Accessory Navicular Excision and Continual Pain: Why?

Surgery date: 1/9/17

Accessory navicular excision with reattachment of post tib tendon w/suture 

Current diagnosis: Stage II PTTD

Please understand I am still regaining strength since surgery so not all the weakness is due to bad tendon. Prior to excision I had painful tendinitis but full calf and tendon strength in the foot.

Video of Ability to do Heel Raises

Front View Amount of Pronation

Back View Amount of Pronation

Dr Blake's comment: This patient is really struggling post op accessory navicular removal. I had her send me a video (not sure it is working for you guys) of her ability to do single leg heel raise. She could do this just fine. The standing barefoot pronated positions are fairly equal (the right had the surgery), so nothing seems amiss that I can find. The post tib tendon is Stage 2, which is still considered one that can be successfully treated with orthotics, taping, PT, icing, strengthening and achilles stretching. She has to find out what can be improved/modified in these areas. 

Here is more from the patient (out of order because I am out in left field sometimes):

Dr. Blake,

I want to send you a copy of the MRI but I am not sure where to have it sent to.

Dr Blake's comment: Dr Richard Blake, 900 Hyde Street, San Francisco, CA, 94109.

If I could get a cheap flight my husband and I would consider flying out to see you for an appointment.  Let me know if this would be possible and how far you are booked out.

Dr Blake's comment: Only a week, but since we need ample time to perhaps make an orthotic, could you fly Thurs, seeing me in the afternoon, and again see me on Monday. 

My surgeon told me if I could come up with a situation using OTC orthotics and materials (wedges, etc.) that works for me, I could take that to a podiatrist and tell them exactly how to make the orthotics.  That's easier said than done as I don't have all the materials I would want to use to accomplish what I have in my mind.  I know I want an orthotic with a low arch that is tipped at an angle to combat the pronation, and I want the pressure points to be soft/gel.

Dr Blake's comment: So, at least start with the varus wedge from Altra. 

https://www.altrarunning.com/women/womens-stability-wedge?c3ch=PLA&c3nid=A2275-1-A&c3api=7940,109107172001,&utm_source=GoogleShopping&utm_medium=cpc&utm_campaign=AltraBrand

My husband will take some better pictures ASAP and send them to you.  The surgeon has told me I am in stage II of Post Tibial Tendon Dysfunction.  He recommends 1) gastroc release surgery and then if that doesn't work 2) flatfoot reconstruction: tendon transfer and calcaneal osteotomy.  He said the second surgery is a 6-month PROJECT and from what I read online it sounds like I would never be able to do high-impact sports again and would lose foot function.  Well, I guess that wouldn't be much different than my lifestyle now but it makes you wonder if it's worth it?  Considering the stiffness I have in my foot after the accessory navicular was removed I am very leery of any additional negative effects of more surgery.

Dr Blake's comment: You may well be a candidate for these, but definitely try alot of things first. I am glad I may have the opportunity to see you and assess your achilles tightness/flexibility, posterior tibial strength, etc. Nothing you sent from the photos above look bad enough to warrant anything but perhaps a posterior tibial tendon exploration. Ideally you could get an independent review from another surgeon here to get their perspective. Surgeons love to cut, and you never tell one surgeon what another one said, but they can differ alot in their approaches. 

I am really thinking it would be wise to wait at least 6 more months to see how I do before committing to another surgery.  I asked surgeon if I could try new medicines or another cortisone injection.  He said we could try Celebrex and an ultrasound-guided cortisone injection NEAR the tendon where he sees inflammation, but not IN the tendon itself.

Dr Blake's comment: I hate any thought of cortisone near a tendon, even with guided ultrasound. I would think it is resonable to put local anesthetic without cortisone into the tendon sheath to find out if it is the tendon that hurts. You are numb for 5 hours, so you have to be very careful. 

What do you think of all this?  

I am so frustrated and in so much pain and I feel like I have very few options and many years of pain ahead of me whether I opt for the surgery or not.  I know it's not a doctor's place to comment on personal life choices but my husband and I are looking at moving in the next year or so and starting a family...I can't imagine doing all that with the level of pain I have.

Dr Blake's comment: No guarantees, but you should be fine. Gastroc releases are done in extremely tight achilles that are flattening your arches, and flatfoot reconstructions in flatfeet that need to be reconstructed. I do not see any of the flatfoot. The amount of pronation should be helped by orthotics, taping, and gradually strengthening your foot. Someone would have to evaluate the achilles and see if it is tight and by how much, and can it be stretched out. I have alot of normal people take up yoga and get the achilles really stretched out without trying too hard. 

http://www.drblakeshealingsole.com/2013/10/achilles-tendon-flexibility-measurement.html

I personally do NOT think the gastroc release will work and the physical therapists told me do not get this surgery.  They see patients in recovery and it sounds like they think it's not very helpful.

The tendon feels diseased.  It's the tendon that needs to be scraped or reconstructed or removed or injected or something.  It's felt this way for 3.5 years now.

Dr Blake's comment: You know your body the best then the little time any doctor spends with you. Keep It Simple Stupid is a good mantra for a humble health care provider. We are stupid if we make it too complex when it does not need to be. I can not remember the last MRI on the tendon and what it looked like. Also, please see if the radiology department can do a diagnostic tenography of the posterior tibial tendon, but no cortisone injected. I hope this helps. I' m trying. 

http://emedicine.medscape.com/article/386322-overview#a2

Problems with both feet: Email advice!

Hi Dr. Blake, I hope you don't mind I am in need of your advice. I have written you before for your advice on my left foot. Tenosynovitiis is my diagnosis and plantar faciitis. I did not have the second set of PRP injections on June 30 because I was getting considerable relief in my symptoms. At that time I was wearing the hoka one one shoes with the budin splint. I increased my activity one day at the gym using a eliptical machine that put my weight on my heels and was able to work out for 45 min at a good intensity. The next day I woke and the tenosynovitis was much worse. I realized at this time that I had been curling my toes frequently also, testing to see if they were getting better. I read your blog and came upon a quote " it is not unusal to go 3 steps forward and 2 steps back". So I went back to "Rule of Foot".  I do a 5 min ice massage on the effected area every hour. I do an ice dipping protocol every day 10 sec dip in ice water every 15 min X 2 hours and this seems to be really helping. I went back to a flat firm shoe with my orthotics ( no splint). In an effort to immobolize I do not curl my toes. This foot is responding to this regimen.  When I wake my foot is very tight with the plantar fasciitis so before getting out of bed I massage my foot especially the plantar ligament.

Dr Blake's comment: Good for you. Handling Re-flares successfully is a vital part to any rehabilitation. It is funny how rehab is always presented linear, but really spiral (sometimes we are closer to our goal, and a minute later we can be further away. I love walking the labyrinth. First saw one here in San Francisco at Grace Cathedral. It is a spiritual walk, but can be a guide to rehab also. 

You are mindfully walking, rehabbing, towards your goal (in this case the center). As you walk you find yourself close at times, only to be moved away by the path (or during rehab, a setback).

https://youtu.be/o7u80ZLEh3M

Unfortunately I now have a new problem. My right foot which also has plantar faciitis has developed symptoms. For the past 8 months I have had a tight , pressure,dry crunchy, feeling right across the ball of my foot. I do not have any heel pain. I have been limping on this foot for 8 months. If you remember I had orthotics that had heel lifts in then putting my weight on the balls of my feet. I replaced them with vionic orthotics. This right foot has some falling of the arch on x-ray. While I have been caring for my left foot I have also been icing my right. I have been stretching my right and it responds to that. My problem is that my right foot likes the hoka shoe. As soon as I went to the flat shoe for my left foot I started getting a real " ache" feeling below my big toe at the bottom inside of the ball. I feel it there occasionally  but when I push around in the area of pain I cannot locate the exact spot of soreness. After reading your blog I wonder if it is muscular? When I wear my hoka on my right foot and the flat on my left, both feet are happy. But I cannot walk anywhere like this it hurts of course. Does this tight pressure symptom accross my left foot sound like plantar faciitis to you?
Dr Blake's comment: No, could be sesamoid. Can you get an MRI on that area? You can try the flatter New Balance 928 that has some rocker. 

I have been resting my left foot with the Tenosynocitis and putting it up. I feel that the resting has been causing the plantar faciitis on the right foot to worsen.
Dr Blake's comment: When you are dealing with both sides, it is easy favor the "better" foot which can cause problems. Also, a lot of foot problems, more joint than muscular or fascial, get very tight with immobilization, even if it is from rest. Try moving the big toe joint ten times up and down per hour to see if that helps. 

I have not been going to physiotherapy because after going twice a week for the past 5 months I got no relief  (in fact all of the pulling and "digging in" on my left foot would make the tenosynovitis so much worse). I did find that the ultrasound helped the tightness in the balls of my feet.

With this sudden pain in my right foot what would you recommend?
Dr Blake's comment: Well, you have to create the 0-2 pain level for the right, without upsetting the left, how about an Anklizer boot on the left, and placing an EvenUp over the right shoe for the next 2 weeks to calm things down. 

What kind of physio treatment am I looking for?
Dr Blake's comment: Really need a diagnosis first before therapy, or they may make you worse. 

Will ultrasound help?

The right foot likes a hot bath with Epsom salt and a massage the area almost feels normal but than quickly goes back to stiff, crunchy, plaque like feeling.

How do I treat both feet with such different needs?
Dr Blake's comment: First of all, you must list the needs of each, and keep them separate. Do for the right what is needed, and separately do for the left what is needed. Send a check list to me what you have found so I can keep these clear in my aging brain. Rich

Help!

So thankful for your help,

Healing Sesamoids!!!

Hi Rich!

Just wanted to send you an update on my sesamoid injury. I'm doing great! I can walk barefoot when I'm staying indoors (been doing so for several weeks), and I can use regular footwear when walking short distances (although still good shoes, just without specific sesamoid protection). Without any significant pain, of course. I'm still using the Hoka shoes with orthotics when walking longer distances, for example an hour's walk. 

Still, I have to admit I haven't been as good as I should be at following up the contrast baths and foot exercises regularly. The reason for that is that I'm pregnant, and I've been feeling really tired and sick at the beginning of the pregnancy. Despite this, I've used Exogen every day and I've been doing the contrast baths and foot exercises regularly again for the last six weeks. Also, because of the pregnancy, I can't have any images taken of my foot, therefore I don't know what the fracture looks like at present. 

I feel like I can mostly do all sorts of activities again, but I still can't run without pain and I can't go for long walks without protective foot wear. Should I continue on with foot exercises, contrast baths, etc, any specific exercises I should pay attention to? Is there anything I should do differently now when I'm doing much better? Do you have any advice on footwear at this point? 

Dr Blake's comment: Thanks for the great news. For our reader, I placed your original posting 9 months ago below. And, congratulations on the pregnancy!! I wish you all the best for a healthy and happy little one. I just love my grandson, and we have 2 boys. Boys, boys, and boys. Lucky we have a wonderful daughter in law, and my other son just got engaged to a good soul!!
     As you feel better, and have other issues, it is easy to be lax at what you do. As long as you are doing the Exogen (and 9 months should be perfect) you want to do the contrast bathing 3 times a week as a deep flush. Ice also once a day now just to keep the inflammation under control. You should be able to do a walk run program with the Hokas by now, so if not, you may need a separate orthotic device with higher arch and more dancer's accommodation. And, some of my patients need to spica tape and use cluffy wedges to run also. But, gradually building up to 30 minutes running is the next step in your healing. You need to review the walk run program I have on the blog. As you return to full activity, you need to keep up a 10 minute daily routine of strengthening: single leg balancing, met doming, heel raises are normal. Make sure your achilles are stretched out because tight achilles lead to more forefoot pressures. Keep up the healthy diet, Vit D if you are not in the sun enough, and any other bone supplements you take. I have my patients alternate walking and alternate running with the Hokas and more normal but stable shoes that bend easily in the front at the ball. By alternating, you really get a feel of how important the Hokas are to limit the bend. You should slowly need that protection less and less. 
     As you walk with any shoe and orthotic, feel where the weight is going through the front. If it is entirely on the first, either ditch the shoe or modify the orthotic. Then weight should be even 1st and 2nd mets, or all the way across the front of your foot. I sure hope this helps some. Congrats again. Rich

Hope you're doing well and having a great summer!

https://www.blogger.com/blogger.g?blogID=673715911736059911#editor/target=post;postID=8800716870601474755;onPublishedMenu=allposts;onClosedMenu=allposts;postNum=117;src=postname

Tips to Improve Balance: Bravo!!

http://www.kinetic-revolution.com/how-to-improve-your-balance-with-one-simple-cue/?utm_source=twitter&utm_medium=evergreen_post_tweeter&utm_campaign=website

Caroline Jordan: More Reflections on her Sesamoid Healing

Caroline is a gifted fitness professional who developed a devastating sesamoid injury one year ago. This is part of her wonderful reflections on her own problem with the hope it can help others. 

https://youtu.be/yruHwHCnSFU

Chronic Heel Pain: Email Advice

Dear Dr. Rich Blake,

I found out about you from the "Physical examination of heel pain" on Youtube. I have chronic heel pain that I don’t even remember when it start. I have seen physicians, physical therapists, two podiatrists and they both said I have plantar fasciitis. However, my symptoms don’t fit into the classic picture of plantar fasciitis. I reach out to you because I need another opinions and you are very knowledgeable and caring (because you take time to write blog and help people that is not in your areas). I just finished my second year of veterinary school. I didn't enjoy learning during labs and farm trips because of the heel pain. I avoid going to clinic to learn during summer because of the heel pain as well… Next semester I will start surgery class, I am now very worried how I can stand still for hours during surgery with the distraction of the pain. I live in Brooklyn and don't have budget to visit San Francisco. I would deeply deeply deeply appreciate it if you can give me some insights via the internet. 

Dr Blake's comment: One possibility is seeing Dr Karen Langone in Long Island, or at least getting a referral from her to someone closer. 

I have bilateral pain in my heels only when standing still for more than ~ 3 minutes. After about ~ 4 minutes, the pain would be too severe that I can't bear it and have to move my feet off the ground. It is very hard for me to stand still. When I wait and stand at the bus station, I have to walk around or shift my weight from one leg to another. The longer I stood on my feet, the worse the pain got.

Walking and sitting can make the pain disappear.  However, if I have been stand for really long time that the pain is very severe, at the moment I take my feet off the ground (e.g. sitting), the pain immediately become more intense and then gradually subside if the feet remain non-weight bearing. Walking for long distance can also produce the pain.

• The pain doesn’t feel like a sharp pain. I am not sure how to describe it but I think it is more like a dull ache that gradually build up when I stand still.
• Sitting with both my feet on the floor (bend knee at 90 degree) can also produce the pain (not as painful as standing still). If I bend my knee at more than 90 degree (less weight on the feet), there is no pain.
• The pain seems to locate at the bottom of my heels, not at the center of the heel but more anterior.
• It doesn’t hurt when I get up in the morning or walk after a rest.
• Pain gets worse with continued activity (esp. standing) and increased weight bearing.
• Pain is also worse while standing on hard surfaces.
• I don't notice any swelling, bruising, bump, lump in the arch or heel.
• It isn't painful when I press on the center of the bottom heel and the anterior heel area. (or maybe I didn't press hard enough) 

                         Dr Blake's comment: It does not sound like plantar fasciitis at all. Try to find pain with your fingers when you are sitting or lying. Mark an "x" on the area, maybe different for each foot. If you can not find one, it is referred nerve pain unless an MRI shows us differently. 

• I am not overweight (normal BMI), don’t smoke or drink.
• Wearing OTC insoles and custom insoles and shoes that have very good arch support and higher heel drop (e.g. Vonic, New Balance walking shoes ) makes the pain worse, and my arch hurt.)

                        Dr Blake's comment: Sounds like tarsal tunnel or some version.

• Standing and walking with barefoot also makes the pain worse.
• Wearing Keen Uneek shoes that has slight elevated heel and mild arch support makes me feel better.

Have you heard of or seen any case that is similar to my case? Do you also think it is plantar fasciitis? I have thought of Infracalcaneal bursitis but the pain is not right underneath the center of the heel. I didn't feel any bump or reproduce the pain when I press on the central heel. Does it sound like stress fracture, nerve entrapment or even partial rupture of the plantar fascia to you? Can you please help with some advise?

Dr Blake's comment: Nerve irritation from a somewhere is the highest possibility. I will have to look up these shoes. A peripheral nerve specialist is your best option right now, along with a podiatrist who is willing to rule out heel pain not caused by plantar fasciitis. Good luck. I have alot in this blog on treating nerve pain in the foot. 

Sorry this is very long. Thank you so much for your time and help. Thank you very much. 

Bests,

https://youtu.be/plbBvPASXwM



Dear Dr. Rich Blake, 

Thank you very much for your quick reply. After I read the post, I went to my doctor office as soon as possible and convinced her for giving me a MRI referral for both right and left feet. And the reports came out today. During the scan, the technician used different method to do the scan for each feet. When my right foot was scanned, she put something under my heel close to the edge of the heel. For the left foot, that thing was put under the plantar surface of the left foot.  

Right:

- Unremarkable MRI scan of the right ankle and tarsal region of the right foot.

- No soft tissue or bony abnormality are seen along the plantar region of the heel at the annotated area of complaint.

Left:

- There is a 6 mm bone cyst in the distal tibia at the level of the previous growth plate. 

- There is a small tibiotalar joint effusion, though no apparent disruption of the collateral ligaments.

- No soft tissue or bony abnormality are seen at the area of concern along the plantar surface of the foot adjacent to the heel.

- The remainder of the left ankle and tarsal region of the left foot is normal. 

Dr Blake's comment: This makes tarsal tunnel (nerve pain) the highest possibility, although with bad mechanics of fallen arches, the nerve pain can be secondary. The nerves are not injured, just irritated due to poor mechanics. 

As you said, the MRI showed that the plantar fascias are normal. I am not sure if the bone cyst and effusion are significant on this MRI in my case. 

Dr Blake's comment: I doubt it. Typically, the MRI can tell if it is an active cyst or old. If not, then a bone scan to rule out high activity in the cyst is needed. See what the doc says. 

To answer your question, yes, I have both back and neck pain... swayback , functional shorter right leg, upper cross syndrome, carpal tunnel. I have been doing some core exercises (based on my visit to a PT last summer) to improve my postures. My posture is slowly improving. My gluteus medius and right lower back doesn't hurt as often. When I stand for longer than 1 hour, my lower back, hamstrings, calfs start to hurt. Usually my feet hurt before my back starts to hurt so I did not connect them together. My doctor didn't think it is a neurological issue (cause it is not a tingling pain), so she refused to give me a EMG/ nerve conduction test referral today. 

Dr Blake's comment: Tell her that it can just hurt. Nerve problems produce pain alone (1/3 of the time), pain and abnormal sensations like tingling, bugs crawling on your foot, buzzing, etc (1/3 of the time), and only abnormal sensations (1/3 of the time). 

I feel like there are multiple diffused areas and they don't hurt all of the time so it is hard to draw a cross. The anterior plantar region of the heel bone has been hurt for few years and always hurt when weight bearing. Starting this summer, the lateral ankle area starts to hurt as well when I stand or walk. The medial ankle area hurts when I start to rest but disappear after enough rest. However, it is not absolute, sometimes both sides hurt at the same time some time they doesn't hurt. 

When I wear shoes with good and thick arch support, the area that hurts the most is the area of abductor hallucis (Area 1). I feel the arch support is pushing onto my arch and it is very dis-comfortable, pain appear only after 10s I stand on these shoes. Not sure if the pain is come from the muscle or something else in that area. Keen unkeen sandal and crocs helps with this problem. 

Dr Blake's comment: Patients in general love orthotics and that feeling of good arch support. On the contrary, tarsal tunnel nerve patients can not stand that pressure. It is fairly diagnostic in my mind. 

Also, starting this summer, I feel a sharp pain behind the heel but very close to the edge (Arrow 2) once in a while when I walk or stand. 

Dr Blake's comment: There is a good pesky branch of the sciatic nerve that hates shoe pressure, hates achilles stretches, and is often confused with achilles tendinitis or even plantar fasciitis. Someone skilled at the difference with nerve heel pain and tendon/fascial heel pain, can usually sort it out. If it hurts when your knee is straight and you try to bend your toes towards your nose, but does not hurt with the same ankle motion when your knee is bent, then that makes it easy. Or if bending over to touch your toes hurts the heel/foot, but not if you bend your knees first, you always have the diagnosis of nerve pain. 

On the other hand, I feel pain behind the heel (Arrow 3) when I take the first few steps in the morning. It doesn't happen everyday but It will definitely happen after I stretch the calf or take a long walk the day before. On a bad day, it will hurt when I press on it or lay on the bed. It forces me to sleep on my side instead of on my back. Does sound like insertional achilles tendonitis? Or an irritated nerve issue?

Dr Blake's comment: Still irritated nerve. 

Sometimes, I feel my ankles are stuck, especially the right feet. I need to pop it to feel better. If it cannot be popped, the whole day i will feel uncomfortable in the lateral side of the ankle.

Dr Blake's comment: On the photo you sent, your foot is pronated. This can lead to lateral ankle and subtalar joint impingement. When patients can not wear orthotics, they usually can tolerate a 4 degree varus wedge at the heel only. This is something podiatrists make, but are also sold on line. You would want a podiatrist to tell you if it is stable. 

https://www.altrarunning.com/women/womens-stability-wedge

Above are all the feet problems that I can think of. Are these symptoms more likely to be related (neurological) or individual problems? If the feet pain is neurological, how to tell if it is come from the ankle (e.g. tarsal tunnel) or from the lower back?

Dr Blake's comment: The tests above give you some idea of the relationship to the back. The neural flossing is another way to tell. One version is when you point your foot and straighten your knee, you always bend your neck and look at your toes. See my video on neural flossing. But, it takes a good neurologist or physiatrist  or neuro-physical therapist to put the pieces together and come up with a logical treatment plan. 

http://www.drblakeshealingsole.com/2013/11/neural-flossing-initial-lesson-for.html

What is the next step I should take? Do I still need to see a podiatrist? Which other specialist I should see next? Is nerve conduction test necessary?

Dr Blake's comment: For this you need a team. Podiatrist to work on foot mechanics and treatments, neurologist or physiatrist to work on diagnosis and treatments, and physical therapist to work on diagnosis and treatments. Start with who can see you first. Below is one place you can start. Good luck Rich

http://www.neuropt.org/professional-resources/neurologic-specialist-certification/find-a-neurologic-certified-specialist

Thank you very much for your time and advice!!

Bests, 

Reflections one year post injury sesamoid Injury

Post Op Accessory Navicular and Posterior Tibial Tendon Surgeries

Dear Dr Blake,

http://www.drblakeshealingsole.com/2015/01/accessory-navicular-general-treatment.html

I came across your website and hopefully you can help with some advice.

I am 44, male and had a operation in December 16.  I had an excision of accessory navicular on left foot with reattachment of of tibialis posterior tendon. I was suffering from inflammation and pain on the tendon for many years and got worse ever after having custom orthotics (two pairs).  (being overweight not helping).  I used to play a variety of sports – badminton, tennis and cricket and hoping to resume soon.  I did play tennis for 1hr at moderate pace last week and did not suffer any issues.

Dr Blake's comment: Functional orthotics are actually designed to make the posterior tibial tendon work better, so that is a problem we sometimes face when we are trying to support and prevent the tendon from being over-stretched. Post-op hopefully they will work better for you. 

I have done all the rehab, physio and still do some physio now when time allows.  I only get mild pain now but want to make sure I have full recovery.

Dr Blake's comment: Hopefully you are using level 6 theraband 2 sets of 25. I will send you the link below. 

The problem is that I have quite large (size 11 US) and wide, flat feet and find wearing insoles very difficult as they invariably do not fit my feet.  I have been wearing the attached in my work shoes (3/4 length, full length don't fit) and seem to work fine, although I can’t wear too thick socks.  I was advised by my physio that I should wear some sort of low arch insoles which would help.

Dr Blake's comment: Could you go back to the custom ones? They should work, although I know you are a bit leery of them. Taught to the doc who made them. Your photos show fairly wimpy orthos for a big guy. 

Do you have any recommendations for insoles that would fit my requirements as my current ones do not fit my trainers and more importantly I want to buy some trainers which I can wear during my sporting activities. (ideally will wear one pair for all, or running shoes)  Ideally I would like to wear trainers that have appropriate support without the insoles.  Any advice on trainers?

Dr Blake's comment: If you want to stay OTC go to Sole inserts since they have more support. Also, get the New Balance Cross Trainers about 1/2 size larger. They have good width selections. The New Balance 1260, 990, or 860 should be fine. But you want to pick the one that feels the most stable to you.  Hope this helps you. 

I hope you can help in this matter.

Many Thanks

PS You also do well taping for long activities for the next several months while you get your strength better. 

https://youtu.be/AcSSyBfFocE

Achilles Injury: Always think about the Soleus

http://www.runnersworld.com/injury-prevention-recovery/soleus-strength?utm_source=t.co&utm_medium=social&utm_campaign=sharebutton

https://youtu.be/xjsYz_YFGyY

Great Tips of Marathon Running

http://www.kinetic-revolution.com/ten-tips-for-your-best-marathon/?utm_source=twitter&utm_medium=evergreen_post_tweeter&utm_campaign=website

Great Help for Achilles Stretching: Recommended by a patient with foot pain and needed something soft

Many patients need to stretch the achilles, but their foot pain acts up while stretching. Try this wedge help ease the discomfort and foot pressure. 

https://www.amazon.com/gp/aw/d/B002C9IMVQ/ref=ya_aw_od_pi?ie=UTF8&psc=1

Dr Blake's Italy Trip with a Twist: Enjoy

I recently celebrated 40 Years Wedding Anniversary with my lovely wife Patty. I journaled the trip, but made her a spy in a little adventurous twist. The spy stuff is fictional, the rest not.

https://drive.google.com/file/d/0BwmEZgwJ3YN7eXNxTE9vb0VGZ2M/view?usp=sharing

Spikey Massage Ball for Foot Pain recommended by Patient

https://www.amazon.com/NUMBER-RATED-Massage-Fasciitis-Instructions/dp/B018TEDTRE/ref=redir_mobile_desktop?_encoding=UTF8&psc=1&ref_=ya_aw_od_pi

Progress in a Sesamoid and Nerve Hypersensitivity Challenging Injury

Dr Blake

Wanted to pass on some good news for a change! I'm doing much better and have walked 7 miles this week!  That's the most since last summer!  A couple of things have seemed to help me.  Started using the Exogen which you recommended about 2 months ago.  I had some AVN per the orthopedic doctor and I believe that has helped.   Riding a regular and stationary bike has also helped. Also have used a spikey ball 2 times a day and that seems to help the blood flow to the area.  Another thing that I believe has really helped me is a foam wedge used for stretching. The bike, spikey ball and the stetching give immediate relief to me that seems to last a few hours. The biggest help has been my PT who has guided me through this!  She made a doctors appointment at the orthopedic and even went with me to go see him!  It's been a long journey and still have a long way to go but starting to see the light!   Thanks so much for your help and encouragement!

Healthy Nail Salon Program!!

If your city does not have one, get it!!

https://sfenvironment.org/article/healthy-nail-salon-program

Big Toe Injury from Fall: Email Advice

Hi Dr. Blake,

 

I realize you must get absolutely tons of emails from desperate foot patients humbly looking for advice--and, yes, I'm one of them as well.

First off, I am very grateful that you take so much time out of your day to work on your blog and also respond to perfect strangers. I'm glad I found it, since there is SO much helpful advice and perspective! (and I'm long overdue for making a donation, since I think I've read just about every single post at least twice). Since you are so generous in offering general opinions online, I'm hoping you may be able to advise on my situation (sesamoid-related, surprise surprise! I think you may be one of the best DPMs in the country for this issue). I'm on an HMO in DC, so it'd be challenging to see you for a proper visit, but I would be more than willing to pay a fee for you to give second-opinion correspondence from long-distance.

 

Long-Winded Nickel Tour:

I had a fall-injury in early March which impacted mostly the ball of my foot, and hurt my medial sesamoid (MRI report indicated "stress reaction"). I went in a boot right away, since the pain was awful. I also almost immediately developed CRPS symptoms (no swelling, but horrible pain and purplish discoloration). I have a history of the OTHER foot having a plantar injury with CRPS from 8 years ago, so I knew the signs and how to deal with it (get a pain management doctor, get on gabapentin immediately, keep the foot moving as much as possible, etc.) Fortunately, with a lot of daily work, the CRPS symptoms have slowly abated a lot in the past 4 months.

 

However, I think my bigger problem is the sesamoid (my podiatrist calls it a "deep bruise") that does NOT seem to be healing. I've had a total of 3 MRIs  in 4 months; here are the impression notes:

 MRI in March:

"Moderate edema within the medial hallux sesamoid with adjacent plantar subcutaneous soft tissue edema. Findings may be seen with a stress reaction or sesamoiditis. No acute fracture identified. Mild hallux metatarsophalangeal joint effusion with mild osseous marrow edema and subchondral cyst formation at the hallux metatarsal head. Findings most consistent with stress reaction or early osteoarthritis."

Dr Blake's comment: This is normal for a stress fracture (no fracture line seen) although the impact of the sesamoid may have irritated and damaged the metatarsal also (where they come together, seen in impact activities). Sources of pain at this point are nerve hypersensitivity from CRPS, inflammatory bone and soft tissue, sesamoid, and first metatarsal.     

MRI in May:

"Interval improving marrow edema along the medial hallux sesamoid and the head of first metatarsal. Subchondral cystic changes along the head of the first metatarsal along the plantar aspect of the dorsal aspect with resolving mild marrow edema"

Dr Blake's comment: Good improvement in 2 months. I tend to wait 6 months, so this is fun to read. 

MRI in June:

"Minimal interval improvement in marrow edema within the medial hallux sesamoid. Stable degenerative changes in the first metatarsal head at the crista" (not sure if "minimal" means "the radiologist can't really see a difference…")

Dr Blake's comment: The first change was probably just the decrease in overall swelling and inflammation. I would never expect any reliable change in a month. Do not get another MRI until October or December even. 

 

I went and looked at the images myself--to my (admittedly untrained) eye, the marrow edema doesn't look like it's changed at all in 4 months' time!

Dr Blake's comment: Probably right, but a very indirect reflection on healing. The bone is getting stronger, but the remoldeling phase causes the bone to have more water than it should. It could be healing just fine. Also, have you been icing twice daily and doing contrast bathes each evening to help control the deep swelling. Also, as you bear more normal weight the swelling gets pushed out more normally. The bone mineralization process needs this period anyway. With no fracture line, you do not have to be overly concerned about the bone healing. You have to flush, insure you have good bone health, create your 0-2 pain level yet increase your activity (this is why we need to experiment with orthotics, dancer's padding, Cluffy wedges, rocker shoes, spica taping, etch.

 

I'm on my second DPM (first was a nightmare who didn't seem to even believe in CRPS), and I'm limited in choice by my HMO unfortunately--the second DPM has 30+ years experience, but doesn't see many sesamoid injuries, nor does any other doctor in the HMO--I think it's maybe because they serve general population and therefore not as many athletic types.  He said he doesn't read MRIs, so can't take a second look at the "progress" of the bone. He originally wanted to cast the foot for a period in the beginning, but I objected because of the CRPS symptoms (immobility=very bad). DPM has now advised to wean out of the boot with J-pad orthotics and Hokas/Altras, but I can't maintain 0-2 pain level (per your advice) in the sesamoid area for more than several steps--and I've experimented with dozens of shoes/orthotics/dancer pads/adhesive felt/jerry-rigged orthotics combinations, to try and offload the bone without upsetting the rest of the foot. No dice there.  I’m having a custom one made, but I'm not expecting miracles or even a better solution than what I've already constructed.

Dr Blake's comment: Sometimes you have to really work with the inflammation and nerve hypersensitivity alot, before the mechanical support gives you 0-2 pain level. Typically a good arch support, a metatarsal support and 1/4 inch dancer's padding, cluffy wedge, and spica taping will give you level 2. What level does it give you? If more than 2, try to work with anti-inflammatories, contrasts, ice, gentle massage and range of motion to bring the pain down. If you touch your skin, and the skin is sensitive, then there is a lot of nerve hypersensitivity. Work with bio feedback like mirroring to get the toe working. Any thing that increases normal touch or motion will tell the nerves all is fine, so stop hurting. People have to neural floss or use Neuro-Eze to relax the nerves. Some need an oral med, like Elavil or Lyrica, to at least calm the nerves while you sleep. 

 

I've read every single one of your (very helpful and informative!) posts about sesamoids (along with lots of other reading/research), and am doing everything I know of to help it: Vit D and other supplements, daily warm soaks, daily stretching/intrinsic strengthening of the foot (per a physical therapist), daily stationary bike and floor exercises (trying not to atrophy too much elsewhere),  trying all the different shoe/orthotic combinations, acupuncture, more antinflammatory foods.   Have recently added icing and 2x daily contrast baths--I tried in the first 2 months, but ice/cold often makes CRPS much worse, and my foot was definitely not happy with it then, when I had to ice the sesamoid in the first few weeks! Now that CRPS has calmed down a lot, though, I'm tolerating cold therapy, so I'm religious about the contrast baths (along with everything else. I am on the extreme-compliance end of the patient spectrum).

Dr Blake's comment: Since the fall cases impact to hurt the soft tissue, sesamoid and 1st metatarsal, it was a significant injury. You could have an element of turf toe (ligamentous involvement) in there. Be kind to yourself and do not rush, because it is probably not just a sesamoid injury. I would consider getting a CT scan to work at the 3 dimensions of the bone, a nerve evaluation for possible nerve entrapment, and of course an Exogen bone stimulator for the next 9 months. 

 

 It wasn't covered by my insurance since I don't seem to have a fracture, but I got an Exogen anyway, and doing that once a day--just in case it might help. I’m very worried that the marrow edema hasn't really improved in 4 months, and that it might start to get necrotic.

 

I've also read the horror stories about people not being able to walk normally for years because of sesamoid issues (or the bone eventually going AVN after fighting for months to save it, and then necessitating surgical excision). I'm desperately trying not to become a member of that camp! I will do ANYthing to help this get better. From my other-foot injury 8 years ago (which got complicated and had me on crutches for a whole year, with several awful years of leg-atrophy rehab following), I already have an INCREDIBLY deep appreciation of walking and mobility in general, so you can imagine how this latest injury is taking a huge toll on my psyche and soul. I'm extremely depressed/grieving and afraid that I'm looking at many more months of immobility and problems. Before March, I was very active walking-wise, ~7 miles/day, and need to walk a lot for my job (and sanity). I'm fully aware of the domino-effect of injuries--and I'm also having some mild symptoms of sesamoiditis in my other foot now, presumably due to compensation.

Dr Blake's comment: First of all, you are doing what you can as a super patient (if all my patients were this good!!) Somehow you have to stay positive to keep the blood flow going. Anxiety is a vaso-constrictor to the sesamoids, and a vaso-dilalator to the quads to make you run again from danger. This is why CRPS patients in general need meditation, gentle healing music, and psychiatric help. I am so happy the CRPS is better, but some nerve hypersensitivity, the type that lingers and lingers, may be still there. Typically a skilled neuro-physical therapist can help with this (what pain to honor, what pain to push through). I can not recommend over 2, but I have had patients okay pushing themselves with 5-6 pain max. That sensitivity is not the place for this blog. 

 

I'm so grateful for all the helpful information on your blog. Is there anything additional you might advise me to do here? I have these specific questions, if you are at all able to answer them:

 

• I now have good flexibility in my foot and joints (it doesn't hurt to flex, only to weightbear) and don't see the benefit of spica taping at this point in the injury. Should I be taping?

                            Dr Blake's comment: You can spica tape to hold your big toe down, and your sesamoid completely off the ground. We call it the ballerina walk. Give it a try to see if it helps. 

• I've read that biophosponates *might* be helpful for stress injuries (I believe the studies are limited, though--can you speak to this as a possibility?

                           Dr Blake's comment: First get a Vitamin D level and bone density and report back. 

• Does weightbearing on the sesamoid cause more internal bone inflammation and edema? i.e., Should I just get back in the boot full-time (sigh)? The edema doesn't seem to be going anywhere and I'm terrified that the weightbearing I'm doing may be hindering healing.

                           Dr Blake's comment: Without knowing you any better, and believing that maintaining 0-2 is safe for healing, spend the next 2-3 months in the boot and on crutches. We want some weight bearing for bone mineralization, swelling reduction, bio feedback, etc. Tell me what it takes to create the 0-2 consistently and we can go from there. That will be your July 1st benchmark, and you re-evaluate where you are August 1st. 

• Is it possible that the internal edema hasn't really healed in 4 months because the already-tenuous blood supply to the sesamoid has been compromised or injured by the internal bruise? And if so, is the bone likely to eventually die?

                           Dr Blake's comment: Sure, anything is possible, but not likely. The CT scan now, and in 3 months, will help assess the possibility of avascular necrosis. That is a much better test in the next 6 months than another MRI. You have done way to much to get necrosis (Exogen, contrasts, some weight bearing). I worry more about turf toe which could require surgery. Have them look at the ligaments really well to see if there is any sign of sprain. 

• Could the Exogen possibly prevent necrosis? Would you recommend upping the frequency? (I'm on once/day)

                            Dr Blake's comment: Sure, most recommend 2 times daily. It is one of the biggest factors to fight against dying bone because its purpose is to wake up those bone forming cells. And studies show that Exogen helps healing in pretty bad bone!!

• If you cannot do a long-distance consult, is there anyone you'd recommend in the DC/Baltimore area? I'm stuck with my HMO right now, but may change it at the end of the year, or even pay out of pocket for someone who has a lot of experience with sesamoids.

                           Dr Blake's comment: I love Dr Stephen Pribut. He is wonderful. Pay for a consult and after you get the CT scan, and let me know what he says. We should start there. Good luck. 

 

Please let me know if you'd be able to consult coast-to-coast.

 

Very warmly and appreciatively,

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https://youtu.be/QE36ArOWg_c

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