Possible Sesamoid AVN: Email Advice

Dear Dr. Blake,

First of all, thanks so much for the invaluable website. Your knowledge - and the experiences shared on the website - have provided me with so much support and education whilst I've battled through the sesamoid minefield!

Here are my details:

• Active 27 year old;
• Pain in the area of my right lateral sesamoid for about 5 weeks;
• Before the pain started I ran about 5 miles 3 times a week;
• I think a spin class, in which I had to wear tight fitting cycle shoes and pedal right over the sesamoid area, triggered my pain, but from MRI images my doctor thinks it has been fractured for years.

For the first week or so the pain was intense. So intense I could walk only on the outer edge of my foot.  So intense it kept me awake at night and even the pressure of the bed sheet hurt!

After the first week the pain got much better - I started wearing a gel dancer's pad and think that helped to take off the pressure from the area.

Since then, the pain is always there, but it's minor. I can walk "normally" and the pain is a 2 or 3. It's just really annoying. Occasionally it gets worse and is more like a 4 or 5; doesn't seem to be any rhyme or reason to this - it can get worse even when I've been lazing around all day and haven't been on my feet much.

I'm too scared to run - it feels like I'm living my life on a tight-rope right now and that one bad move will put the pain right back up and undo any healing I've helped promote. Does that make any sense? I'd give anything to put back on my running shoes and go for a run - I don't think it would cause pain during the run but I'm terrified of making it worse.

My doctor thinks my lateral sesamoid is AVN and said the MRI shows "signs of degenerative change" around the area. 

His view is that I should try custom orthotics (they'll cost me nearly $1000) and then if it's still causing me pain in 3 months, surgery is the only option and is "risky" with "potential side effects". I get the impression he thinks I should just "live with this". Apparently I should avoid getting a shot because it could make it worse?

I'd be so grateful for your thoughts: does this look like AVN to you (MRI pic attached)? Apparently he thinks it is AVN because the lateral sesamoid is "black"? If it is AVN, can the sesamoid recover from this? If not, when it "dies" completely could it become symptomless?

An article I read by you online suggests a CT could help to diagnose AVN and that an Exogen bone stimulator could help; what is your thought on this? Your article actually resonated with me so much because it sounds like my exact situation, I couldn't believe what I was reading because I feel exactly the same as this patient: http://www.podiatrytoday.com/blogged/treating-possible-case-avascular-necrosis-sesamoid-bone

Best wishes and thanks again for the great website,

Dr Blake's response: Thanks for your kind words and patience with my response. I am sorry I could not put the image on my blog, but it had your name in the corner. However, it looks like a normal healing fracture of the sesamoid, the black on that view is the bone swelling. On the images that show normal bone black, the sesamoid will look white. The initial healing of a fractured sesamoid is 3 months, and I do not like my patients to push off during that time. They typically wear an Anklizer type removable boot, with a insert with a dancer's pad. You can go out and buy OTC inserts that provide cushion at the front of your foot and some arch support. You can buy 1/8th adhesive felt from www.mooremedical.com to use for your dancer's padding. You can use the 

https://www.powersteps.com/product-pages/original

powerstep insole above to attach the dancers pad and even apply more arch. If the area under the sesamoid is still too hard, you can sand down the buld in half. Work on the swelling in the tissue with twice daily 10 minute ice packs, and evening contrast bathing. Before you get out of the boot, get your CT scan and look for the sign of AVN called fragmentation. I have had patients become asymptomatic with AVN, but it takes a year to know where it is heading. You typically qualify for an Exogen bone stimulator at 3 months post initial MRI or xray if the ordering physician repeats the test and documents delayed healing. The 4th and 5th months are the months that you begin to wean out of the boot into normal shoes. You have to be maintaining 0-2 pain levels and this rule dictates what you need (what does it take to keep the 0-2 pain level): carbon insoles, custom orthotics, rocker shoes, spica taping, etc etc. Hope this all helps and makes sense. Rich

Sesamoid Fracture: Email Advice

Dear Dr. Blake

Thank you for all your efforts that you put into this blog - tremendously helpful for people like me that are suffering from a sesamoid fracture.

Here a side view using CT scanning showing the broken tibial sesamoid with different bone densities acoss the fracture

This bottom view of the tibial sesamoid using CT Scanning shows that it was bipartite before the injury due to the rounded nature of the fragments across the fracture site. 

My sesamoid fracture happened around 4 months ago (stepping too hard on that bone on a hard surface) and I broke it twice again since (after week 5 then after week 12 due to too much pressure). Before the latest trauma I was walking almost normally again (therapy was no sports, little weight on the sesamoid, carbon sole, taping big toe, gradually increasing weight, no crutches or cast).

Now, the fracture seems not to be healing again and is terribly sensitive. I use crutches since the last trauma (due to awful tenderness on palpation on the fracture; four weeks now) and an orthoic similar to the one you describe (insole with soft pad under the broken bone with weigh support on the arch and 2-4 metatarsal; stiff sole with rocker bottom). However, the third trauma resultied in a new stinging pain that goes up to the knee on a light touch on the sesamoid and I cannot take benefit of the orthoic so far.

You can see the tremendous reaction of the body to this injury which looks like gout, and gout could be layered on top of the sesamoid injury. This could also suggest RSD which is an over-reaction of the nervous system leading to vaso constriction and vaso dilatation episodes (vaso motor insufficiency). 

Received diagnosis so far (X-ray week 3: bipartite sesamoid, bone bruise; MRI week 7: fracture or stress fracture of medial sesamoid; CT week 12: sesamoid fracture, with bone bridge after some healing). I enclose a few CT and of course would be happy for any specific advice you have to get the healing process started again (I read most for the relevant entries in the blog). As I have a family I am completely stuck and I am desperately looking for a way forward!

My specific questons:

- Where I am not sure on your advice on the blog is, if during the initial period following the trauma you recomment total immobilisation with NWB for some time or if is advisable to put some weight on the foot (e.g. with using crutches) also at an early stage to the extent pain remains 0-2?

Dr Blake's comment: I would definitely see if you get great pain reduction with an Anklizer type removable boot with your orthotics inside to off weight. We always want as much weight as possible as long as you can keep the pain within 0-2. I would discuss with your doc about the redness and the possibility of gout flare or RSD flare. Both would influence what is done next. 

- Would you also recommend some very light physiotherapy at an early stage to increase blood circulation (e.g. moving the big toe lightly, soft massage on the inflammated area) or to leave it completely?

Dr Blake's comment: You are going to need to find a good PT that understand this, so starting now is great and being proactive. Just to avoid the development of nerve hypersensitivity you want to massage the area 3 times a day with NeuroEze, Biofreeze, or another cream/gel recommended by your doc. Nonpainful massage is wonderful and desensitizing and moving swelling. 

- Is it in your experience now rather likely, that after two repeated traumas it is much less likely to heal (pseudoarthrosis) and therefore it would make sense to look into surgery rather sooner than later?

Dr Blake's comment: Yes, and no. Repeated traumas can cause worsening of the fracture, but it is probably just making it longer to heal. Since you have passed the 3 month level, you should really get an Exogen bone stimulator for a 6 month rental. It will reduce the chance of non healing for sure. 

- Any idea how to bring the inflammation down?

Dr Blake's comment: Massage, not continuing to irritate, see if contrast bathes help, but start with one minute of warm water (100 degrees) moving your toe up and down, then 4 minutes of cold tap water (no ice), alternating for 15 minutes total. If that helps you can slowly add more time to the warm, and less time to the cold. Hope all this helps you some. Rich

Best regards

Possible Sural Neuritis: Email Advice

Hello:

I saw you blog and figured I'd give it a go.  I also want to walk to Camino in Spain - I need to conquer this sural neuritis first.

Anyhow - I'm male and 44 - basically healthy. It started about 7 months ago ( about a month after I'd taken cipro) with ankle pain - the podiatrist said it was plantar fasciitis - then Achilles tendinitis - then I got an MRI and there was a small tear in a minor tendon than goes to my ankle - in which I was referred to another podiatrist/orthopedist who diagnosed the sural neuritis and gave a nerve block which did nothing - I have pain in my heal, outside ankle and Achilles - it's barely noticeable in the early morning and gets worse throughout the day as I'm on my feet quite a bit.   I many times find that sitting later in the day is the most painful and walking is better.  I used to run and could easily stay on my feet all day with no pain.  My current Dr. Says it's just a waiting game now to see if it heals - he says I can do any athletic activity I'd like but I might pay for it in the following days (and I do).  While my ankle is completely stable - it goes numb (ish) after 2 miles walking and my toes get painful and feel cold - but aren't physically cold...  I just say when a doctor "suspects" a cause, I feel like a bit more investigation would be in order - or does my description sound like sural neuritis and it's just that hard to accurately diagnose...

Anyhow - thanks for your time.

Dr Blake's response:
     Thank you so very much for your email. Sural neuritis is diagnosed two ways: you tap on the nerve and you get a tingling or other nerve symptoms in the area of your pain, and you inject the nerve and the pain goes away for 5 plus hours. If this is not the case, then something else is going on, and that could be many things. You can treat sural neuritis with nerve flossing and NeuroEze gel application (both done 3 times a day), and see if another injection of long acting local anesthetic would help. You can also shot gun the approach to wellness with 2 months in a removable cam walker (midcalf in height) and 8 visits of physical therapy. The physical therapist would see you twice a week and probably get a good handle on what is wrong. If the only thing wrong on the MRI is a small tear in one of the peroneals (which sometimes is only an artifact of the technique), then the removable boot would help that. Have the physical therapist really test the strength of both peroneal tendons and see if one is painful and weak signifying a tear. Hope this helps some. Rich

Sesamoidectomy: Email Advice

Long back story but as of today I'm about 8 months removed from a tibial sesamoidectomy. Surgery was successful but I'm still dealing with post op discomfort. I think it is shoes and I'm guessing I still have a bit of swelling down there.

I wear.Clark's with new balance pressure reducing insoles to work. I still have a feeling of fullness on the sole of my forefoot behind my big and second toe. Just got a new pair of ascics sneakers and they feel pretty good. Just looking on some advice for dress/ work shoes. Appreciate your time.

Dr Blake's response:
     Thanks for the email. So you want a stable shoe with some good cushion in the sole. You want one with a removable insole so you can and padding and dancer's pads. The adhesive felt to make a dancer's pad can be purchased atwww.mooremedical.com and get the 1/8th inch adhesive felt. This way you have room in the shoe to customize to your foot. Try to ice for 10 minutes once a day and do contrast bathing once every third night to continue to push out some of the chronic soft tissue inflammation. The scar tissue naturally heals from 9-12 months and that will also make you feel better. Make sure you are walking normally through your foot and not cheating by hanging out on the outside for your foot. In the long run, that will hurt you. Rich

If God is Not Done with You, then He is not Done with YOU!!

LOOK CLOSELY AT PHOTO 1
(Don't go  to photo# 2 until you look at #1 closely..)This is an interesting, even  breathtaking couple of photos. 
Be sure to  read the 1st caption below picture before going to the 2nd photo. 
Look  closely at the first photo take your time, then  scroll down very slowly



Look at the picture above and you can  see where this driver 
broke through the  guardrail, on the right side of the culvert,  
where the people are standing on the road,  pointing.... 

The pick-up was traveling  about 75 mph from right to left 
when it  crashed through the guardrail. 

It  flipped end-over-end bounced off and across the  culvert outlet, 
and landed right side up on  the left side of the culvert, 
facing the  opposite direction from which the driver was traveling.

The 22-year-old driver and  his 18-year-old passenger 
were unhurt except  for minor cuts and bruises.

Just outside   Flagstaff , AZ , on U.S. Hwy 100.   


Now look at the second picture  below...
 



 



 




If God isn't done with you, Then God isn't done with you !! 

Generalized Heel Pain: Email Advice

Hi Dr. Blake!
I noticed that one of your hobbies is hiking. I feel like you might have some good advice to get me through a field season. I was recently diagnosed with PF and Haglunds Heel and my heel is on crooked.  I hike 10ish off trail miles a day for work. Several of those miles are in streams on river rock, jumping off of log jams, etc. And all of these miles are done in waders and wading boots.
I have insoles, my right foot is taped (I haven't had my left foot examined yet), cortizone injection 3 weeks ago and I am a frequent user of Ibuprofen. I'm not completely weight bearing yet. 
Do you have any stretches that I can perform out in nature? I watched your stretching video, but I don't have any walls around me. I've been doing the stretch you say is a no no. But, I do it one leg at a time. I hang my heel off the river bank or a log. I do try to find a good boulder to try to stretch on, but it's difficult to get a balanced stretch.
I usually, but not always will have time in the work truck between sites where I use a tennis ball over my foot~ is there any stretches I can do in the truck?
OH, and is backpacking possible?  
Thanks so much for this service you do with your blog,

Dr Blake's response: Shannon, first of all, tell me what hurts (ie bottom of heel, arch, back of heel, achilles, calf), and when it hurts (getting out of bed in morning, putting boots on, walking at work, evening hours, sleeping), and what makes what better or worse. Rich

Thanks for your speedy response!

Since having the cortisone shot in my heel, that spot is pain free. The shot is in the heel (center left (my left)).   But, everything around it feels pain.  The back of the heel gets painful. My Achilles is often sore. I don't feel the morning pain since the shot, and I do stretches before getting on my feet. I do get stiff after I get home and sit a while. When I'm working I have been feeling pain about one mile in. No pain at night since the cortizone shot.  I had to stand on my feet in one spot for 5-6 hours the other day...pretty painful by about the 2nd hour. I notice that I walk on my toes more often and that can't be good for my back.

Ice and heat help.

I'd love to soak it in Epsom salts but my foot is taped.

Ibuprophen ( We call it I-be-broken in our household) helps. I recently took a 4 day break from it and my heel and ankle were sore.

I've been massaging my calf muscle and foot and that helps keep my calf from tensing up.

I hope this is helpful.

Thank you!

Dr Blake's response:

Hey Shannon, switch to support the foot taping so you can get it wet and do Epsom salts, may make a difference. Go to www.supportthefoot.com. Get the regular size. Just seems like the inflammation is out of control. Could you wear an Anklizer boot on in the field 4 hours a day to rest it better? I would love an MRI to see if you have a bone bruise/stress fracture!! At least, making the right diagnosis can help with PT recommendations on what to safely do. Hope this helps some. Rich

Thank you!! I just ordered the Support the Foot tape. I've actually had a big change this week with my foot. I tried the hard plastic insoles and they've helped dramatically! I was dreading hard plastic, but it really did the trick. I did about 9-10 miles each day last week and I'm able to bare weight. I'm so excited! I think I will be able to go backpacking and hiking (outside of work) this Summer. 
thanks for your advice and thanks for doing your blog~ I've learned a lot.

Have a great weekend!

Dr Blake's Response: Great News. Glad getting the right support helped. The support the foot tape will be good for flareups or long hiking for added protection. Rich

Ledderhose: Plantar Fibromatosis

Hi there,

My son, Oscar, has a large lump on his foot - it's about the size of a squashed grape.

We've seen a couple of specialists in the UK but they have seen very few children with this condition, and none as severe as Oscar's.  I am trying to avoid surgery because of the high recurrence and the other significant problems it can cause.

Do you have any suggestions, or can you point me at any research or specialists?

I am looking at:
- Radiotherapy, but cannot find anyone with experience of this for children
- Orthotics; we have some that help but again it's hard to find anything specific for children
- Other options, e.g. collagenese, but again it's hard to find anyone with experience with children

Thanks for any help or pointers.

Dr Blake's Response:

     Thanks for the email. I am not sure if anyone is doing surgery on this condition. Please see the links below. You should be encouraged by the marathoner one. Soft based orthotics, like some version of the Hannaford style described in my blog, are crucial. I have not injected anything but Kenalog 10 in these lesions, with good sucess, but only in adults. The cortisone has to be repeated every 9-12 months typically. Start doing vigorous cross frictional (across the grain of the fibers) ice massge for 5 minutes 3 times a day (melt an ice cube or get a CryoCup). See if the tape from www.supportthefoot.com can help with activity, and you can ice and shower through the tape. Hope this helps some. Rich

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2945849/

http://www.drblakeshealingsole.com/2014/08/hallux-limitusrigidus-email-advice.html

http://www.drblakeshealingsole.com/2012/06/plantar-fibromatosis-or-fibromas.html

Sesamoiditis: Email Advice

Hi Dr. Blake, 

I have had sesamoiditis confirmed via MRI for 3 months now. I went to a podiatrist 2 weeks after I woke up with intense pain in my left big toe. She gave me a cortisone shot and sent me on my way. 4 weeks later the pain came back (not as intense as the initial pain) but was still limiting my ability to walk very far without pain. 

Dr Blake's comment: With sesamoiditis, one cortisone shot is fine, but I would stay away from long acting cortisone as a treatment option. It can slow down bone healing, and I think sesamoiditis can be a small stress fracture in disguise. What did you do the day before that made your sesamoid scream so much?? When treating this problem, you need an off weighting orthotic for the sesamoid and an understanding of how to make your own dancer's pads. 

Here is a dancer's pad made of insole material cut up. You can purchase from www.mooremedical.com 1/8th inch adhesive felt, with emphasis on the adhesive part. In this way you can add dancer's padding to off weight the big toe joint area in any shoe, or on any insert. The goal is to try to get less pressure on the sesamoid as you roll through you foot. 

https://www.mooremedical.com/index.cfm?/MooreBrand%C2%AE-Adhesive-Felt-Orthopedic-Rolls/&PG=CTL&CS=HOM&FN=ProductDetail&PID=174&spx=1

For 2 months I've been in a surgical boot with offloading padding (new podiatrist). On most days my pain level is 0-2 but if I walk alot I end up really sore at the end of the day. My new podiatrist made custom orthotics and wants me to transition to orthotics in a neutral athletic shoe since my pain level has remained at a 0-2. I've also been icing 1x/day. 

It's now been 3 months and I haven't seen much improvement from 2 months ago when I put the boot on. 

Dr Blake's comment: Sounds like you are doing the best you can. Keeping the pain level between 0-2 and getting out of the hideous boot has been crucial. And typically 2-3 months of immobilization is just incase there was a small stress reactions. I have been following these sesamoids for years and at times the bone edema which makes everything very sore, is hard to resolve. So, you can email a photo from the original MRI that has the same view as the one below. If it looks like this one, I would definitely do a 6 month bone stimulator from Exogen (probably have to self pay). You have to wait 6 months at least between MRIs to see the percentage of healing. I have had them go out 3 years before the bone toughens up in the worse case scenario. We can do a new post alone on the image you send if you remind me. 

Questions:

1. How long is the recovery typically for sesamoiditis?

Dr Blake' s comment: Weeks to years. Sorry. Why would it take a long time? Perhaps foot alignment that puts too much pressure on the sesamoid. Poor or compromised bone health (like Vit D deficiency). The type of activity the patient does that may be high stress to the sesamoid. Inadequate treatment somewhere down the line. Too much immobilization that weakens the bone. The development of nerve hypersensitivity mimicking poor bone healing due to high pain levels. Etc Etc.

2. How would you recommend transitioning from boot to orthotics to ensure I continue to heal?

Dr Blake's comment: Typically keeping the pain level between 0-2, with an occasional sharp stab that lasts seconds and no residual. You want to transition when you can be in control of what you do, and can get off foot, or put boot right back on, so start after work going one hour for every days, then 2 hours, etc. Once you are fully weaned out for day to day activities, start weaning at work with one hour, then two, then three, etc etc.

3. Is there anything else I can be doing to speed up the healing process?

Dr Blake's comment: Vitamin D blood levels, possible bone density test, health diet (2 four ounces of red meat if you are a vegetarian per week), perfect the orthotics, get the dancer's pad material, ice for 10 minutes twice daily and do an evening flush of contrast bathing.

https://youtu.be/rRt5hC24Afg

4. I've had tingling in the ball of my left foot recently and my podiatrist says that means I'm healing, but I always thought tingling meant nerve damage. Thoughts?

Dr Blake's comment: Nerve Hypersensitivity is common, and presents in many ways like this. Get online some NeuroEze gel and begin to apply 3 times a day for 2 minutes into the injured area. 

5. Can I never wear heels again? I have high arches. 

Dr Blake's commment: Yes!!! Maybe with a small dancer's pad for good luck? When I watch people walk in heels (in San Francisco it is both sexes LOL), you can see that some heels work better than flats at getting the weight to the lateral side of the foot (4/5 toes). You have to try on many of the same heel height and see where the pressures go. Good luck. Rich

Thank you in advance for your time. Your blog has been very helpful. 

In good health, 

Accessory Navicular Syndrome: Email Advice

Hi Dr. Blake,

I have been reading your blog religiously in light of my increasing foot problems. Your blog is a huge source of trustworthy information and education for anyone suffering from foot problems. Thank you for the time and care you have put into this blog because it is truly rare to find quality, trustworthy information out there regarding some of the more obscure foot problems you write about.

I am writing because I have bilateral accessory navicular syndrome, with my left foot giving me the majority of the pain. I am a 24 y.o. female who has recently moved to NYC (relevant detail).

I was diagnosed with ANS in 3rd grade when a kid threw a frisbee right at my foot in gym class, which caused my left foot to roll. I limped around all day after that, and experienced pain in my arch for the first time. I went to see the podiatrist, and he told me I had ANS and prescribed custom orthotics. He also put me in a small boot and soft cast for about 2 weeks. He mentioned surgery was a possibility if my pain persisted. I continued to wear my orthotics for a very long time without any additional incidents of pain. I did notice that if I walked more than usual, my left foot would be a little sore, but the pain would alleviate with rest.

Dr Blake's comment: This is the typical response in a young child with beginnings of problems related to the accessory navicular. The doc immobilizes, then gives orthotic devices, and everything seems fine for a while. The type of orthotic device may not be supportive enough in the long run, plus needs to be redone with a shoe size change of 1 to 2 sizes. This is a pain for parents. The common problem I see here is that posterior tibial strengthening is not done at this young age, and that could prevent future problems. 

https://youtu.be/QP3Ud4d39dc

Unfortunately, when I left home for college, I got the idea that I no longer needed my orthotics. I met a running coach at a tennis shoe store who encouraged me to leave my orthotics behind to “train” my foot to properly hold itself. I naively listened to him. I became more active during college and started doing things such as running and yoga. Unfortunately, my left foot started giving me more problems during this time, and I was wearing unsupportive shoes often, such as flats and flat sneakers. If I ran/walked more than usual, my foot would ache the next day but it would always recover with rest. I thought that this coming and going of foot-aches and pain was just my “new normal”. But in general, I did not have pain.

Dr Blake's comment: This why there was a war with podiatrists and minimalists unfortunately. Some feet, like those with inherited weakness such as accessory navicular, ligamentous laxity, tarsal coalitions, flexible high arches, plantar flexed first metatarsals with exposed sesamoids, etc etc, should have a strengthening program but with protection. 

Last year I went on a trip to SF, and the combination of wearing new chunky heels, walking up and down the inclines of SF, and overall just A LOT of walking, my feet just gave out. Not only did I experience arch pain, but I also experienced pain at the ball and heel of my foot. Bearing weight on my foot was just terrible. It took me a WEEK of wearing supportive tennis shoes (no orthotics), elevation, and icing it for my foot to feel better.

After that incident, I have just not recovered fully. 6 months ago, I moved to NY and now walk more often than I did in TX. The pain has become chronic and dehabilitating. I went to my old podiatrist and he prescribed new custom orthotics and put me in a soft cast and Cam walker boot for 2 weeks and Cam walker with ace bandage for the following 2 weeks. When he took an Xray of my left foot, he said that I actually have 2 small extra bones instead 1. He also gave me PT exercises to do. However once I was out of the Cam walker and I started walking <1 actually="" again="" allows="" and="" as="" back="" because="" but="" cam="" did="" do="" doing="" exercises="" flare="" getting="" groceries.="" help="" i="" increasing="" independently="" insurance="" into="" issues.="" it="" me="" mile="" much="" myself="" not="" of="" pain="" pt="" put="" recovery="" simple="" slower="" span="" supervision="" the="" them="" things="" time.="" to="" up="" walk="" walker="" was="" with="" without="" would="">

Dr Blake's comment: Without insurance problems, here is where an MRI is crucial to see where the problem lies. Is there inflammation in the accessory bones, posterior tibial tendon, or navicular itself. You can also have a fluroscopic exam  to see how much movement there is between the accessory bones and navicular. If the MRI points to an inflammation/sprain problem, the cam walker, plus orthotics, plus taping can be helpful. If the bone is involved, perhaps a bone stimulator for 6 months while you keep the pain level between 0-2. Also, PRP injections for a sprain, or prolotherapy injections, are showing good promise.

I went to see podiatrist #2. He was very confident in recommending a cortisone shot, with the idea that he would give me 2. He gave me the shot right above my AN bone, and I reacted terribly. I could barely walk home from the subway and the pain was present for 1.5 weeks. I could not bare weight on it at all or wear the Cam walker because I had a bruise where the doctor injected the shot. I took Diclofenac Sodium for an NSAID but it did not really help with pain.

Dr Blake's comment: I am not sure what injection was given, but long acting cortisone shots can not be given around tendon insertions. I hope when the dust settles you are fine.
My doctor podiatrist failed to tell me any possible side effects before administering the shot, and I was completely blindsided. I felt worse than I did before getting the shot. This doctor says he doesn’t know what to tell me. I really want to avoid surgery. He says I can try doing 7-8 sessions MLS of laser treatment or PRP (Platelet rich plasma) injections. Have you heard of those treatments? He tells me that he cannot tell me the success rate that he’s had with these treatments since my situation is unique. He has also prescribed PT but I have yet to find a physical therapist yet.

Dr Blake's comment: Right now without your MRI to elucidate the origin of pain, it is hard to advise you. Laser is being used alot, and I know there are different ones, but I can not tell you if it would help. Sorry. Are you icing twice daily, and doing contrast bathes each evening, and perfecting posterior tib taping? 

https://youtu.be/e1JAewWT9Fc

I haven’t had an MRI yet, but he said he could justify ordering one if I wanted. Money is tight for me at the moment. I am trying to evaluate if it is worth getting an MRI. I don’t know if there is tendon or ligament damage or bone edema, etc.

Dr Blake's comment: Get the MRI, self pay is normally around $400-$500, and they may have installment plans. I am sure the doc wants one, but is trying to be cost containing for you, but the money is worth it at this point. 

I would like to do PT and find someone experienced with this condition. Is there a case in which a patient with ANS/PTT should NOT attempt PT…. for example when should & should not a patient start doing PT? I just don’t know if my feet are ready to do PT.

Dr Blake's comment: The goals you are to use immobilization techniques (boot, orthotics, taping, Aircast Airlift PTTD brace), and anti-inflammatory measures (icing, contrasts, topical or oral anti-inflammatory, activity modification) to get the pain between 0-2 levels. If you can not do that, you use PT, laser, acupuncture, etc to bring the pain down. If not, you go into a permanent cast for 6 weeks to totally rest it. Once you are in that 0-2 range, physical therapy gradually strengthens, changes your gait, makes suggestions about orthotic modifications, does soft tissue and joint mobilization, makes sure your calf is not tight, etc. So, you typically use PT in the restrengthening phase of rehabilitation, but some need it in the immobilization phase also.

https://youtu.be/g0sD0gUbEMU

I don’t feel l pronate with my orthotics on, and my arch does not look collapsed/flat. I rest, ice, and elevate my feet. Epsom salt soaks help a little. Should I be using heat also? The pain is under my arch, and if I walk to much (especially in the CAM walker), my calves, glutes, and leg get sore. If my foot starts hurting while I am walking, there is sometimes a shooting pain up my posterior tibial tendon. I tend to shift my weight more on my right foot now and it is beginning to hurt also. The outer right ankle sometimes aches while walking.

Dr Blake's comment: Always err with ice. Heat can be used to warm the tissue up before exercise. Please get an EvenUp for the other side when wearing the Cam Walker, if you are having problems keeping the hip heights level. You probably should be doing daily calf, hamstring, quad, and glut stretches. You should be wearing your orthos in the Cam Walker, and perhaps taping also. Even simple Kinesio taping for the arch as long as you surround the accessory navicular with the tape can be very helpful. If the pressure of the tape irritates, you can pre-cut a hole out for the bump before applying. 
https://youtu.be/NLfzvAJgyJ4

I am seeking your opinion because my current doctor seems to not have an opinion on my condition. After the disaster of the cortisone shot, he seems to not want the responsibility of making any recommendations. I really want to try as many conservative treatments as I can as I am very adverse to the idea of surgery. However, I don’t want to hurt myself by prolonging  this process.

I appreciate your time and knowledge so much. I can send you pictures of Xrays (might take time) or my foot if you suggest.

Thank you in advance for your help.
-SurgeryAdverse

Dr Blake's comment: I am happy to have you send a CD of the MRI when you get that. They can burn the xray images if done at the same place only. Sounds like you have alot to do before any surgery is anticipated. Glad the orthos have been done right. Good luck and I hope this helps some. My mailing address would be 900 Hyde Street, San Francisco, Ca, 94109.    Rich

Patient's Response:
Thank you so much for your quick reply! 

I hope to get an MRI soon- within the next month. I have a new job and will be getting new insurance so it will hopefully be more affordable. Thank you for encouraging me to get an MRI, your justifications make sense and will hopefully give me & doctors more insight on how to move forward.

I haven’t heard of a contrast bath yet but I will try that. I have tried taping but I’m not sure if I am doing it right. I have been watching your videos and others and will continue to try to perfect it. Sometimes the bottom of my foot feels cramped after I tape which I’m not sure is normal or not. I am icing a couple of times a day and elevating my feet.

Thank you again for your help. I will send you MRIs once I get them. It is so nice to get a second opinion.

Have a great weekend!

Missing Sesamoid in Child

Hello Dr. Blake!

     My daughter injured her R foot in January. Initial x-rays at an urgent care center ruled out a fracture.  She was still mobile but the foot was uncomfortable (a 7 on the pain scale).  We finally went to a podiatrist and they did more xrays.  It was discovered that she is missing one of the sesamoid bones.  So, here we are in a boot 4 weeks later.  Pain is improving but I am wondering what we should do long term.  

     She is 9 years old and very active, just loves to play, no organized sports or dance.  

Any advice you can give would be very helpful!

Dr Blake's response:

Hey Melissa, I am sorry for your daughter's problem. Only a small percentage of people only have one sesamoid, so we do not know alot about that. However, do they think she hurt the other sesamoid? If so, you treat it as a fractured sesamoid with 3 months in the boot. During the 3rd month you have some form of orthotics made for her to protect her, so as she weans out of the boot, she will have the protection of the orthotics. You should be icing once a day now, and doing contrast bathing every other day in the evening as a deep flush. She should have a healthy diet. You should learn the skills seen in my blog of spica taping, designing dancer's pads, and Cluffy wedges, since they can all come in handy in the months after coming out of the boot. Hope this helps some. Rich

Question from fellow podiatrist

Hi Dr Blake,

I had a patient who presented today with pain in the anterior as well as anteromedial aspect of both knees, hamstring pain bilateral, ITB pain on left side and numbness on soles of both feet. The patient has had the knee pain for over 30 years due to a fall during sporting activities. Severity is about a 7/10 and standing / walking makes the knee pain worse.

Patient only has hypertension and takes medication for it.

On examination, there was limited knee flexion, hip internal rotation, MTJ ROM, 1st MPJ bilaterally.

STJ axis was severely medially deviated for the right foot where the line of the axis exits through the mid arch area.

The STJ axis was medially deviated for left foot, however it was less severe with line of axis exits below the 1st metatarsal head.

Supination resistance was very hard for right foot(where I could not even move it) and hard for left foot.

The patient RCSP was 8 deg inverted (right) and 6 deg inverted (left)

Jack's test was moderate for both feet with no arch increase / windlass mechanism activation.

Did not do a gait assessment as patient uses a walker and he finds it difficult and painful to walk.

My diagnosis was patellofemoral pain syndrome with medial plica irritation bilaterally as I was able to reproduce the symptoms on palpation bilaterally. The patient also had tarsal tunnel as the Tinel's sign was positive bilaterally. I have also ordered knee x-rays.

My thoughts are that the excessive pronation is causing compression on the tibial nerve as well as increasing the stress on the patellofemoral joint. Besides that, the tight and weak quads, tight hamstrings may also be causing patella maltracking as well as irritation of the medial plica as the quads have to work harder during gait.

In terms of treatment, I have advised patient on footwear and icing. I have also learnt some tool assisted massage which I can use for the tight quads and hamstring since I think the patient is not able to do quad and hamstring stretches as he is using a walker. I am also thinking of supine straight leg lifts as part of the tx plan to strengthen the quads.

As far as orthoses prescription go, I am a bit lost. Do I just use an accommodative device

or use a Fettig modification on an inverted type device?

Have you had cases like this where the STJ axis is medially deviated but the RCSP in inverted and also where the STJ axis is laterally deviated but the RCSP is everted? What kind of orthoses prescription do you use for these cases?

I find this case to be challenging and your thoughts would be greatly appreciated.

Regards,

Dr Blake's response: Thank you so very much for the question. First of all the deviation of the subtalar joint is only one part of an evaluation. Medial deviation is a sign that the foot has a tendency to pronation, whereas lateral deviation is a sign of the tendency to supinate. However, other forces can override this, especially sagittal and tranverse plane external forces. I suspect his external hip position is pulling his whole foot laterally, and the rigid nature of his knees and feet can not alter that. That being said, this is a typical presentation of an elderly patent who needs accommodative orthotics with valgus wedging added to the ortho after dispense. The soft based full width orthotic devices will give him great shock absorption and added stability. After dispense, correct any lateral instability (aka supination) with some form of valgus wedge. And you are correct to work on the tight and weak muscles to ease his walking. Hope this helps. 

Paper Tape for Blisters: Stanford University Study

http://med.stanford.edu/news/all-news/2016/04/stanford-trial-shows-paper-tape-can-help-prevent-foot-blisters.html

And see some of my other posts on blisters.

http://www.drblakeshealingsole.com/2010/04/general-principles-on-blister-care.html

http://www.drblakeshealingsole.com/2010/06/back-of-heel-pain-or-heel-blisters.html

Baseball is Back!!!

​Two 90-year old guys, Leo and Frank, had been friends all of their lives. When it was clear that Leo was dying, Frank visited him every day. 

    One day Frank said "Leo, we both loved playing baseball all our lives, and we played all through High School. Please do me one favor: when you get to Heaven, somehow you must let me know if there's baseball there."
 
    Leo looked up at Frank from his deathbed and said, "Frank you've been my best friend for many years. If it's at all possible, I'll do this favor for you."

    Shortly after that, Leo passed on. 

    A few nights later, Frank was awakened from a sound sleep by a blinding flash of white light and a voice calling out to him, "Frank... Frank ..."

    "Who is it?" asked Frank sitting up suddenly. "Who is it?"
 
    "Leo-- it's me, Leo."
 
    "You're not Leo, Leo just died."

    "I'm telling you, it's me, Leo" insisted the voice.
 
    "Leo!....Where are you?"
 
    "In Heaven," replied Leo. "I have some really good news and a little bad news."
 
    "Tell me the good news first," said Frank.
 
    "The good news," Leo said, "is that  there's baseball in Heaven.  Better yet all of our old buddies who died before us are here, too. Better than that, we're all young again.  Better still, it's always springtime, and it never rains or snows. 

And best of all, we can play baseball all we want, and we never get tired."

 
    "That's fantastic," said Frank "It's beyond my wildest dreams!  So what's the bad news?"

    "You're pitching Tuesday." 

Life is uncertain - eat dessert first!!!

Fracture yet Still Smoking: Important Video

Low Back Pain and Orthotic Devices: Email Advice

Hello Dr Blake-

I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM

I found a pair of orthotics that were  custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.

My question is would you be able to to make a new pair of orthotics for my back pain  since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.

Thanks-

Dr Blake's response: 

     Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control. 

     When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also. 

     The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done. 

     There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich