing for awhile. Be a good multi-tasker, but never do contrast baths near a power surge. As the soreness goes away, you may experiment with just 20 to 30 minutes of warm water soaking alone. See if you get the same results. Good luck.

Rehabilitation of any injury is a logical game if you know the rules. Inflammation can get much worse with heat, so ice initially, and then as you aggravate or irritate the injury as you move through the rehabilitation process, ice some more. Ice is for initial injury for 4 days, and for months and months with repeated irritations. So, there will be many days where you ice and contrast bath both at different times of the day. You have to distinguish between the chronic pain with swelling (time for contrast bathing) and the acute pain of aggravation (back to ice). At times the aggravation can be for 2 days to 2 weeks, so the icing alone will feel like you are back at square one. The rehabilitation process for patient, therapist, and healthcare provider is one of learning to minimize these aggravations/irritations while allowing as much function as possible.

And more Adele....