Return to Work not Perfect, but should get better

Dearest Dr Blake,

Good Morning Dr Blake.

i have been meaning to write to answer your question re how you can make your blog better...

i think that the blog is just perfect the way you have structured.
it is truly a site filled with informations and stories that are enlightening and lessons that are useful to many who are on a journey to heal, understand and continue to be humans.
it shows your passion, dedication to your profession and to your patients
I have been trying to recall how  i found you in 2013 but i cannot dig it out of my memory.  I know that i will remember one day ...

i just completed two four hours shifts ~tues n wed.
my spine was already stuck in multiple areas  before the first day
R hip and top of T spine; so much so that i couldn't move or use my arm but i went to work as planned
Luckily Charlie (her physical therapist) was able to see me wednesday before my 2nd shift bec I know it's not smart to put my body though that again. he popped my T1-2 back in alignment thus i can move

I can feel that i'm sitting into my sit bones but not standing into both my feet; the external hip rotator excercise that you posted on may 1 truely help stretch the L hip, pelvic, inner groin n abd and the stiff neck  as well as made my body sit into the sit bone.
i'm hoping that this particular motions will free up n strengthen the R side and the whole lateral n medial line/chain

Thank you Dr Blake for everything you have done to take care of me;  i don't know what i would of done or where i would be if i didn't find you or your blog...

Have a fabulous anniversary trip and I will see you when you return because I did not get the week of vacation in June.

Forever grateful

Dr Blake's comment: This patient was out of work for 5 months, so needs on average 3-4 per month off to get back her strength. This was emailed separately. We are starting one month  3 times a week 4 hour shifts, then 1 month 3 times a week 6 hour shifts, and then 1 month 3 times a week 8 hour shifts. After that, based on what her body tells us, we will go from there. She stands most of her day, and has a critical job requiring 100% on top of her game, so it will take awhile. 

Sesamoid Fracture Healed!!!

This is one of my email patients who I gave advice at the beginning of 2017. I am happy to have helped. 

Hi Dr BLAKE,

After 8 months of Exogen Bone Stimulator and other conservative treatments as per your blog, my fracture is finally healed.

Today, I went for an x-ray and the bone comes up all white on x-ray with no cracks. The Dr said, the fracture is completely healed. 

My pain is 5+ years old. I'm lucky to find your blog and follow your advise. You saved me surgery and other potential consequences.

If such a old non-union fracture can heal with 8 months of treatment, then I think there is hope for all the folks who follow your advise.

Many thanks,

Lisfranc and Midfoot Arthritis: Email Advice

Hi Dr Blake,

Thanks for taking the time to answer my email and for good advice. You wanted me to send another email focusing specifically on the right foot, which is the one causing me a lot of pain today. As I mentioned earlier, I’m 52 years old and my foot pain debuted in 2005 (in my left foot). However, the pan in my right foot began later – after I had surgery on the left foot in 2014.

In my right foot, the Lisfranc is damaged because of arthrosis. I haven’t injured this foot, and I have never had any problems with it before. It’s painful when I walk and when I rest after walking. After a regular day at work, I often have so much pain that I have trouble walking. Also, I often experience muscle cramps in the calf and both over and under the foot. However, magnesium supplements have helped a lot with the muscle cramps. I have custom-made orthotics, but I don’t use them at present because they are uncomfortable in my Hoka shoes (they were originally adjusted to other shoes than the Hokas). Wearing the Hokas has actually relieved the pain a little and they are much better than other shoes I have tried. Contrast baths, as you recommended, also relieve the pain and I try to do them every day. In addition, I take extra vitamin D and calcium, as my doctor recommended this after I had a bone scan about a year ago.

I use quite a lot of painkillers (tramadol and peracet with codeine, but no NSAIDS) to be able to work. I must mention, though, that some of these painkillers are for my chronic back problems, which I’ve had for over 20 years. I’m a teacher, and walking is thus a required part of my job. My foot has gradually worsened and become more painful during the last 3 years, and I now feel that the pain severely affects my quality of life. My orthopedic surgeon, who performed surgery on my left foot, strongly recommends surgery on my right foot as well. In his opinion, this is the only way to relieve the pain and get better. The surgery he would like to do is the same as last time – involving fusion of the 1^st to the 3^rd Lisfrancs. I’m scheduled for surgery in May 2017.

My main question is if it’s possible to get better without surgery? Assuming, of course, that I would not have to take strong painkillers for the rest of my life and that my feet would be relatively well-functioning without doing the surgery. From your last reply, you seemed to think that there might be a chance to get better with conservative treatment. In that case, can you elaborate on what I would have to do – how would a potential treatment plan look like? I would really appreciate your views on orthotics, taping, foot exercises, etc., especially if there are some things that are especially recommended for Lisfranc arthrosis. Due to my work, no weight-bearing at all is not an option.

Alternatively, If I choose to do the surgery (again), how would a good rehabilitation plan look like? Last time (with my left foot), I had poor physical therapy – what should I look for in a good physical therapist in the rehabilitation phase?

I attach x-rays and CT scans of my right foot only. I’m hoping you can help me, and I look forward to your answer!

Best regards,

The arthritis is noted by the bone cysts (holes) and the irregularities on the edges of various bones

You can see from this side view that the arthritic changes cover a big area

On this image, the arthritic changes are on the first cuneiform navicular joint, and the 2nd and 3rd met cuneiform joints, and possibly the 4th met cuboid joint.

Actually, the first met cuneiform joint on this and other images looks fine

Dr Blake's comment: First of all, I am very sorry this is so tardy. I am learning electronic medical records for my office, and I have been in a 3 month fog!! Below I am attaching the excerpt from my book on Midfoot Arthritis which you definitely have to see if you are not getting any of the treatments listened. Definitely, the arthritis is extensive, so your surgeon probably is on the right track. So many patients however can avoid or prolong the need for surgery, so Golden Rule of Foot: Treat the patient not the imaging. I have seen too many of these do fine with orthotics, maybe a period of removable boots, taping, contrasts, even bone stimulators to strength bone are considered. 

3. Midfoot Arthritis/Arthralgias

     So many of my patients develop midfoot arthritis as they age. Golden Rule of Foot: Pain and swelling in the middle of your foot if you are over 60 or have had previous injuries to this area is midfoot arthritis until ruled out by MRI, CT Scan, or bone scan. Like any arthritis situation, it has both a conservative treatment side and a surgical fusion side. I have only had to recommend fusions to a handful of all my patients over the years.  

    The top 10 treatments for midfoot arthritis/arthralgias:

1. Ice Pack for 10 minutes twice daily to the top of the foot

2. Contrast Bath each evening home for 20 minutes total as a deep flush

3. NSAIDs only when needed to sleep or when the pain over 4 consistently

4. Learn a daily form of tape from supportthefoot.com or Kinesiotape circumferential arch wrap. Daily until symptoms improve, then as needed, like with long hikes.

5. Removable boot, hiking boot, bike and hike shoe, or post op shoe  when need to limit motion more.

6. Custom made functional foot orthotic devices with high arch support as a cast initially full time, and then just with activities more stressful.

7. Daily Foot and Ankle Strengthening forever. Go to Youtube and type drblakeshealingsole foot and ankle strengthening playlist.

8. Activity Modifications to create pain free environment, and build core strength and get cardio.

9. Physical Therapy or Acupuncture to reduce inflammation.

10. Occasional cortisone shots to reduce inflammation (the least as possible).

https://www.amazon.com/Secrets-Keep-Moving-Guide-Podiatrist/dp/1483586553

Expensive, but Great, Cushioned Stable Shoe: The Adidas NMD CS1

A patient brought in a pair of these wonderfully stable super shock absorbing Adidas shoes. They a Maximalist Shoe with Super Width for stability and Super Softness. The Price may be pause, but eBay was selling it much cheaper. For all of us cement pounders, a possiblility!! See the stabilization plugs for pronators or supinators. 

https://www.endclothing.com/us/adidas-nmd-cs1-pk-ba7209.html?gclid=Cj0KEQjwxbDIBRCL99Wls-nLicoBEiQAWroh6nnajBUaJ2EG0nO6uv4lD25d7V8x3IOHmI6uGojeO9waAnBW8P8HAQ#fo_c=1408&fo_k=65a3b5cf0fd338805983c7c99893bd5a&fo_s=gplaus

Link to purchase my book. 

https://www.amazon.com/Secrets-Keep-Moving-Guide-Podiatrist/dp/1483586553

How To Avoid Running Injuries For Good: Guest Author C. Haley

How To Avoid Running Injuries For Good

by C. Haley

There are so many different running related injuries which runners all dread. The thing is that with proper training and care, many of these injuries can be avoided all together. The most injuries occur due to overuse, overtraining and inappropriate training. By pacing yourself carefully and mindfully, you will reduce the risk of putting too much stress on your body, and will reduce the risks of running injuries.

The mileage increase should be maximum 10% per week if you are training for a half marathon or marathon. This is the safe level of increase for your body. Also, you should rotate between hard and easy running days and weeks in order to keep your body safe and allow it to gradually improve its fitness level, strength and stamina. Keep a running diary and log your running in order to make sure you can identify any problems with overtraining you may be experiencing or risking. Also, get sufficient rest and non-running days in your weekly running schedule. Usually, 1 to 3 days of non-running is sufficient for proper body recovery.

Also, make sure you are wearing proper running shoes for your foot and gait type, and replace them as soon as they starting wearing down and losing their shock absorption and stability features. Make sure that your shoes address your foot problem, and if you suffer from plantar fasciitis, high arches, or flat feet check comforthacks.com for specific recommendations.

Don’t wear crossfit shoes for running and vice versa. Browse fitaholicgear.com for the top picks of the year and get a second pair. For runners who run 20 miles a month, the running shoes need to be replaced with new ones every 4 to 8 months.

To avoid injuries, you should eat a balanced and healthy diet with enough vitamins, calcium and magnesium to decrease the risk of injuries too.

Stretching before and after running are steps which you should never skip if you want to stay away from running related injuries. If any injury occurs, make sure to visit a good podiatrist if you get injured and injury treatment of the feet, ankles, or legs.

Here are some tips to stay injury free:

·        Make sure you listen to your body. If you feel a problematic pain or the need to rest - then take the necessary precautions in a timely manner in order to reduce the risk of deepening of the problem, overtraining and injury.

·        Do not push yourself too hard. Don’t overdo it with your training, don’t rush yourself into big mileage increases in little time, and make sure you get sufficient rest.

·        If something is working for you - do not try to change it. If your running shoes are comfortable and offer sufficient shock absorption - do not change them. If your training program is working for you - do not switch to another one for a faster effect. At least, do not do it rapidly without preparing your body for it.

·        Make sure you increase your mileage slowly. Follow the 10% rule for the weekly increase, but make sure you take a recovery week in every 3 weeks of increase.

·        Wear the proper running shoes, and make sure you replace them as soon as wear and tear occurs.

·        Maintain a healthy diet. Try eating more healthy fats, calcium, fresh vegetables and healthy protein dishes. Eat sufficient amounts of food when training, because you will need the fuel to improve your running and stay healthy at the same time.

·        Do some strength training. Engage in some strength training 2 or 3 times a week to improve your muscle growth and strength, for a leaner body, for better core strengthening and for better overall performance. Of course, be careful to not overtrain yourself, and set your strength training for non-running days.

·        Gently warm up before running and gently stretch after the run. Make sure you stretch after you warm up for better flexibility. Start running at a slow pace with smaller steps for about 10 minutes, in order to properly prepare your body for the run.

·        Consume protein or carb mixes following long runs and workouts.

·        Make sure that running and exercising is a happy experience for you. This will help you enjoy your training, improve your performance and help you stay motivated and safe from injury.

Kind Words from Someone Who Understands the Importance of Feet!!!

Dear Dr. Blake, 

This is a long-overdue hymn of thanks to you for care in Dec 2009 & Feb 2010. 

In  August 2009, I sprained my right ankle badly.  I left for a Hawaii vacation 3 days later and limped all week in flip flops because I could not even wear a sneaker on the sprained foot. As the right ankle healed, I realized that I had developed pain in the opposite foot in the base of the 2nd toe, which is a hammertoe in the making. 

The pain increased. I saw one podiatrist, which didn't help.  On the recommendation of friends I made an  appointment with you, and after about 6 weeks of conservative care and shoe adjustments, you put me in a boot.  INSTANT RELIEF from pain - thank you so much!  - and I started PT as well, with anti-inflammatory meds and contrast bathing.  I also visited Cyrus at The Next Step in Albany, said goodbye to at least a dozen pairs of shoes, and outfitted the rest of them with orthotics as needed. I keep my wardrobe of orthotics-plus-shoes well cared-for. 

Since that time, I have slowly ramped up my activity levels, including Pilates reformer (GREAT for strengthening my feet!), dance, jogging, swimming, and plenty of walking.  I am healthier and happier than I've been in decades.  Even though I've just had a rotator cuff repair (hit some hidden ice while jogging in December), I know it's just a temporary reduction in activity level to help the repair stick. I also know my feet much better than I ever did - and they are helping me stay active and pain-free.  That hammertoe is still just hanging out, not causing trouble, and its associated joint in the ball of the foot is as quiet as a lamb.  The sprained right ankle occasionally reminds me to work on arch strength to help it out.  It's all part of the deal. 

I've purchased your book and have been following your blog off and on, recommending it to anyone I know with foot issues.  I'm on board for a mindful, active, healthy aging process to the best of my ability; I'm 58 now and feel that I've got decades of good solid movement ahead of me. 

Thank you so VERY much for your excellent work, for continuing your outreach to the world via book and blog, and for helping us all participate more fully in our own medical care.  You're an inspiration. 

​My left foot sends its own particular thanks from inside its very sensible pair of Dansko clogs, too. ​

​best regards, ​

Link to purchase my book for great tips for healing:

https://www.amazon.com/Secrets-Keep-Moving-Guide-Podiatrist/dp/1483586553

Dr Blake's comment: Thank you so very much. Thanks for honoring your feet and taking good care of them. I am so happy I could help. Rich

Morton's Neuroma: Email Advice

Hello,

     Today I was diagnosed by my orthopedic doctor with morton neuroma, after initially being diagnose with sesamoiditis from my sports medicine doctor. He noted that while there is some inflammation in the sesamoids, in my MRI, my symptoms do not correlate with sesamoiditis and definitely don't warrant 6-8 weeks of an aircast boot & NWB. He also said even though my MRI didn't exactly show a morton neuroma, he said the nerves are hard to show up on MRI.

Dr Blake's comment: This is very true at times. You can have Morton's nerve pain that hurts like a neuroma. The irritated nerve does not show up on an MRI. You are supposed to get contrasts to rule out a neuroma in an MRI, so the MRI if done without contrasts may have to be repeated down the line. Hopefully not!!

     I don't have the big toe pain, he thoroughly examined my foot, where the pain is near the middle of the top of my foot, feels like I have something under my foot when I put pressure on it.

Dr Blake's comment: It would be helpful if you sent a photo with you pointing to the area. but it is not where you get sesamoiditis. 

     I have burning stinging pain in the ball of my foot, with off and on toe cramping. Which is all why he came to the diagnose of morton neuroma. He recommended cortisone pills for 5 days, to begin slowly walking again after 3 weeks of inactivity and good supportive shoes with wide toe box as well as custom orthotics. He said if after a a week my pain doesn't lessen, he recommends cortisone shots, which I've heard horror stories and am scared to get. What are your thoughts, is it possible to have MN and not have it show up on an mri ? 

Dr Blake's comment: It all sounds right, but a little rushed. Could you use 600 mg ibuprofen three times a day for 10 days? During this time add daily ice pack to the bottom of your foot for 15 minutes twice daily. Then you could avoid the cortisone pills for now. Try a small longitudinal Hapad arch pad as a metatarsal arch instead of initially going to orthos. I have plenty of photos in my Morton's Neuroma posts. And, yes, you can have the symptoms of a neuroma, without the findings on MRI, and without MRI evidence of a neuroma, surgery is probably not warranted unless you are a rare case. The cortisone shots can be irritative, but horror they are not. I have no problem giving an occasional cortisone shot, and usually the patients are happy. Read also my posting on Double Crush, in case the nerve is referred. 

Also are orthotics worth it, or can I use the metatarsal pads to offset weight on the MN? I've heard success stories of the alcohol injections, is there any good doctors in the Denver area?  I would sincerely appreciate a response, though I know you are extremely busy. 

Dr Blake's comment: Try Dr William O'Halloran in Denver. Great guy. Yes, off weight with Hapad first. Do a diagnostic local anesthetic shot first to see if they can find the right nerve to inject. Good luck!!

Thank you very much. 

http://www.drblakeshealingsole.com/search?q=Morton%27s+Neuromas

https://youtu.be/_7qNgYNUrmw

     

     

Another External Hip Rotator Strengthening Exercise

https://youtu.be/vFdl7qRbEjU

Can We Make This Blog Better?

In March 2010  I started this blog now 7 years ago almost to the day. I want to thank all my readers for your encouragement these many years. Your thoughtfulness and kind comments have actually helped me immensely get through some rough times. I had a stroke last year, but am doing very well. I still have a strong practice, around 90% of before my stroke. I am a glass half full kind of guy, but this really threw me for a loop. I feel better and better and hope to keep going. Any thoughts you all have on making the blog better are really appreciated. Thank you for being part of my life!!


Link to purchase my book for great tips on healing:

https://www.amazon.com/Secrets-Keep-Moving-Guide-Podiatrist/dp/1483586553

Never Give Up!!

Hey Readers, I do not always do everything right, or get my patients well. I am willing and able to make referrals for a good thought process, especially if I have not seen something before, or someone has more experience that I know about, or my patient is not getting well. This was a kind letter from a dad that I had treated, and who talked his daughter into seeing me. She has a difficult problem, but some initial simple but common sense treatment helped her. And she is still doing much better months afterwards. So Keep Trying to get well! Docs and PTs, etc, all use general rules that may or may not apply to you. We all get tunnel vision. I am an old podiatrist with 36 years of experience and definitely have fixed ideas. But, I can still learn from patients, and articles, and I generally have good common sense. I remember one year or so ago I saw this patient with severe nerve pain on the bottom of his foot. He had hundreds of thousands of dollars of nerve testing, biopsies, and consults from very smart people. But he still could not walk, even with boots, crutches, special shoes. I put alittle lipstick, my favorite shade of red, to mark the sore spot on the bottom of his foot. I then had the mark transfer to his shoe insert by stepping on it. I then fashioned a $5 off weighting pad to float the sore area. He walked down the hall with no pain for the first time in 2 years!!

Dear Dr. Blake,

     I can not thank you enough for your wonderful, thoughtful care of my daughter, Melissa. She was sure that things would go as they did with roughly 5 prior podiatrists..... no listening, let alone solution, to the pain she experiences other then surgery, orthotics, etc. But you evidence not only compassion and listening but have the gift and mastery to offer simple solutions that have profound consequences. Hours after meeting I received a text from Melissa stating that the simple intervention of some padding under her toe was already relieving pain, enabling her to walk better and use her foot. She actually texted "I'm crying because I'm so happy".... she had given up on there being any help and that she just had to resign herself to a life of pain!! She found that massage work was not either as physically exhausting or pain inducing as it had been (doing it on one foot!). It would not be possible to overestimate how profound this is and the difference it will make in her life. I suspect that the connection to John King might also prove to make a big difference. I can't begin to thank you and express my appreciation.... you are the consummate doctor and healer I experienced... and we are very fortunate to have crossed your path. best,

Articles on Positive Effects of Bicycling and Parkinsons Disease

Some of us are unfortunate to get a neurological disease like Parkinson's. More and more research is pointing to exercises to help with muscle loss, or help activating the correct muscles when you are active. Here is a few of these articles that give us hope.

http://www.foxnews.com/health/2012/04/24/bike-riding-helps-parkinsons-patients-ease-their-symptoms.html

https://www.ncbi.nlm.nih.gov/pubmed/26684265

http://www.sciencedirect.com/science/article/pii/S0278262616301075

Strengthening the Hip External Rotators: The ClamShell with Resistance

As a patient walks or runs or bikes or skis (or any straight line repetitive motion activity), following the heel contact, the knee should internally rotate slightly, and then the strong external rotators begin to correct and pull the knee strait. If the external hip rotators are too weak, this does not happen. As the body moves over the knee as you move forward, the knee is out of normal alignment and pain ensues. Here is another of the common exercises used to strengthen this important muscle. 

Here the runner is maintaining good knee position

Here the runner's left knee is too internally rotated

https://youtu.be/CiqvDV8pzRk

Discussion on Avascular Necrosis of the Sesamoids: Email Advice

Hi Dr. Blake,

I hope all is well ! I read over your blog and focused on the AVN posts, which were helpful.

About a year ago, I started noticing a dull pain in the ball of my left foot, but nothing unbearable. This must have been from walking around in a bad pair of shoes for a week. The dull pain did not at any point between April 2016-December 2016 get any worse.

 I did however decide to go see a podiatrist in December to see what was going on. He put me on two different anti-inflammatories separate times and took x-rays (normal results). In January, after not having felt an improvement, he ordered an MRI. This is when we discovered that I have AVN of the fibular sesamoid. He put me in a post-op shoe for a few weeks, which did not help at all. In fact, it made the pain worse. I decided to get another opinion so I went to see another podiatrist who gave me a cam walker to wear for 6 weeks. She also suggested a bone stim. I wore the boot every day, but felt pain when I was walking in it.

Dr Blake's comment: Both the shoe and  walker typically stop you from bending the big toe joint but put extra pressure on the toe. So you need some form of dancer's padding to float the sesamoids even in these contraptions. Definitely if someone mentions AVN, because of the high risk of surgery if the bone stim not work, you have to use the bone stim for 9 months. 

 After 5 weeks, I realized that it was also aggravating the problem and starting hurting other parts of my foot (assuming this is because it forces you to walk in an unnatural way). I switched to sneakers with Hapad dancer’s pads and have been wearing them for the last two weeks. I found a third podiatrist who recommended orthotics. I just received my custom orthotics today and after putting them in, I feel a bit of pain when I walk in them (the same amount as when I wear the dancer’s pads). Not sure what to think of this...I also ordered an exogen bone stim, which will arrive tomorrow. Following the doctor’s suggestions, I will be using the stimulator once a day for 20 minutes for 3-5 months. 
Dr Blake's comment: This is a hard call. You have pain from 3 sources: mechanical (being off weighted by the hapad and/or orthotic, inflammatory (do the twice daily 10 minute ice pack, and once daily contrast bathes), and neurological hyper-sensitivity (try Neuro-Eze, pain free massage). Everything needs to be perfected. Look at each component since a littel change in anything can potentially make a big difference. Can you tolerate a bit more arch? How about a little more dancer's padding. If you are not immobilizing, perhaps a hike and bike shoes for several hours per day to rest the area better. Sometimes just go anti-inflammatory program, or consistently wearing spica taping. 

I am very worried that the pain is only going to get worse with the orthotics. If I feel pain when I walk in the orthotics, does this mean that it will not subside? My last hope is the exogen. I really am trying to avoid surgery at all cost because I have heard awful stories. Unless the pain gets unbearable, I do not even want to consider it. 

Dr Blake's comment: The real reason not to do sesamoid surgery initially is that in the long run it can effect the joint, and the lower leg biomechanics. We try to leave in what was originally there. But, it is a very successful surgery, and not too difficult to heal from. So, when a few of my patients need it from time to time, I do feel I let them down alittle, but I am happy they can gain relief. Whatever they have learned before surgery, in trying to prevent surgery, they can use post operatively to protect the joint. You would need to find a surgeon skilled at this surgery with good results, expectation to get back to full pre-injury activity, with a little sesamoid protection of the other one. 

Do you have any recommendations as to what I can do? Nothing seems to be working and it’s starting to put me down. I used to love running, but I haven’t been on a run in 2 months because I am worried I will worsen the situation.  Even before I started wearing all these shoe-alternatives, I would go on runs a few times a week and the pain was stable. I am so confused!!! I feel as though I should never have gone to see a podiatrist and ignored the problem because now the pain is worse. Are there any exercises I can do that will help?

Dr Blake's comment: You have to give this time. One year from now until you are feeling very fit is not uncommon. Avoiding the bend of the joint for the next 6 months is a start with the hike and bike shoes, spica taping, carbon graphite inserts, or just stiff shoes and orthotics. Just try to create a consistent 0-2 pain level in what you do. Bike, swim, and elliptical without lifting your heels are common exercises. Keep your foot strong with metatarsal doming, single leg balancing, inversion and eversion resistance bands, and FHL strengthening with theraband as long you only work the plantar flexion range. A physical therapist should be able to give you a good program, but protect the sesamoid also. Definitely this should include 9 months of the bone stimulation twice daily, and icing twice per day, and contrasts at least 5 evening a week for a deep flush of the stagnant blood flow trapped in the sesamoid. 

I live in NYC and am still trying to find the right podiatrist. Do you have anyone in mind?

Dr Blake's comment: Contact any of these 3 pods to get a name of someone good near you: David Davidson, Robert Connenello, and Karen Langone. 

I would appreciate any suggestions you can give me because I have been feeling hopeless.

Thank you for taking the time to read this.

Best,

Below is the report for my MRI that I got done in January:

Study Result

Narrative

History: 23-year-old female with left forefoot pain for 4 months. Evaluate for sesamoid injury.

MRI of the left foot

Technique: Routine multiplanar imaging of the left forefoot was performed on a 1.5T MR scanner according to standard protocol.

Comparison: None available.

Findings:

A skin marker has been placed along the plantar-medial aspect of the forefoot at the level of the tibial hallux sesamoid.

There is a homogeneous low signal of the fibular hallux sesamoid on T1-weighted and fluid-sensitive sequences, likely reflecting sclerosis, which can be seen in the setting of avascular necrosis. The tibial hallux sesamoid appears within normal limits.

There is no evidence of acute fracture. The joint spaces and alignment are maintained. The articular surfaces are intact. There is no significant joint effusion.

The visualized extensor/flexor tendons and ligaments are intact.

There is no Morton's neuroma. There is mild first webspace intermetatarsal bursitis.

There is no abnormal signal in the musculature to suggest atrophy or denervation.

The subcutaneous tissues are unremarkable.

Impression:

Findings compatible with avascular necrosis of the fibular hallux sesamoid.

Strengthening the Weak External Hip Rotators

I am very happy I found this video. It is beginning drills for activation of our important external hip rotators. As you strengthen a muscle or muscle group, isometric and active range of motion are important types of strengthening. Excessive internal knee rotation due to weak external hip rotators is so commonly seen, and so commonly a cause or factor in knee, hip and foot conditions. These 3 wonderful exercises are simple, but effective at getting them to work. You can add therabands for progressive resistance strengthening as the patient getting stronger. 

https://youtu.be/fMf4zuZ585I

One of my early videos on evaluating, and testing, for weak external hip rotators. These are huge muscles that can be very weak in even experienced marathoners. Why? Not sure in many cases, but shows how important these activation drills are. 

https://youtu.be/5NLLjPQuNHM

Avascular Necrosis: Article supporting Bone Stim

Some of my patients get avascular necrosis (dead bone) after a sesamoid fracture. I have seen patients heal just fine with prolonged protection with orthotics and dancer's pads, improved bone circulation with contrast bathing daily, creating the 0-2 pain free environment for healing, and the Exogen bone stimulation. Attention should also be made to the overall bone health with healthy diets and Vitamin D deficiencies. Occasionally, it is apparent that a Bone Density screen is needed. Poor bone health overall will definitely slow us down. This review article on avascular necrosis, like all articles on this subject, are all weighted toward surgery, but does have many good points on conservative treatment and appropriate imaging. For the sesamoids in particular, get a CT scan if AVN is noted. The chance of healing is low if the bone has fragmented, which only the CT scan really shows well. 

https://curesearch.org/Avascular-Necrosis

Sesamoid Patient and Performer!!

People of all walks of life get sesamoid issues. This patient is many months from wearing her removable boot, but still has some symptoms. She also is the lead singer in a popular band, so this shoe should work. It is more of a flatform than traditional heel and she combines it with a 1/4 inch felt dancer's pad. This is why I can see 100 patients with the same injury and never be bored. The sesamoid are associated with interesting people!!!

Hi Dr. Blake and hope this email finds you doing well!

Thought you might get a kick out of seeing my latest "sesamoid friendly high heel shoe" for my singing on stage with my band:
*Note:  Only to be worn with 1/4" FELT Sesamoid Pad!    ;-)
    Is it helpful to use Exogen for as long as possible?  I recall reading 9-months treatment but am wondering if longer is helpful??    Thanks again!  

Twenty Toes Performance: Incredible!!

https://vimeo.com/184028817

Twenty Toes from Roxana on Vimeo.

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.

Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.

Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 

Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.

Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.

Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps. 

https://youtu.be/l_4HESXCG40

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.

Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.

Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).

Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.

Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"

Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?

Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from www.mooremedical.com stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.

Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)

Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.

Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.

Thanks!!!

PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.

Sorry these are on their sides!!