Biomechanics for the Podiatrist: Thou Shall Not Varus

  Blogging on Friday is Biomechanics for the Podiatrist    


The phase "Thou shall not Varus" is a bunionectomy phase for students and beginner surgeons to avoid over correction of a bunion. In this article, I would like to discuss a simple fix for patients who bring in shoes that over supinate them. This is also called under pronation, lateral instability or Varus Instability. After the foot is placed over 3-4 degrees of varus positioning, that foot can destabilize quickly and become laterally unstable. The YouTube video below describes this common problem most commonly observed as the patient walks away from you. 


     Lateral Instability or Excessive Varus Positioning can be helped in the office with simple shoe wedging at the time that the problem is noted. The following photos explain the process.

A scalpel is used to cut into the lateral side of the midsole normally from the heel to the metatarsal heads.

Then Barge Cement is used to glue the 2 sides of the opening and the 2 sides of the wedging material.

Here the 1/4 inch wedges, and they may be any thickness, are standing up with both sides glued and the glue is drying.

Here is a closer look at the wedge which is skived and the curved end to be placed into the distal end of the opening.

Once the glue has dried, the opening is forced wide, and the wedge is stuffed into the midsole as deep as possible.

Here is the side view of the wedge in place, the sides ground smooth, and super glue (or knock-off) used to seal any loose attachments.

Another view of this wedge from the back.

     One of my Golden Rules of Foot: Thou Shalt Not Varus. Over Supination has been blamed as a cause or aggravating factor in more than 17 injury pain syndromes, including peroneal tendinitis, ilio-tibial band syndrome, ankle sprains, stress fractures, knee and hip joint arthralgias, low back pain, etc. Patients who are too varus positioned as functionally unstable. Personally, I believe over pronation should get a little less press and over supination more. Definitely, this simple in office shoe wedging technique will help 1000s of your patients.

Twitter: Thursday Blogging is Twitter Updates

Please follow me on Twitter every Thursday for new updates. Thanks, Dr Rich Blake

Twitter address: @richblake756

Email Correspondence Tuesday: Notes 5 Months Post Sesamoid Fracture Removal

Blogging on Tuesday is now Email Correspondence Day Hi Dr. Blake, It has been about two months since we last emailed and I have a few more questions for you.  Right now I am at five months since surgery after removing the fibular sesamoid bone from my right foot. Things have improved a bit since the last time we talked, I have gotten orthotics that sort of help but I haven't managed off setting the sesamoid bone area. The fibular sesamoid is the one closest to the 2nd toe and the one shown here irregular, not round like the tibial sesamoid. Both lie under the first metatarsal protecting the main joint from trauma, and helping the tendons which travel into the big toe to work better (same two functions of the kneecap).  Dr Blake's comment: Needs to be more arch support designed into the orthotic device or more of a dancer's pad. Very crucial at this stage and pre-op in attempting to prevent surgery in the first place.   I have started going to acupuncture which has not really helped with the pain but is definitely relaxing I wont ask her about icing though :),  and I am still going to pt to which he has been working on breaking down the scar tissue in order to increase the mobility of the great toe joint. It appears that the joint is mobile, but the scar tissue around it prevents the movement. It seems I have created a mass of scar tissue that is not going away without a fight. Dr Blake's comment: See the blog post on Hallux Limitus/Rigidus Self Mobilization. It normally gains 10 degrees if done daily. Have them measure the joint range of motion of dorsiflexion (see photos below). You need 60 degrees to walk normally, and 75 for most sports. If you are quite restricted, you could have local anesthetic shots to numb the joint, and the doc or PT right after do the same mobilization work. This is normally done once a week for 4-5 weeks, or until normal range of motion is obtained. If you can find out what the Range of Motion of dorsiflexion and plantar flexion is now, that would help seeing progress over the next 7 months. This mobilization technique gets at the deepest scar tissue around the bone within the joint well.   I am heading to see the surgeon this week for another follow up and the pt would like me to ask his opinion of other options for dealing with the scar tissue. Pt feels like he has gotten as much as he can broken down and is concerned about damaging the upper layers in order to get into the deeper scar tissue. During the pt sessions I have not used the equipment like I see other patients using other than the bike to get my foot warmed up and he has spent the rest of the time using several other ways to heat up and manipulate the area to get things moving. Dr Blake's comment: Range of motion of the joint post operatively improves in 3 waves. The first improvement is during the first three months as the swelling and pain resolves (you are behind right now). The next improvement is slow as activity naturally bends the joint, but the improvement plateaus from 3 to 9 months (with few degree changes per month). Then, the final improvement is from 9 to 12 months as the nature maturing process of scar occurs and the scar thins externally and internally as it loses most of its fluid. The scar on your skin changes from red to white and shrinks in size. So, but 1 year you have done through the 3 nature driving forces to improve the range of motion. It is up to the health care provider to tell you if you are behind that nature curve or not. If measurements are taken before surgery (rarely), that would be great to compare. But, if they are started now, you can at least go from here.   I have been a good patient and using ice and heat, stretches, working on breaking the scar tissue and strengthening my poor little foot. In the last two weeks I have begun to participate in karate class either going through the motion of kicking the heavy bags (without contact and mostly kicking with the noninjured foot) and doing katas with not so great stances, and of course I have to work all day on my feet.  The podiatrist I consulted with before surgery suggested to go in through the top of the foot rather than the bottom to help reduce the amount of scar tissue and right now with the amount I have gathered I am very pleased the surgeon went though the top, I don't need any more scar tissue in there. My pain level is consistently at a 5 and still goes up to maybe an 8 on really bad days. I believe I have a pretty high tolerance to pain and am not a big sissy, but maybe not. :) Dr Blake's comment: Pain leads to swelling and muscle tightness. You have to control the excessive pain to get it into the Good Range of 0-2 for a 3-4 month period. This may require a weight bearing removable boot. Whatever it takes!! So in a round about way I am getting to my questions. Do you think I may be expecting too much and too soon as far as doing too much workout wise? Dr Blake's comment: Definitely since you are not able to keep the Pain Level in the Good Pain range. Just because you had surgeon, you can not ignore pain levels above 2. It is discovering what you have to do to keep your pain between 0-2 that you discover good treatments and true measures of disability. You also can gauze in a positive way how you are doing month to month.  I am generally at the dojo 2 to 3 times per week and if I work out it is for about an hour, otherwise I am modifying an exercise video a day or two a week and riding the boring stationary bike.  My other question is what are your suggestions about breaking down the scar tissue? I am smashing and massaging my foot in order to break it down. The pt guy mentioned that there may be other ways to help with that which may include a shot of some kind or numbing my foot and essentially get it moving. This scares the hell out of me considering this saga of my life has gone on for 14 months now and only for the last month maybe have I worn regular shoes with the orthotics and without along with the spica taping all day during the work day. Dr Blake's comment: A small amount of local anesthetic is placed into the top of the joint, then the same mobilization is done that is on my video. These are directions that you want moved to free up the deep scar tissue. They are not the normal motions of the joint. Mobilization takes 2-5 minutes at most. Short Acting Local called Lidocaine or Xylocaine, starts in 5 minutes and lasts for 1 hour. You ice pack for 10 minutes after and go about your life. Any podiatrist and PT could do it if they watched the video. The joint dorsiflexion and plantarflexion is measured before the injection each visit spaced 1-2 weeks apart. After 4-5 sessions, you wait one month to rest the joint, but continue everything else.  When measuring the big toe joint dorsiflexion (aka first metatarsal-phalangeal joint), the landmarks used are the bisection of the toe in relationship the bisection of the first metatarsal (see the two lines marked) A goniometer (something that measures angles) is used to measure the dorsiflexion bend of the big toe joint. The toe is moved on the stationary first metatarsal to firm resistance and then the angle measured. 60 degrees for normal walking is needed on average. 75 degrees needed for high heels and most sports requiring you go up onto the ball of your foot (i.e.. tennis, etc). When I get home I take the shoes off and begin the evening of icing and stretching.Do you know about any of these methods to get my foot moving? Its almost like if it could just be shaken out like a towel then maybe we could have more mobility. Dr Blake's comment: The 25 minute routine I would do each evening is 5 minute hot soak, 2-5 minute self mob, and 10 minute ice soak or pack. Gentle cross frictional arch massage from ball to heel with massage oil for 5 minutes before the ice pack would also help. Do not try to push the joint through normal range in pain at any time. Walking tends to stretch the normal direction just fine.   Finally the outside of my calf has been killing me and the ankle continues to feel weak while walking. The pt said that the calf is connected in some way to the arch area of the foot (which is always achy) and is sore because I have been using the foot more than I had been. I thought I have another question, but it is gone at the moment. Dr Blake's comment: If you are in pain, you will compensate and strain the ankle and leg muscles. It is normally the outside or lateral ones when you are trying to favor the big toe joint (medial or inside). Get the pain under control ASAP.  Again I really appreciate your willingness to help those of us online who need more information and suggestions of what to do next while we try to heal from breaking this nasty little bone. If I lived in Northern California rather than Southern, I would definitely be knocking at your door and have thought several times about a road trip to visit you. Yours is the only blog that I have found where I have gotten good information that I can use immediately in order to help make things feel better. Thank you, thank you in advance for your help! Dr Blake's comment: Remember a couple of things about post op joints (applies to feet, ankles, knees, and hips). First of all the first year post op is to regain range of motion, begin a workout program, manage all swelling and scar tissue issues, and develop tone back in foot muscles. But, it is the 2nd year that is truly the Restrengthening Year. This is the year from 12 to 24 months post op that the power, quickness, endurance, agility of the foot and lower leg muscles make their triumphant return. You are gaining strength now, but the main focus is pain control, re-establishing your base of exercise, and removing all unwanted scar tissue and swelling ( all this can not be accomplished unless you get the pain under control. I sure hope this helps. Rich Stacie (name changed to protect the innocent)

Photos of the Week: Plantar Fascial Tear 3 Month Comparison Healing

Monday Blogging is now Photo of the Week

Image of a Plantar Fascial Partial Tear of the superior fibers medial slip with an Intense Inflammatory Reaction Noted Above, Below and Into the Heel Bone Itself (very painful to step on)

After 3 Months in a Removable Boot, Your Sole Arch Support, and EvenUp for the other side, the Plantar Fascial is healing well and the Inflammatory Reaction calming down. The patient will start physical therapy and gradually wean from the boot. 

Plantar Fasciitis: General Schematic Initial Visit

Ice as An Aid in Athletic Rehabilitation: Dr Hal Rosenberg discusses

Dr Hal Rosenberg great discussion on the benefits of ICE over heat. Golden Rule of Foot: When in Doubt, Ice. 

Heat vs Ice: Accupuncture vs PT (Email Exchange)

The following is an exchange with Ahab following his injury to the sesamoid bone under his big toe. Ahab later finds out the sesamoid bone is broken. 

Hi Dr. Blake

I took 2 tablets of aleve twice a day

for 3 and half days

it brought down the swelling, but i was having

reactions to the meds

should i just reduce the quantity ?

is it really going to reduce inflammation for good?

or is it just while the drug is in my body?

Any thoughts?

Or thoughts on ice/heat?

Some say never ice - because it prevents blood flow?

others say ice forces blood to flow later?

Thanks,

Ahab


 Dr Blake's response:

Ahab, 

Still not sure what your diagnosis is? Rich (Ahab was able to send his MRI Report noting a fractured tibial sesamoid under the big toe joint)

Thank you very much for you responses. I know I can't look back - but I was being very conservative

for two months - then i thought 'maybe i need PT' - the podiatrist gave me a prescription over the phone

withouts seeing me - even thought I told him - 'how do i know if i'm ready for pt'? 

Dr Blake's comment: At this time no one knew the sesamoid was broken.

he told me the PT he send me too only worked on feet. She was super confident and told me

to drop the boot and cane, to wear regular shoes, and she manipulated the big toe, wrenching it

painfully to "get it moving again' - then she had me walk directly on it - saying that it would get the 

blood flowing, and that the pain was ok. I walked directly on it for a week in regular shoes - until I 

couldn't do it anymore and questioned her reasoning. I saw her one week later - and at that point 

the foot was very very swollen - that's when I asked for crutches, and that's when the podiatrist gave

me a prescription for an MRI. My question is: obviously the PT did the wrong thing, not knowing

that my sesamoids were injured - how much damage did she do? Is this going to make the recovery 

take longer? she also had me lifting marbles with my bad foot, and she said : "bend it as much as possible,

you can't hurt it by bending it" - I was trying to make it bend like the good one. 

Do you think turned back a lot of the healing which had taken place  in the first two months?

An acupuncturist recently said to me that 'ice is for dead people' - and to not ice the foot. I've stopped

icing recently, and there is a lot of swelling. I've been told that this is the body's natural way to

heal the injury. Is that correct?

Dr Blake's comments:

Ahab, You are basically getting advice that is canned (meaning protocol driven, with little to no thought behind it). A thoughtful PT does not increase pain, and understands that without MRI the diagnosis is unclear and caution must be taken. With sesamoid injuries, without a clear diagnosis of the extent of damage, you have to treat the worse case scenario (ie fracture). PT can be used to reduce inflammation, gradually start you strengthening your foot, etc. The PT did not damage you further, may have forced the issue in getting the MRI you needed, but definitely caused a setback (we don't need these physically or emotionally). I try things all the time to help problems, that cause another problem that I have to deal with, or aggravate a condition, so I do not like to cast the first stone. The accupuncturist should become a healer. No acupuncturist that I know will recommend ice. It is not in their training. But, it I practiced at the level of my training 30 years ago, I would not being doing a good job. Golden Rule of Foot: When what you are taught doesn't work on all patients, discover when to use your skills, and when to modify them.  Have them read the literature on the effectiveness of ice. Hunter's Response is proven. Ice reduces inflammation and helps healing period (end of sentence). I know when accupuncture will work for foot problems and when not. I love accupuncture to reduce swelling and relax nerves, etc, but all my patients who go to accupuncture ice pack the area when they get home. Rich

My Niece Kelley many years ago in an Ice Bucket

Rich,

You have obviously treated many sesamoids - so I am leaning towards your advice.

I have been icing continually - and the swelling was down. Ice seemed to mask the pain.

I read something about - 'inflammation is the body's natural way to heal' - so stopped icing

on friday night. By this morning the foot was all swollen again. If you say to continue icing,

 I will do that. I'm seeing another podiatrist on Monday who has supposedly treated many 

sesamoids - this podiatrist wants to see the images with me - which I think may be a good 

sign. The podiatrist who ordered the MRI didn't even mention the word fracture to me - 

I had to order the report myself to see that word - he later told me "Patients don't like to hear

the word fracture." - If he's trying to avoid giving accurate information - I don't know. He didn't

even recall how I received the injury when I went for a follow up after the PT. He thought I just

stubbed the toe, instead of going straight up on it. 

My question is - you recommend icing for your patients with sesamoid issues with the purpose

of having new blood flow into the injury? Is that correct? Icing certainly makes the foot look

less frightening 

Is the sesamoid bone actually inflamed? If it's not displaced, then why does it seem to be 

pushing out further on the injured foot as opposed to the uninjured one? Or is it the tendon

around the bone which is inflamed and giving the appearance that the bone is pushing out?

Extremely grateful for your help,

Ahab

Dr Blake's comment:

Ahab, Here are 2 links to look at. 

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

http://www.sportsinjuryclinic.net/treatments-therapies/cryotherapy-cold-therapy/effects-cryotherapy-cold-therapy

Rich,

Thank you for these links. I put ice on my extremely swollen feet, and they were immediately feeling better.

When I don't ice the swelling can be so great that it is clear, or seem to be clear that 'something must be done' - if it's not 

ice, then it has be another method - perhaps an acupuncturist would know. I can apply ice myself. 

this was a response (not to your icing links - but to your email mentioning Hunter's  Response from an acupuncturist) - 

do they make any sense to you?

"Ice is very useful for preserving things in a static state. It slows

or halts the decay of food and dead bodies but does not help damaged

tissue repair itself. Ice does reduce the initial swelling and

inflammation of a fresh injury, and it does reduce pain, but at a

cost. Contracting local blood vessels and tissues by freezing them

inhibits the restoration of normal circulation. The static blood and

fluids congeal, contract, and harden with icing, making them harder or

impossible to disperse later. It is not uncommon to see a sprained

ankle that was iced still slightly swollen more than a year after the

original injury.

Cold causes contraction of the muscles. When you go out on a cold day,

the muscles contract automatically to produce warmth. You can feel how

the body literally draws into itself when exposed to the cold. Every

athlete knows that it is harder to stretch and easier to pull a muscle

in cold weather. Icing an injured area causes further contraction in

muscles, ligaments, and tendons that are already contracted in

reaction to being overstretched. This further slows the natural healing

process and prevents the return of normal movement.

Acupuncture has five effective alternatives to icing: emergency

acupoints to move energy, kill pain, and stimulate circulation;

cupping and bleeding the local area to actually draw out and disperse

blood and fluid that is coagulating and blocking normal circulation -

often reducing pain immediately; self-massage with liniments such as

trauma liniment that move blood, reduce inflammation, and kill pain - 

removing static fluids and blood and reducing swelling; energetically

cooling herbal poultices and plasters that reduce inflammation and

also stimulate circulation and help torn muscles and tendons heal; and

herbal pills or powders that are taken orally to promote blood

circulation and prevent blood from stagnating further.

If you ignore all of this and decide that you simply must ice, try to

apply it for only ten minutes every hour. This will help to reduce the

swelling while minimizing negative side effects as listed above."

Dr Blake's comment: I love acupuncture (even though I rarely spell it correctly), and this discussion is really not about Amir getting acupuncture, it is about when during each day during these next 6 to 12 months of healing should he use ice. 

Thanks,

Ahab

Dr Blake's response:

Ahab,


 Thanks for the fun exchange. Just remember that you should always feel better after icing or heating an area. In sports medicine, ice and heat are used a lot and in many different forms. Accupuncture is wonderful tool to help in many ways. I look at ice therapy and accupuncture as both ways to improve circulation and healing when done at the appropriate time for an injury. Since you get injuried, then go through various periods or moments of re-aggravation ice can be used following these flareups for many months. I had to ice my shoulder after I played basketball for 7 months, but it allowed me to keep playing. I would heat the shoulder up before, and then ice it down after. This is very common. Golden Rule of Foot: When In Doubt, Ice. Heat  when used at the wrong time is the cause of too many set backs. Ice, as long as you do not produce frost bite, rarely causes the increased swelling which is our Enemy in a sports medicine practice. Golden Rule of Foot: Swelling slows healing and must be treated daily. A great form of anti-swelling measure is Contrast Bathing. It can be started 4 days after an acute injury, and normally several days after each flareup like you had. Make sure you learn this powerful tool. Rich Good luck. I will place these emails on my blog because it is a common battle. I hope both sides are laughing alittle. Listen to your body after you try anything. Know that as your symptoms change daily/weekly, you may have to change how you are using heat and ice at home, or with a health care provider. Rich If ice feels great, so be it. If ice irritates, and you do not know how to change the method of application or time utilized, change to one of the many forms of heat. I do not believe however that chronic swelling after an ankle swelling can never be proven to be linked to the ice program. How is that possible to make that correlation? LOL I hope at least one of my readers can see how wonderfully gifted health care providers can get caught on generalizations, and won't change when the exceptions walk into the office. 

Post Plantar Fascial Release: Email Correspondence

This is a series of 6 email interactions between David (post op plantar fascial release) and myself over the last several days.


Wow, I really appreciate how freely you communicate with people who write you.  I would certainly come see you if I did not live on the wrong
coast.

      Probably contrary what would have been against your best advice, I had
the partial plantar release surgery performed by a pretty well known
 podiatrist.  I had previously encountered athletes (adventure
 racers, mainly) who had been cut by him and raved about the results.  I
 suffered with PF for nearly three years and tried various (but probably not
 every) conservative measure.  I had the surgery on December 15th, and at
 this juncture the end result is a mixed bag.  Well, the heel doesn't hurt.
 So, that is a positive.  I have not resumed running (or run walking) yet
 (and for other reasons which I will get to..) but I do bike, walk
(distances of up to 8 miles at good pace..) and have done up to 175 floors
 on a Stairmaster (the good / escalator variety..)  Typically, it does not
 hurt while exercising, but sometimes, after a long / intense session, I
 have some lingering pain the next few days along the lateral side of the
 foot and ankle.


Dr Blake's comment: This is extremely common post plantar fascial release since it is the medial band that is cut (big toe side), leaving the lateral band (baby toe side) to do all of the work post op. 


  It is not enough to make me limp (eh, give it a 2 or so..)
but it is disconcerting.  I, for the most part, understand why
 this is happening, but I wonder how much I should be concerned about it, and how
 conservative I should be with it.  All in all, the foot is probably in less
 pain than pre-surgery, but feels a little less...functional, if that makes
 sense.

     Prior to surgery I had pain in the ball of my foot (I was running a fair
bit prior to surgery..)  It was essentially undiagnosed, and after the
 surgery it did not bother me again until about two months post surgery.
 Then it really flared up again, and sesamoiditis was diagnosed.  I got an
 MRI and it showed a bipartate sesamoid (confirmed by x-rays taken years
 earlier..) with "mild edema on the proximal, tibial sesamoid".   Strangely,
my left foot started experiencing what I woudl describe as sesamoid pain a
week or so later, although I did not notice the same degree of swelling.


Dr Blake's comments: Sesamoiditis (pain in the small bones under the big toe joint) is like many other injuries with a strong mechanical cause. And, if it is one of the weak links in the chain on the one foot, it is probably one of the weak links on the other foot. Mechanical problems tend to occur bilaterally (both sides), although can be separated by a time interval. 

 I got custom orthotics with a first ray cut-out for both feet, and
 sometimes wear a soft sesamoid pad / sleeve with it.  I most often feel the
 ball of foot pain not when I am walking or standing, but when I am sitting
 wearing shoes; even if the foot is not weighted at all.  It is usually just
 a dull ache.  Sometimes, if I come down hard while walking or biking, I
 might feel it a bit (more of a sharp pain) but that does not generally
 linger.  I have been conservatively treating it in this fashion for about
 2.5 month now.  I was told that these things are just slow, and it can be a
 good 6 months.  I would say that it is somewhat better, and the swelling is
 substantially down at least as far as I can perceive.

 I was told that my fat-pads there are rather thin; disconcerting for my
age.


Dr Blake's comments: I have found thin fat pads under the ball of the foot and under the heel on many patients presenting with pain in those areas. It is good to call it to their attention, so they are mindful of the padding in that area with stressful activities. 
 Anyway, I am somewhat disheartened.  I really hoped that the PF surgery
 would end an unpleasant chapter in my life, and now I have some brand new
 problem I have to try and heal, along with the post surgery recovery.

Dr Blake's comments: David, athletics equal pain and recovery, followed by participation, followed by more pain and recovery, and the cycle goes on. It will only end when you decide not work out, but instead work on heart disease, diabetes, obesity, and all the other side effects of poor activity. 

 Does it seem like I am doing the right thing?  How slow should I take my
 exercise program in light of BOTH problems?  How worried should I be about
 the lateral pain, and does it, generally, go away?  And why the hell did
 the ball of my left foot start hurting?

 I was previously a rock climber; recreational, not great, but I enjoyed
 it.  I hoped to return to it, but I am beginning to have my doubts.

 I'm 44, 6'5", and weigh about 205.  I wear a 14-narrow shoe.  Prior to
 injuries three years ago I ran around 15-20 miles a week.  I am a moderate
 pronator, and did not start wearing orthotics until I was diagnosed with PF
 in April 2009.


Dr Blake's comment: If you are a moderate pronator, and you get orthotic devices, make sure that you feel you are running at push off through the center of your foot and not the first metatarsal (cut out or no cut out). If not the orthotic needs to be corrected in the arch more to get you off the sesamoid. 
 Well, thanks for reading this.  You really do a great service.  My
 podiatrist who I went to for the surgery is a few hours away, so it is hard
 to make recovery / check-up / management type appointments.

David
Dr Blake's initial response:


 David, I am just back from vacation, so I will probably tackle your
 wonderful email this week some time. But, that being said, you should spend
 the next year strengthening your feet. Release of the plantar fascia puts
 alot of strain on the muscles to support the arch. Look at the blog and
 start doing 2 exercise each evening for your feet, no more than 5 -7
 minutes total. Since you released the medial 2/3 of the PF, the lateral 1/3
 is taking on too much pressure. Are you stretching it out 3-4 times daily,
 and do your orthotics support the lateral side of your foot well (do you
feel centered with them?). Sorry to be brief. Ice pack 2-3 times a day for
 5 minutes to the bottom of both feet is mandatory. Rich





Dear Dr Blake, 
I truly appreciate your time and reply, and hope to not strain your
 patience with my response.  First, I hope you enjoyed your vacation.  I am
 preparing to go backpacking in Wyoming this summer, and hope that I will be
 able to do so.  If you asked me in April I would have said that I would
 have been fine for this summer, but man, that was a bit of a set-back this
 past weekend.  My previous number of floors was 80, but I was feeling so
 good that I more than doubled it.  I know, 10% more per week / workout,
 right?  Lesson learned...  It does feel somewhat better today.

Dr Blake's comment: Golden Rule of Foot: If healthy, increase your exercise level no more than 15% per week, if recovering from an injury, only increase 10% per week. 

 I will resume icing as you advise; I have two of those blue-ice gel packs
 which are conveniently foot-sized, so that is pretty easily accomplished.
 I was, perhaps, over icing previously (I had stopped for a few weeks until
 resuming this morning..) and it almost seemed that my sesamoid on my right
 foot was worse with the icing than without.  It would often have a blue
 discoloration, roughly oval shaped, right at the ball of the foot where the
 pain was.

Dr Blake's comment: Forget the blue ice--often too cold and produce ice burns. Get a reusable gel ice pack or two that will easily mold to foot even when frozen.

 Exercise: things like towel scrunches, balancing on one foot, picking up
 marbles, etc?  I can do that.  You have quite a few on your blog.  Any the
 you want to specifically recommend?  I am stretching both feet using a
Pro-Stretch rocker 2-3 times per day, and have been doing that for some
 time, and will adhere to further advice.

 Interesting that you asked about how my foot feels / felt.   This is very
difficult to put into words, and I tried to explain it to my surgeon as
 well as a sports medicine doctor I was seeing; and they both looked at me
like I had two heads or something.  If anything, the first two to three
 months after surgery, my foot felt "twisted" within the shoe.  It felt like
 the lateral edge was pressing down and was not lying flat in the shoe, and
 the entire foot was turned and twisting inside the shoe.  Indeed, my foot
 was not sitting straight within the shoe and I occasionally had to knock
 the edge of the shoe to get it all straight.  It became more pronounced
when I spent as much time off my feet as I could from February 15th through
 to the beginning of March when the sesamoid first flared up.  I eventually
 started walking (3ish mile walks a few times a week..) and whether
 coincidence or not, it seemed to even that feeling out to the point where
 it is almost gone.  I thought it completely gone last month, but the recent
 lateral pain caused at least that sensation again, but not as extreme.  I
 did mention that this was hard to put into words?

Dr Blake's comment: After foot surgery of a structure that has an important role, many sensations of distortion, malfunction, instability can be described by patients. Patients often need surgery, but the surgeons often are not experts at foot function and rehabilitation. I am happy to say about podiatrists: 95% of the surgery I see is done well. I am unhappy to say that the rehabilitation post surgery should improve, or the patient's expectations should be lowered. 
As said above, the foot is feeling a bit better today.  And let me be
 honest here.  While it hurt, I did spend all day Saturday doing lawn work
 which included cutting down trees and clearing brush, and I went mountain
biking Sunday followed by a round of golf.  Maybe my expectations are high,
 but my surgeon (like me) is a go-go-go kind of guy, so I they are
 justifiably high.  If this is just the roller coaster that is recovery (my
 sports Doc, who is a friend, always says "healing is a process..") I guess
 I can accept that, and will certainly take the steps needed to make is more
 manageable!

 Again, thanks,
David








Dr Blake's comment:


David, The flatfooted balancing and metatarsal doming are the best. Do at the end of each day. Use a wine bottle with warm water to gently massage the lateral part of the plantar fascia 5 minutes twice daily. Ice other areas inflammed twice daily also. Change your orthotics for better sesamoid protection, or at least ask if this is possible. Rich

Dear Dr Blake, 
Thank you again for the reply.  Last night I did 5 "sets" of towel pulls and 3X30 second one leg stand while barefoot.  Neither were terribly problematic.  I will try the metatarsal doming.  Quick question: I watched the video, and is this done from a seated or standing position? 




 I'll need to empty a wine bottle with a screw on cap to get to the warm bottle massage, and will start on that immediately.  ;)

I'm not sure what to do about further relieving pressure off the sesamoids.  Maybe build up the bottom of the orthotic more so the cut-out can be deeper?   I don't feel them too frequently when walking, standing, etc, but they are touching a surface, at least to a limited degree.  As it is now I have a depression / cut-out on the first ray and wear a sesamoid sleeve which has a thin dancer pad built into it.

I was biking yesterday and passed a fellow jogging along nicely with a mid-tibial blade style prosthesis.  While he probably has his own problems to deal with, sadly,  I felt jealous..


Dr Blake's comment: Only when an athlete is addicted to his/her sport would they understand that comment. Surgeons, doing surgery on athletes, need to understand how David's comment affects the nature of the patient/doctor relationship, and the outcome. A lot of dynamics play here!!

Dr Blake's response:
David, 

Met Doming is done from a sitting position only. Yes, deeper hole will help if the arch is supported enough so that you do not just fall into the hole (sometimes a careful balance). Rich



Dear Dr Blake:
Thank you again for your replies.  The lateral pain was gone by the middle of the week, and that aspect of the foot, the surgery recovery, has really felt better.  Today it felt quite close to pre-surgery normal, but without the pain.  I will be diligent about exercise daily, per your advice, to help prevent future injury and foot fatigue.

While I hope it never comes to it, is sesamoid surgery further complicated by a prior plantar fascia surgery?  I am in no hurry to get cut on again, but I would likewise like to know my options.  The sesamoid seemed to be getting better, but has become a bit more painful and puffy the last day or two.


Dr Blake's response:
David, 
 I will put this correspondence on my blog, removing you name. I am glad I was helpful. The effect on a future sesamoid injury depends on the overall effect of the plantar fascial surgery. Did it ultimately cause your foot to flatten some, putting more pressure on the sesamoids, or did it weaken your foot too much. I would be diligent this next year on your foot strengthening exercises and wearing your orthotics. Rich
 Feel free to email further questions as they come up. 


Dear Dr Blake,


That phrasing above was awkward on my part.  Ever since the lateral flare up calmed down, the right foot has felt pretty good and near normal.  I guess I meant to say it has "never felt better" but even that lacks clarity.  I have not pushed it like I did on the stairmaster that one day.  I will be working on that more incrementally.  The sesamoid has been bugging me more the last few days and I guess that remains my main concern.  I don't =think= it flattened my arch terribly much if at all.  I wear orthotics, although I was not wearing them when the sesamoid problem started (frankly, they hurt and put pressure on the incision site).  That is no longer the case.  I'm seeing a more local podiatrist Monday who can work with me more directly on perfecting my inserts / orthotics to protect the sesamoids.  I met with him before for the heel pain, and he seems like a hands-on kind of guy.


Dr Blake's comment: David, good luck. Please place comments on this blog post if you would like in the future. Please use your witness protection name of David (which is not your real name of course). Rich Your great descriptions will help many. 

Orthotic Adjustments Needed: Too Much Supination

Dear Dr. Blake,

Our PT has observed some things to me regarding Alex's orthotics and heel lifts and I wanted to get your advice.  I have attached pictures that illustrate what I am describing.

If you look at the heel views, both of Alex's shoes shoe some shifting outward, but the left is much more noticeable than the right.  Looking at Alex's achilles tendon, it shows that his left heel is shifting outward (the tendon is to the left of the mid-pt of the rear of the shoe, as compared to the right achilles tendon which is more lined up with the mid-pt of the rear of the shoe).  Viewed from the top (heel top view pic), you can see that there is a gap in the shoe on the inside of his left heel.  As the day progresses, this gap grows larger than can be seen in the photos.  It is enough to stick a few fingers into the shoe along with his foot even with the shoe tied more tightly.  Also, I think with the heel lifts, Alex's foot is higher and closer to the top of the shoe, especially the left side insert where the arch is higher, the insert touches the inside top rim of the shoe while the right side sits lower (insert left and right shoe pic).  I am wondering if the added height of the lifts along with the insert, is causing Alex's foot to maybe angle him to much outward (evert?).

Alex's PT is wondering if maybe the heel cup were to be built up a little more on the outside of the heel, if that might not keep Alex's left foot/heel from shifting outward.

Please let me know what you think.

Thank you,
Joan

Joan, Thanks for you patience in my response. I was on vacation to Hawaii last week (someone has to support Obama's state). 


Definitely Alex is being thrown too far to the outside (inverted). Could you please bring him in for an adjustment (although if this is difficult I could do an initial adjustment as long as I had his shoe and orthotic for several days). Lifts and orthotics can elevate the heel too much in certain shoes, and especially in this one. The adjustments to lower the heel and center his foot should be relatively easy, but if the shoe is standing inverted now with his feet and no inserts, he will have to purchase a new shoe. Hopefully this shoe can be salvaged. 


I definitely prefer the appt however. Always great to see you. Thank you for the wonderful photos.


 I hope you do not mind I will put them on the blog. You are just wonderful to keep an eye on all this, and please thank the PT--excellent pick up. This is okay for a little while, but would eventually cause another problem.


 Rich 

Hallux Rigidus/Limitus: Use of Carbon Graphite Plates to Restrict Motion

Hi Dr. Blake,

I have to come in and get the new orthotics you made for me in the fall readjusted. I have been wearing my old orthotics.  But the reason for my email  is that I met a woman last week who has bone spurs in the

big toe metatarsal and she wears a carbon steel insert in her shoes to immobilize   that joint. She said it really is effective and she swears by them. Nobody has ever mentioned this type of orthotic for my Hallux Rigidus. My feet sweat so much

that the tape (spica) doesn’t last very long.   What are the pros / cons of the carbon steel orthotic as opposed to the one that you made for me?

Thanks,

Evonne

Evonne, The carbon steel inserts are somewhat difficult to use for some patients. It is also a surface that is so unforgiving, I worry it will hurt someone. I have only used once on a patient, and was very frustrated. That is not to say that I should recommend the product more. I will attach several links l so you can try and give me your feedback. I will definitely share that feedback on my blog. Rich Definitely purchase one, and bring in for your next appt. Schedule one hour. 

http://www.jmsplastics.com/plastic_sheets/nrg_plates.php   (see the Morton's Extension Plate) (can be used under the orthotic device)

http://02b20d1.netsolstores.com/X1BladeforTurfToehalluxrigidusPain.aspx  (this can be used under the orthotic device)

http://www.myfootshop.com/detail.asp?p=1&ProductID=881   (this can not be used under orthotic device)

http://www.mmarmedical.com/Carboplast_Morton_s_Toe_Plates_p/4008x.htm  (also be used with orthotics)

Sesamoid Injuries: Email Advice

Dr. Blake! Thanks for posting and explaining the MRI of the sesamoid. I found this in search of deciding wether the cost of a MRI will be useful in aiding my tibial sesamoid fracture. I wish I had started doing research earlier. I am learning new things such as using the exogen bone stimulator twice a day instead of the recommended once a day.

I did not see a Dr. for my foot until 3-4 months after the injury. My Dr. put me in an immobilization shoe (which i alternated wearing with a carbon fiber insert in cuter shoes) for 2 months. I had a prolo shot, then arfter 2 months recieved my exogen machine and vitamin prescription. she was going to let me go back to work (with continued immobilization) and made it sound like the 2 fractured peices had mended together on one side.
I grew nervous and just got a 2nd opinion. When I looked at the x-ray...the tibial sesamoid looks like a pile of mush with no defined sides...YIKES!! He put me in a bigger CAM boot, prescribed a steriod, wants me off for another month as well as an MRI. Any suggestions you have for me?? How will a MRI help my treatment??
Thanks! ....Discouraged in Texas Tiffany

Tiffany,

     Thank you so very much for the comment to my post on Sesamoid Injuries. Glad some of the fine tuning of the management is coming across like Exogen BID and the value of MRI in these injuries. You have had some interesting treatments like prolo shots and carbon fiber inserts which I seem to never use. If you can comment on them, I know people would be interested. Does the Cam Walker work better than the immobilization shoe, I assume it does so rarely use the shoe? X-rays are so misleading that I do not trust their role in any definitive way in making decisions. They are part of the picture only. 

     To say the sesamoid looked like mush does not sound appetizing, and I have only seen once. It may be the normal healing of the bone as it regroups and reorganizes. Sometimes osteoblastic activity (bone forming) looks a little chaotic at first, even when it is doing a good job. When you talk to the doctor, discuss CT scanning. CT Scanning just shows bone and will tell you if the bone is normal looking or disintegrated (thus the mush look). If disintegrated, surgery is normally done. You get an MRI in order to get another MRI and perhaps another MRI. MRIs shows what is injured (sesamoid, metatarsal, tendon, etc). MRIs for their true value in these circumstances need to be compared 3 to 6 months from now (the longer you can wait the better) to another MRI to check if things are looking better. They look better if they are healing. If the doctor is not going to consider surgery for the next 3 to 6 months anyway, because they want to see if you can heal this thing no matter what the X-rays show, then get your baseline MRI. If the doc is so concerned with the X-ray and honestly feels you should have surgery, get the CT scan first and discuss the findings together. Get an MRI if you agree to try to avoid surgery.

     Remember that steroids  and anti-inflammatory meds slow bone healing, use cautiously, or just ice is what I recommend. Make sure you develop a plan to protect the sesamoid with your doctor as you go from boot to shoes. This normally requires orthotics, spica taping, dancer's padding, some physical therapy, etc. The same treatment used to prevent surgery at this stage is used after surgery if needed. Hope this helps you Tiffany. Dr Rich Blake