Biomechanics 3: Sports Medicine Summary

 

The following information will form the core of my 2 lectures at the California School of Podiatric Medicine at Samuel Merritt Universitty in Oakland California January 2012. Each lecture is 3 hours and divided into 2 hours didactic and 1 hour on gait evaluation. Students should be prepared to walk with and without shoes.

Intro to Blog and AAPSM

During the course of the lectures, we will discuss the below topics, but will not have time to open and explore all the links. We will watch all the videos and answer all the 60 self assessment questions. I will let you know if you should open a link during lecture time. You are responsible to the level of understanding brought out in the Self Assessment Questions. This blog is a four year project of Dr Rich Blake. I am in my 22nd month, so I have a long way to go. Please come back often in your studies to get more information as it becomes available. I am excited to be part of your education and I look forward to having you as my colleagues. Remember to join the AAPSM as soon as possible (http://www.aapsm.org/). It is the heart and soul of podiatric sports medicine.

Objectives (as outlined by the Department of Biomechanics of the California School of Podiatric Medicine):

These include:

• General Definitions of Injuries 
• Specific Discussion of Injuries 
• Generalization on Gait and Role of Mechanics on Injuries 
• Podiatrist as Part of a SportsMedicine TEAM 
• Further General Rehab Thoughts 

1) What are some General Definitions of Injuries commonly seen in podiatric practice?

First of all, What is Sports Medicine? And why is it a fun way to practice?

http://www.drblakeshealingsole.com/2010/05/what-is-sports-medicine.html

Self Assessment Question #1: True or False: A Typical Sports Medicine Approach is based on a TEAM approach between health care provider and patient.

http://www.drblakeshealingsole.com/2010/08/injury-recovery-principles-crossing.html

Self Assessment Question #2: True or False: Patients with injuries should decide themselves when it is appropriate to have surgery.


Acute Injuries --- Generalizations:          When is an injury acute, subacute, or chronic?  What is RICE?   What is KISS?

• Happened with last 2 weeks (if not, they are subacute up to 2 months, and chronic after 2 months)
• Understand Good History Taking (have a consistant system of questions).

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

Self Assessment Question #3: What does the P in the mneumonic stand for?

• Understand RICE       What are the goals of RICE?

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

Self Assessment Question #4: While doing contrast baths, do you end with heat or cold?

http://www.drblakeshealingsole.com/2010/03/secret-of-contrast-bathing.html

Self Assessment Question #5: In treating an injury, when do you stop doing contrast bathing?

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

Self Assessment Question #6: What is the best way to apply cold therapy for an injury?

Rest is a 4 letter word--Activity Modification is better way.  What are common Activity Modifications for an Injured Runner?
Compression should be greater distal, and less as you go proximal
Elevation is always good, even only a few inches off the ground. When should someone elevate the foot of their bed for sleeping?


Chronic Injuries--what most of your patients will be dealing with. Injuries over 2 months old.   What is a Plateau in Symptoms?

• Understand Magic 80% Rule              What does 80% better mean to an athlete?

http://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html

Self Assessment Question #7: At what % of recovery are sport specific drills usually started?

• Understand Good Pain vs Bad Pain Principle

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Self Assessment Question#8: What is the range on the pain scale of Good Pain normally?

• Understand the KISS Principle

http://www.drblakeshealingsole.com/2010/03/kiss-principle-of-medicine.html

Self Assessment Question #9: Why is it important for health care providers to learn simple techniques?

Sprains  What is the difference between sprains and strains?

• How are they subdivided?

First Degree--ligaments stretched (no obvious ecchymosis on exam)
Second Degree--ligaments partially torn (some ecchymosis) Why do 2nd degree sprains hurt more than 3rd degree sprains at times?
Third Degree--ligaments torn completely (significant ecchymosis on exam)

http://www.drblakeshealingsole.com/2010/10/ankle-sprain-advice-from-afar.html

Self Assessment Question #10: Why can some ankle sprains, without breaks or tears, take 2 to 3 years to heal?

• The ligaments do not repair on their own!!            Why are most ankle sprains not casted acutely?
• Strength must replace loss in ligament integrity       What is the Romberg's Test for ankle instability?

http://www.drblakeshealingsole.com/2010/08/video-on-ankle-strengthening-eversion.html

Self Assessment Question #11: How do you isolate the peroneus longus from brevis in Thera Band exercises?




http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Self Assessment Question #12: When balancing on one foot, how long do want to do it for?

Strains

• How are they subdivided?

First Degree--muscle/tendon soreness from stressful activities
Second Degree--partial tearing of the muscle/tendon (ecchymosis will occur within 4 days)
Third Degree--complete tear (normally surgery is recommended, some cases will respond to casting)

http://www.drblakeshealingsole.com/2010/08/achilles-tendon-ruptures-surgery-or.html

Self Assessment Question #13: Can Achilles Ruptures be treated conservatively?

• Tendonitis is the tendon part of a first degree strain. If the pain is in the muscle, it is called a strain. If the pain is in the tendon, it is called tendonitis.
• Understand the BRISS Principle of Tendonitis treatment  Why is the understanding of muscle function crucial in treatment of tendonitis?

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

Self Assessment Question #14: What do the initials stand for in tendinitis treatment?


Overuse Injuries      What are some possible etiologies?

• The general concept is the the tissue injured is stressed higher than its breaking point (tissue threshold) and it either strains, sprains, breaks (like bones), or gets irritated (like nerves).
• Always think and investigate 3 causes of any overuse injury    What are 3 common causes of plantar fasciitis?  What are 3 common causes of achilles tendonitis? What are 3 common causes of metatarsal stress fractures?

• How we overuse something, and cause it to hurt, can be varied, but usually predictable (see the Law of Parsimony)

 http://www.drblakeshealingsole.com/2010/06/musings-from-footstool-5-law-of.html

Self Assessment Question #15: What is the Law of Parsimony? How does it fit into the KISS Principle?


Fractures/Traumatic Injuries      What are some common foot fractures?

• Traumatic Injuries are produced by an event (catastrophic to the patient)
• It is very important to understand exactly how this event happened (remembering back to that moment)
• It is also very important to understand if the injury was merely accidental, or if  there are reversible preceding events that can be avoided in the future.  
• Like overuse injuries, it is important with all injuries to take a good history (we need to know how it happened, why it happened, and can it be prevented in the future) Why is it important to know Vit D25 levels in this regard?
• Traumatic Injuries can be bruises (contusions), sprains, strains, fractures, nerve damage, arterial injuries, or most likely a combination of a few of these.

What is a stress fracture?

What is the difference between a stress fracture and a regular fracture? A better definition of a stress fracture is a fatigue fracture (the bone is fatigued from overuse and then breaks). So a stress fracture implies a fracture produced by overuse. A stress fracture also signifies a small crack not seen on xray, only the new bone formation is seen 2 weeks later denoting a healing response from the bone. However, this is partly untrue, but now part of normal lingo. A stress fracture may start as a small crack on one side of the bone, and become a complete fracture as the athlete pushs through the pain. A stress fracture may start as a complete break in the bone easily observed in an xray. So, to me, a stress fracture is any fracture, big or small, that starts by a history of overuse where the bone may be fatigued. What are the 4 stress fractures in the foot that a very slow to heal?

http://www.drblakeshealingsole.com/2010/11/foot-stress-fractures-answers-to-email.html

Self Assessment Question #16: What is the daily recommended dose of Vit D3?

http://www.drblakeshealingsole.com/2010/04/patient-footlight-1-possible-foot.html

Self Assessment Question #17: When do you place a patient with a stress fracture in a removable cast?

What are the 3 Phases of Injury Rehabilitation?
One of the advances in sports medicine has been the merging of the 3 phases of injury rehabilitation of traumatic injuries. The 1st phase is Immobilization/Anti-Inflammatory, the 2nd phase is Re-Strengthening, and the 3rd Phase is Return to Activity. Sports Medicine Principles have tried to blend them as well as possible for a quicker, but safe, return to full function. While the pain is resting in the 1st Phase, they are also doing some strengthening (at least proximal to the site), and some cross training cardio and some sport specific drills. And so on.




http://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html

Self Assessment Question #18: What are the 6 basic types of strengthening exercises? What type is a calf raise on one foot?



2) What are some Specific Injuries seen commonly in a podiatry practice


Here I have been asked to discuss some of the common injuries I see from a podiatrist's standpoint. Due to time restraints, only some key points are highlighted.


Ilio-Tibial Band Syndrome:

• Runs from the lateral pelvis, across the lateral side of the hip and knee, and attaches into Gerdy's Tubercle on the proximal lateral aspect of the tibia (in front of the head of the fibula). Can you find Gerdy's Tuberble on your right proximal tibia?
• Women tend to get pain at the hip due to their wider pelvis, men at the knee.
• Ilio-tibial Band Syndrome is almost exclusively a repetitive stress syndrome caused by running.
• Excessive Pronation causes the iliotibial band to rub across the lateral femoral epicondyle at the knee, or greater trochanter at the hip.
• Excessive Supination strains the band as it attempts to stabilize the lateral aspect of the hip and knee from the varus stress.
• A short leg syndrome can commonly cause iliotibial band syndrome as the band attempts with every step to straighten the legs (to no avail).
• Treatment includes correcting the biomechanics, icing several times a day, strengthening the hip abductors (core in general), and stretching alot.    What is the lateral wall lean stretch?  

  http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-29.html

Self Assessment Question #19: With limb dominance seen in Short Leg Syndrome, which side tends to get the ilio-tibial band strain?

 

http://www.drblakeshealingsole.com/2010/11/iliotibial-band-tendinitis-3-common.html

Self Assessment Question #20: What areas do you avoid while stretching the IT Band with an Ethafoam Roller?


Lateral Ankle Sprain:

• Probably the most common traumatic injury affecting the foot and ankle (so master this one).
• When a patient presents with an ankle sprain, decide if it is a high ankle sprain, low ankle sprain, rearfoot sprain, or midfoot sprain. What is a High Ankle Sprain?
• Understand the mechanism of injury, and the force of the injury, to understand the possible problems created by the injury (including fractures).
• An inversion sprain without a fall is better, an inversion sprain without rotation is better, an inversion sprain without coming down from a jump is better, an inversion sprain without someone landing on you is better. It is all about forces. Understand the forces generated by any sprain to predict severity.
• There is no right or wrong on xrays or MRIs. If it is black and blue, it means something tore or broke, so xray at least. If you think a tendon is torn, MRI immediately. If the patient still can not walk in 2 weeeks after a sprain, even with a removable boot, get an MRI.

• Followup on ankle sprains is every 2 weeks. They should get better and better. If the patient plateaus, change something in the rehab, get a test, something.
• With the average ankle sprain, receiving average treatment, some symptoms of pain occur for 3 and 1/2 months, and swelling for 4 and 1/2 months. Return to running with an ankle brace can occur as early as two weeks. But, no limping is allowed. How long do you use just ice?
• As will be stressed in the links below, it is so important to restrengthen the ankle for around 3 months to avoid reinjury. Usually the next ankle sprain is worse. While restrengthening, you must get a brace to stabilize the ankle in vulnerable activities.

http://www.drblakeshealingsole.com/2010/10/ankle-sprain-advice-from-afar.html

Self Assessment Question #21: What is one example for getting an MRI after a common ankle sprain?

http://www.drblakeshealingsole.com/2010/08/video-on-ankle-strengthening-eversion.html

Self Assessment Question #22: How is the Peroneus Longus strengthened differently than the Peroneus Brevis?

http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Self Assessment Question #23: What is the reason some exercises should be done with your eyes closed?


Enthesitis:

• Inflammation at the attachment into bone of ligaments or tendons by definition
• These can be more stubborn than tendonitis since it is harder stretch out.
• Plantar Fasciitis (at the heel attachment) and Achilles Tendinitis (at the heel attachment) are good examples.
• Sever's Disease or calcaneal apophysitis is a growth plate injury.
• PTTD (posterior tibial tendon dysfunction) is a tendonosis (condition of the tendon itself).

http://www.drblakeshealingsole.com/2010/03/treatment-of-plantar-fasciitis.html

Self Assessment Question #24: What is the 3 areas of treatment for plantar fasciitis?




http://www.drblakeshealingsole.com/2010/10/achilles-tendon-strengthening-video-on.html

Self Assessment Question #25: How do you strengthen the soleus differently than the gastrocnemius?


Shin Splints vs MTSS vs Tibial Stress Fracture    What are Shin Splints exactly?

     This is a great example of the Weakest Link in the Chain Concept. Leg pain arises from excessive stress placed on the leg muscles which will be outlined in the links below. The tendon causes the motion, the tendon moves due to the contracture of the muscles (in this case in the shin area), the muscles attach into the bone's covering called periosteum, and the bone resists the force pulling on it. In an overuse situation, the same action can produce tendon pain, muscle pain, periosteal pain (classic shin splints), or bone pain. The bone pain can get inflammed called Medial, Anterior, or Posterior Tibial Stress Syndrome, or can actually break (Medial, Anterior, or Posterior Tibial Stress Fracture). The injury occurs at the weakest link in the chain.

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-3.html

Self Assessment Question #26: What are the 11 common factors that can make an area the weak link in the chain?

http://www.drblakeshealingsole.com/2010/06/shin-splints-part-i.html

Self Assessment Question #27: What are the 10 common treatments for shin splints?


http://www.drblakeshealingsole.com/2010/06/shin-splints-part-ii-anatomy-lesson.html

Self Assessment Question #28: What are the 4 basic types of shin splints?


What is Compartment Syndrome?

• The compartments are fascial enclosures which house several muscles. There are 4 compartments in the foot and 4 in the lower leg. The fascia which covers the muscles can be too tight for the amount of muscle hypertrophy or swelling within the compartment. As pressure builds up within the compartment, the fascia does not give enough, and the blood circulation in the compartment is restricted (the walls of the vessels are compressed due to this pressure).
• Acute Compartment Syndrome, normally produced by a blow to the outside of a compartment, is caused by the swelling in the compartment, and is a medical emergency. A compartment release is crucial to save the muscles from dying.
• Chronic Exertional Compartment Syndrome can be a diagnostic nightmare. Injuries in the foot or leg that seem to have a solid limit of activity (the pain can only run 3 miles before the leg pain gets bad) may be compartment syndrome. Compartment syndrome has always been a surgical treatment, but with deep tissue work, there is a promise in the future of conservative management.
• Diagnosis of Compartment Syndrome is needle catheter in the compartment to measure the pressure. Normal resting pressures are between 0-4 mmHg. Pressures that climb above 40 mmHg and stay there after activity is stopped is considered compartment syndrome. What do you think happens to the muscle strength in a compartment that has a release?

Patello-Femoral Pain:

• Also called Runner's Knee, Biker's Knee, Dancer's Knee
• Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc...
• Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation.

• All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO, Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.   What is a stronger muscle the vastus medialis or vastus lateralis?

http://www.drblakeshealingsole.com/2010/07/video-quadriceps-stretching.html

Self Assessment Question #29: When stretching the right quadriceps, it is best to use your right or left hand?

http://www.drblakeshealingsole.com/2010/11/gait-evaluation-with-emphasis-on-knee.html

Self Assessment Question #30: What is Malacious Malalignment Syndrome and how does it relate to knee pain?


Heel Pain:         When does plantar fasciitis hurt more, am or mid-day?

• Myth: All Plantar Heel Pain is Plantar Fasciitis.
• Myth: All Posterior Heel Pain is Achilles Tendinitis
• You should be an expert on every aspect of these two common injuries, but very crucial to know when it is not plantar fasciitis and achilles tendinitis.
• They are so very common injuries that I see  very sloppy management of heel pain. Too many generalizations are used that don't apply to that patient. If I can get you a little ahead by understanding plantar fasciitis in the links below, it will be a start. Heel Pain is complicated at times, and very debilitated, and common enough to have clinics dedicated to that body part alone.

http://www.drblakeshealingsole.com/2010/03/treatment-of-plantar-fasciitis.html

Self Assessment Question #31: 2 months of treatment for plantar fasciitis and the patient is not getting better, should surgery be considered next?

http://www.drblakeshealingsole.com/2010/12/plantar-fascial-tear-possible-cause-of.html

Self Assessment Question #32: True or False. After a plantar fascial tear period of cast immobilization, there is no need for physical therapy?

http://www.drblakeshealingsole.com/2010/12/plantar-fasciitis-sleeping-splints.html

Self Assessment Question #33: What are 3 common adjustments made to sleeping splints?

http://www.drblakeshealingsole.com/2010/10/plantar-fasciitisheel-pain-orthotic.html

Self Assessment Question #34: What are the 2 most important aspects of an orthotic device for heel pain from plantar fasciitis?

http://www.drblakeshealingsole.com/2010/08/plantar-fasciitisachilles-tendinitis.html

Self Assessment Question #35: What is the common denominator in all 3 stretches demonstrated?

http://www.drblakeshealingsole.com/2010/08/plantar-fasciitis-all-important-wall.html

Self Assessment Question #36: What is the difference between counting as you stretch, and taking deep breathes?

http://www.drblakeshealingsole.com/2010/05/quick-tip-7-rolling-ice-stretch-for.html

Self Assessment Question #37: If you ice for 5 minutes, how long does it take to have your soft tissues thaw out?


Turf Toe:            What is Turf Toe? Does there have to be turf involved?

• Turf Toe can occur to any toe, but primarily the first or second toes.
• The mechanism of injury is the toe in a cleated shoe gets stuck in the ground, the metatarsal dorsiflexes over the toe too far spraining, straining, and perhaps breaking things.
• Primary Injury is to the plantar surface of the joint, or plantar bones or tendons.
• Secondary Injury is to dorsal aspect of the joint with compression fractures, etc.
• Treatment is normally immobilization/anti-inflammatory, then spica taping, shoe inserts to restrict toe bend, activity modification. Budin splints can be used when the injury is to the 2nd through 4th toes.
• Since most of the injury is soft tissue, I would highly recommend an MRI sooner than later so you really have a handle on what was injured.

http://www.drblakeshealingsole.com/2010/09/hallux-rigidus-spica-taping-also-for.html

Self Assessment Question #38: What type of tape is typically used to limit first toe dorsiflexion?

http://www.drblakeshealingsole.com/2010/10/toe-pain-help-with-budin-splints-email.html

Self Assessment Question #39: Can a Budin Splint be used for a first toe injury?


3) Gait Evaluation/Motion Evaluation helps find the Root Cause of many injuries



Sport Specific Knowledge is Important to Properly Treat Patients Injuries:

• One of the best recommendations I ever got from a teacher was to go out to the malls, the parks, the streets, and watch people walk or run. Boy do you see the full range of gait patterns. You can begin to appreciate smooth vs choppy gaits, or gaits that may produce problems. We will watch each other walk in class, just to get the basics down. I have built my entire practice on this skill. And in doing gait evaluations, you can learn what is wrong quickly.

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-15.html

Self Assessment Question #40: What are the 5 common categories of mechanical problems seen in gait?

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-14.html

Self Assessment Question #41: What are 3 common knee symptoms sometimes related to excessive pronation?

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-13.html

Self Assessment Question #42: What are 2  foot injuries associated with excessive supination?




http://www.drblakeshealingsole.com/2010/11/basics-for-gait-evaluation.html

Self Assessment Question #43: If the right shoulder dropped lower than the left in gait evaluation, what leg is normally longer in an adult?



http://www.drblakeshealingsole.com/2010/11/gait-evaluation-with-emphasis-on-knee.html

Self Assessment Question #44: Is squinting patellae associated with genu varum or genu valgum?

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-6-err.html

Self Assessment Question #45: When dispensing a new pair of orthotic devices, why is it important to evaluate their gait?




http://www.drblakeshealingsole.com/2010/08/high-heels-fashion-accessory-with.html

Self Assessment Question #46: What are 3 positives of high heel fashion shoes?

http://www.drblakeshealingsole.com/2010/07/general-principles-of-running.html

Self Assessment Question #47: Where should your center of gravity be while running?




http://www.drblakeshealingsole.com/2010/04/toenail-clippings4-dominance-seen-in.html

Self Assessment Question #48: What is limb dominance seen in gait?

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-29.html

Self Assessment Question #49: How is a decrease in limb dominance achieved?

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-9.html

Self Assessment Question #50: What are the 11 common injuries related to excessive supination?


This same principle applies to dance, tennis, soccer, skiing, racewalking, zumba, etc. If you want to learn, experience. Be a student of motion. Motion is one of the secrets of life. Ask anyone whom has had it taken away permanently or temporarily. Ask any 80 year old what is one of the most important aspects of their life. Motion, to be moving, to keep moving. And there are rules along the way to obey to try to keep moving as long as you can. One of the things I am most proud of podiatry as a profession, it is dedicated to keeping people moving. Amen.

As you treat injuries from different sports, gradually learn about that sport. If a ballerina comes in with an injury, learn alittle each time about her sport. What are the main producers of pointe shoes?
http://www.allaboutdance.com/cats/pointe-shoes?range=41%2C80%2C93


4) What is the best way for a podiatrist to be part of a SportMedicine TEAM?
                                    What is probably the most important characteristic of a Great Team?
We have talked about what is sports medicine. And that there are sports medicine doctors that do not practice sports medicine principles, and non sports medicine doctors that do practice sports medicine since it is more of a philosophy than label. So, when you are in a sports medicine team, you must see where you fit in. I love the team approach to medicine, so this is what I do. I get my patients seeing other doctors and therapists as much as possible, and it works real well. If you are part of a team, try to be the podiatric part that understands when to get consults about nerves, etc, and how to treat knee or hip injuries with lifts or orthotic devices. Get the physical therapists as involved, or they may be in charge of you on a professional team. In the dugout or locker room, the therapist/trainors rule!! The buck stops with them. You need to inform them of your skills, but let them decide when you are to get involved. But, as a very valuable part of that team, you need to be the primary care doctor for their foot injury. The buck should stop with you! If you take on a patient, you should be involved in all aspects of their care (conservative or surgical) until they discharge you, or the injury resolves. I find many podiatrists not able to do this team function since they want to be too specialized (normally towards surgery). A good sports medicine team needs a podiatrist who is conservative in their approach, since 99% of all injuries are treated like that. You, as the podiatrist, are more skilled than anyone at the simple approaches to most injuries. My blog is filled with these treatments that I use daily with my patients. Don't give that part of foot care away. If you want to be the podiatrist for the San Francisco Giants, or New Orleans Saints, etc, but your main interest is surgery, please co-captain with a conservative based podiatrist whom you can trust to call you in when the big guns are needed.
     I can not emphasize the TRUST part. TRUST is everything in a team. If I trust you, our team works. If I do not trust you, the team will never work. Work hard never to break the trust of those you work with. It is the best advice I could ever give you.


5) What are other General Rehabilitation Thoughts

What are the general concepts in Injury Rehabilitation around return to activity?

• Since most athletic activities are based around running, a good understanding of the walk run program is crucial.

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

Self Assessment Question #51: What are the 10 levels of a Walk/Run Program?

What are the general concepts in Injury Rehabilitation around cross training?

• Podiatrists, temporarily sidelining their runners in the 1970s, while the running injuries healed invented triathalons (like Al Gore invented the Internet!!). Cross Training is needed while injured and while healthy. Cross Training is an attempt to keep moving, but avoid injuries by working on other aspects of overall conditioning. A basketball player, like myself, may not be able to cross train by running, but yoga, stretching, bike, swimming, etc may all fill gaps in my overall health. If I am a basketball player that plays 4 days a week, my cross training schedule should not fatigue muscle groups that then limit my basketball playing. The cross training should relax, tone, improve my conditioning so that my basketball improves.

Self Assessment Question #52: Would an injured ballet dancer with knee pain get better cross training with running or swimming?

What are the general concepts in Injury Rehabilitation around bracing and taping?

• You need primarily to brace and tape if you are permanently injured and the brace/tape allows some activity without pain, or if you are recovering from an injury, and you have not regained your overall strength yet.
• This is one of the reasons we want to get patients not of the casts as soon as possible (1 day in cast, 2 days to restrengthen).
• This is also one of the reasons we start restrengthening right after an injury.

http://www.drblakeshealingsole.com/2010/04/tips-to-avoid-castimmobilization.html

Self Assessment Question #53: What is Cast Disease?

What are the general concepts around footwear considerations?

• Footwear is podiatry. And one person's best shoe ever, hurts another. Analyzing the qualities of shoes can and is as important as analyzing the patient's biomechanics.

http://www.drblakeshealingsole.com/2010/10/great-foot-story-practice-of-excessive.html

Self Assessment Question #54: What is to practice Excessive Happiness?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic.html

Self Assessment Question #55: What are 11 reasons that the treatment plantar fasciitis can be different in all the patients you see? 

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_18.html

Self Assessment Question #56: Why must the patient be encouraged to follow up with the doctor/therapist so that they are aware of their progress?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_24.html

Self Assessment Question #57: What are the 2 categories of injury based on severity? And how is there overall success of treatment different?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_25.html

Self Assessment Question #58: If you restart running, but pain returns, how long in general should you wait to try running again?

Self Assessment Question #59: A runner with medial knee pain for 5 days and excessive pronation noted in gait. What would be 5 KISS type treatments that may resolve the situation that you could recommend at the first visit?

Self Assessment Question #60: A patient was running yesterday and got sharp pain in the top of his metatarsals. He had to limp several miles back to his car. That night the foot became swollen. What is your primary diagnosis? What dietary issues should you discuss?

When Do We Begin to Save Our Joints? More Musings from my footstool

This post is dedicated to Lynne.

     Just saw Lynne several days ago. Lynne brought up the age old question at her young age of 59 "do I stop running now to save my knees for the future?" Her knees have some X-ray and MRI findings of wear and tear. Lynne has never had any pain. She did have an episode of knee swelling and sought medical advice. Age old probably sage advice is to stop running since it is the most stressful of her activities on her knees.Lynne is high level triathlete. Yet is it the best advice for Lynne? Does running chew up your knees and hips and ankles silently until you wake up one day and can not walk? What do we know about the Nutritional Theory of cartilage health? What protects joints? What breaks them down? So many questions to be individualized for each of us. 

     My bias for recommending to Lynne to keep running comes from 5 factors. #1 Joint Cartilage is feed from pressure created in the joint from activity (nutritional theory of cartilage health). #2 Pain is our friend and will normally tell us way before severe damage is created that we must start limiting certain activities. #3 Sports Medicine for podiatrists evolved from being able to get injured knee patients to run pain free when the medical establishment was telling them to stop running forever, and I come from that time period of the mid 1970s.. #4 I personally want to keep exercising until I am 100 and I will continue to find ways to exercise (my last 3 orthopedic injuries found me at odds with surgeons wanting to cut, and I was able to successfully rehab each one, and am back playing full court basketball painfree). #5 When you break away from generalizations like stopping running to avoid knee wear and tear, you must own your knee more directly and do positive things daily for it. 

     So, Lynne had been running for 40 years, never had knee pain, did get swelling and her images showed classic wear and tear of a 59 year old. She did not have the knee joints of a 90 year old, so all the running she has done has not been bad for her knees. There was a famous study from Sweden or Norway (way up there) in the 1970s. Twelve 90 year olds who had died had there hip joints examined. All 12 never had hip pain. 6 of the 12 were very active their whole lives. 6 of the 12 were very inactive their whole lives. Guess who had the hip joint cartilage of 20 year olds--yes, the active group. The 6 individuals who had been inactive had hip joints of 90 years old (and not a day older). This study helped secure the global recognition that the cartilage in our joints needed pressure to drive the synovial fluid into the cartilage (a form of forced feeding). 

     Lynne stopped running to save her knees, but may be actually speeding their demise. Lynne can sure be smarter and try not to run down hill frequently where the force that your knee must absorb is up to 10 times body weight. And Lynne can get her knees strong with daily quad sets, straight leg raises, and short arc quad leg presses. Since most of her problem with wear and tear is behind the knee cap, and the load on the knee cap increases dramatically over a 45 degree knee bend, Lynne should do her activities and exercises in a 0 to 45 degree flexion range. Running is perfect for that, some parts of biking may not be. Let pain be your guide.  Lynne should ice her knees with swelling or pain after activities, she should wear a knee brace (I love the Bauerfiend GenuTrain for this problem) when she runs to see if it helps. She could also learn the many ways of taping her knee like McConnell Taping. She should take glucosamine daily. And lastly, Lynne should listen to her body and get back out there, and not listen to general rules that may not apply to her. And as Sue Sylvester on Glee says: And that is how I C it!

Bad Sores: Top Podiatrist Recommends this Product

I recently sent a diabetic patient to a top wound specialist for an opinion. His recommendation to her was to use Winvivo Healing Balm. She definitely looked a lot better in the three wounds I had been trying to help her with. It can be used for superficial or deep wounds. It should not be used in the face of a possible infection. I believe the product has some great potential, but it is always trying to find out who it is beneficial for. 

http://www.winvivo.com/healingbalm.html

Wound in a diabetic after I scraped the callus and dead tissue away (called debridement). Careful debridement is always the number one treatment for these injuries/sores.

Application of Winvino to the wound bed.

Closeup of the wound bed after application of the product. I like it because it can penetrate into a wound. I love another product called Acticoat when the wound is superficial. 

Electronics for Heel Pain: If this works, the Stock is definitely worth buying.

http://www.marketwatch.com/story/bioelectronics-study-on-plantar-fasciitis-to-be-published-in-the-journal-of-foot-and-ankle-surgery-2012-01-19

Brown Fat for Anyone?

My good friend Dr Karen Langone from Long Island, New York, posted this great article on her Facebook page. You should not need any more reasons to exercise. After you study the article from the New York Times, I will give you a quiz on PGC1-alpha, brown fat, and irisin. Does two irisins make one PGC1a or 2 PCG1a s make one irisin molecule? 

http://well.blogs.nytimes.com/2012/01/11/exercise-hormone-helps-keep-us-healthy/?ref=health

Dry, Cracked Heels

http://www.alimed.com/heel-so-smooth-heel-sleeves.html

This is one product available for dry, cracked heels. Works well. 

REFLARES OF PAIN: UNFAIR, BUT PART OF THE PROCESS

This is an email from a typical patient expressing her frustration over a recent reflare of her symptoms. The symptoms are in the front of her foot, and a recent MRI showed no sign of fractures or neuromas.

Hi Dr. Blake,

My foot has been flare up since Sunday after a yoga class, I have been using the contrast bath, but not too much ice though, according to the acupuncturist, she thinks that I need more blood circulation to improve the nerve problem. Icing is not a good option in Chinese medicine.

Last time (Thursday) I visited her, we had a very good acupuncture session, she attached electrodes to needles to provide continued stimulation (like the Stim unit). After the treatment, I felt good, walked without any nerve problem for a while.

Sunday morning I went to a yoga class, I felt OK during the walk from my home to the gym, but there were several standing poses in the yoga class that required strong foot position, then I felt a lot of nerve activities. After the class, I went home to apply a contrast bath, and it seems to quiet down a little.

But yesterday and today, I can feel the nerve problem all the time even when wearing my MBT shoes or sneakers (on a better day, I can almost feel normal in those shoes).

So now I'm applying ice, hoping it will not get any worse.

I forgot to ask you if you have a diagnosis report that I can bring with me when I visit my Physical Therapist and my Acupuncturist. I went to my PT office on Friday, but they were not sure if it's OK to treat me with massage and ultra-sound, so they asked to see the doctor or MRI report and maybe your recommendation for PT. 

Also I want to ask you if it's OK that my Acupuncturist massage my foot, in her opinion, she thinks there is scar tissues developed, so she wants to deep massage them to break down the scar tissues. 

I forgot to ask you if you have seen any possible fracture in my MRI? These two days, I started to feel "similar feelings" as when I had the stress fracture on my metatarsal two years ago. Am I starting to get paranoid or is it really a fracture? 

Can you see it from the MRI if there's any fracture line, since we did not looking for fracture but neuroma, is it possible the MRI might miss a fracture line?

I still have my immobilizer boot from two years ago, should I start to wear it, will that help to improve my condition?

Sorry to ask you tons of questions, I was feeling better last week and felt the condition might be improving, but now I feel the problem again, it really brings my spirit down again and my mind starts to go crazy a little........

Thank you very much in advance.

And here is my response:

 Thanks for the email and sorry about your flareup. Flareups are quite common, and you have may a few more until we get this under control. One of the secrets to not going insane is in quickly controlling the symptoms of a flareup. Definitely the boot and icing are wonderful to do right now. Wear your removable boot 24/7 for three days longer than you need. If it puts stress on your back, go to our sports shop and get an EvenUp for the other shoe. Ice for 10 minutes 3 to 4 times per day. 2 Advil 3 times per day for 5 days on, followed by a 2 day rest is appropriate. Since it is nerve pain, absolutely no deep massage at all. Accupuncture is great. PT is rarely helpful at this time. The MRI shows no fractures. When you know it has been irritated by the yoga, only ice for 48 hours. The contrast bathes may have heated it up too much. Hope this helps. Finished your orthotics today!! See you soon. Rich

Balance: An extremely important exercise for sports and daily activities

Here I present 2 videos on the importance of balance and ways to improve your balance. First, Coach Marc Evans discusses the importance of balance in running. Marc is a world renowned expert in Triathlons. Then, I present my own past video on single leg balancing: the Most Important Exercise in the universe. 

Hip Function with Lifts for Short Leg Syndrome

Dr. Blake, 

When one has a lower leg length inequality, have you measured the effects it has on the hips when one goes into 

a heal lift verses a whole foot lift? I am curious to see what you observation is. 

Tim

Hey Tim, Thanks so very much for leaving a comment on the blog post entitled "Heel Lifts vs Full Length Lifts for Short Leg Syndrome". The schematic below is normal hip function in green and various motions or positions considered abnormal in purple. I see that there is a misprint which should read Hip Motion Asymmetry indicating different motion on the right and left. Over the years I have observed more Hip Hike with heel lifts vs full length lifts and more difficulty in general stablizing the hip height difference originally seen. For athletes who spend a lot or a bunch of time (just to irritate my high school English teacher) on the balls of their feet, the role of a heel lift is lessened in effecting change at the hip level and the base of the spine. 

Normal and Abnormal Motions/Positions of the Hip Area

     All this been said, experimentation with each patient is important. Every doctor/therapist that uses lifts goes off some general rules initially. There has to be a starting place. I like to start with full length lifts (normally stop just before the toes). As I watch a patient walk with lifts, I want to see easy, fluid hip motion, a lessening or elimination of limb dominance (lean of the body to one side), no hip hike (jerk upward), no knee instability which could be a sign of hip instability hiding under the clothes, and for the patient to tell me that they feel more stable and centered. Compromises have to be made when there are toe fit issues, or when stability is not being obtained.

     Another doctor/therapist may want to start with heel lifts. As they treat the patient, they should evaluate in every shoe that the patient uses the lifts whether there is hip stability, hip evenness, elimination of limb dominance and no hip hike at heel contact. There are so many shoe styles, that patients often find that the same lift in one shoe that was working well, has some issues with another shoe. In general, the nuances can be worked out, but most just do not wear the lift in those shoes it does not seem to work with.

    So, to answer your basic question, I normally see smoother, more equal, less jerky motion at the hip and knee with full length lifts than heel lifts. But, if I was starting with heel lifts in a non-athlete that was not on the ball of their foot a lot, I probably could find some shoes out there that worked well for the patient in terms of these issues. I hope I was able to answer your question.

Is Ankle Replacement Surgery on the Horizon for Ankle Arthritis?

http://www.doctorslounge.com/index.php/news/pb/25944

The article above shows that there is hope that good ankle replacement surgeries will be part of the future. There is so much research in this area that I try to tell my patients that have advanced arthritis in their ankles to get cortisone shots as needed, wear high tops and ankle braces if helpful, and do daily ankle strengthening and anti-inflammatory measures (like ice packs). Occassional trips to the physical therapist or accupuncturist to control inflammation can also help. Get multiple opinions before agreeing to a fusion or replacement. Have a conservative podiatrist if possible be your ombudsman to sort through the information available from the surgeons.

Navicular Pain: Accessory Bones and The Right Xray Views

This patient has 6 months of arch pain right where the posterior tibial tendon attaches into the navicular in front of the ankle. The 2 X-rays demonstrate how standard foot X-rays, commonly ordered in emergency rooms or by standard protocols may not reveal the problem. 

This is a standard oblique foot X-ray which shows the outside of the foot better than the inside. Even though the pain was the inside of the foot, and even though I ordered an oblique view to isolate the inside of the foot, I still got the standard oblique view since it is ordered 1000 times more than other obliques. The marker highlights where the pain is, only it is hidden behind the bones.

After sending the patient down to X-ray again, and writing more on another prescription pad,  I was able to get the correct oblique. The marker shows clearly an accessory navicular bone, demineralized, and probably the cause of  pain. Of course, I am now ordering an MRI to look deeper at the 3 Dimensional and tissue activity components. But, this example clearly shows how standard X-rays may not always show the problem, especially when specialized X-rays are needed and not routinely done at any institution. X-rays are normally correct when positive, but may be wrong when read as negative in the face of chronic pain. 

Email Advice: Calf Atrophy, Bunions, Foot Swelling

This is an email I just received with many interesting points to discuss.

Dr. Blake,

     My name is Robin and I just made an appointment to come in to see you. I wanted to reach out and see if there is anything I can do to help my foot until then.

Here's my situation:

      Last night, I started feeling like I have a splinter in the ball of my right foot, especially when I'm walking, when I press the foot on the floor or when I lift my toes up. I'm nine weeks pregnant and wondering if I perhaps have developed planter faciitis.

      Since April, I also have developed a bit of atrophy in my right calf near my knee that I wanted to get checked out as well (I've had an MRI of it and have been to an orthopedist and the conclusion was that it's just atrophy, possibly from sitting cross legged).

      I also have a bunion developing on my right foot, however, and I believe I also have a bunion developing on the top of my right foot under my big toe so I'm wondering if I perhaps am developing hallux rigidus (I've read that calf atrophy can be a sign of this) or if the atrophy is from my patella femoral syndrome.

Here's a bit about my history: 

     I used to wear orthotics (got them about six years ago) for my patella and one foot being longer than the other (I was in pain at that time and wanted to be able to run again, which I eventually was), but I stopped wearing the orthotics earlier this year when I was worried they were worn out and potentially causing other problems. 

     That's about the time I started developing the calf atrophy. I also have stopped running and doing major aerobic/weight lifting activity (outside of walking) since becoming pregnant so I'm wondering if that is contributing to what's happening with my foot.

     In sum, I'm wondering if there is anything I can do in the next week before I come in to help my foot (I started wearing the orthotics again today). I really appreciate the help and look forward to meeting you.

Best,

 Robin

Dear Robin, Thank you for the email and I look forward to seeing you. 

     1. Plantar Fasciitis tends to feel sore in the am when arising and primarily in the heel, although there are cases of it in the arch, and sometimes in the metatarsal area. Starting using an ice cube to massage the area in circular motion 3 times per day to reduce the swelling. Use can also look on the blog for the rolling ice massage technique with a frozen sports bottle. If there is swelling, use could try contrast bathing (also listed in a separate post) to reduce the swelling once per day. It is a 20 minute soaking process. Because it is an usual place for plantar fasciitis, it is more likely a bone bruise or stress reaction to one of the metatarsals. See the video on the KISS principle in designing a float or accommodation for the sore area. You can go straight to my youtube channel drblakeshealingsole. Check that area in all the shoes you normally wear to see if there is any rough spots. Do you think it is sports related? If you are right handed, and a tennis player for instance, you may pivot across this area more than on the left. Check the wear in old shoes on the shoe insoles to see if this area tends to always wear down faster. Check the skin for signs of the callus, wart, corn, etc.

     2. In regards to the atrophy, it usually a sign of low back disc problems or muscle injury. A neurologist or physiatrist or chiropractor can evaluate this for neurological cause. Since you are pregnant, they will not do a low back MRI. The muscle involved should be weaker than the opposite side. Does it affect strength in any way? Look at the post/video on 2 positional calf strengthening and test the strength of the gastrocnemius and soleus on both sides. See if by doing straight and bent knee heel raises you can can find a difference that can be worked on. Use a tape measure and measure the calf size in the same place below your knee on both sides. See if you can record the difference to use as a reference point. If you have calf atrophy now of unknown cause, we have to assume it may get worse before it gets better. Atrophy can be from lack of use like with pain, or with abnormal function (like produced with hallux rigidus).

     3. I will have to evaluate the bunion area for you. Do you have stiffness in the right big toe joint that is not in the left big toe joint? Do you have a history of pain near your big toe joint? Definitely wear your orthotics as much as possible until I see you to give me an idea how they work and feel for you. Read my posts on what to do for bunions, like toe separators and yoga toes. Definitely the pregnancy could cause some symptoms, but you would think that they would be symmetrical. It will be fun playing Sherlock Holmes, definitely one of my heroes. 

I hope this helps you a little. Rich

Sesamoid Injury: Email Advice

This is a comment to one of my posts several months ago. 

Thank you for the information Dr. Blake.  I saw the podiatrist this week and he suggested removing the bone all together. Dr Blake"s comment: The sesamoid bones are two in number and dwell under the first                              metatarsal at the ball of the foot.  He mentioned using an incision on the top of the foot and the bottom of the foot. Dr Blake's comment: I favor a medial or side incision if it the tibial or medial sesamoid, and                             a plantar incision if it is the fibular or lateral sesamoid.  He prefers the top so there is not a scar on the weight bearing part of the foot. Dr Blake's comment: If the plantar incision is in the wrinkle just lateral to the weight bearing                             surface, the visualization and ease of removal is worth the scar risk.  Do you have information of which would be the better way to go? Dr Blake's comment: This is definitely surgeon's preference, and since I do not do surgery, I am                              a little out of touch if recent research is involved.  Do you have pictures of the actual procedure? Dr Blake's comment: Sorry, but I do not.  I think I am coming to terms with having surgery.  Is there a specific amount of time to wait that is suggested before surgery? Dr Blake's comment: Most wait 6 months to see if improvement is noted with the MRI scans                             conservative care.  I know you mentioned it would be acceptable after three months, but is there a golden time frame? Dr Blake's comment: No golden time frame. These things must be individualized. Top                             athletes may have surgery several weeks after injury, you and I years if                             treatment and testing showed initial improvement.  Thank you again for the information your blog offers