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Friday, July 3, 2015

Tip of the Iceberg: Blog Post for Podiatry Today

This is the second of my series of blog posts for Podiatry Today for my colleagues.

Heel or Knee Pain: Removing Hard Rearfoot Posts at times can help

Hard Plastic Rearfoot Posts give great stability, but can be too hard, especially with knee and heel pain. Here the left one has be ground off (It can always be put back on). 

This photo emphasizes the hardness of the post.

Here is a closer look at the ground off post.

I just love Graffiti Art that is all over San Francisco!! Here it is on Market Street seen on a walk today. 

Thursday, July 2, 2015

Accessory Navicular and Tarsal Tunnel: Email Advice

Accessory Navicular Problems: Further info from the initial blog post

Dr. Blake,

I am a 31-year old professional who currently works in an office in Massachusetts. Last year, however, I spent 9 months in Spain teaching English. I had no car and found myself doing lots of walking. I also gained about 15 pounds in the first couple of months there. I noticed after three months of walking in ballet flat style shoes a burning sensation in my right ankle. Long story short, here we are a year and a half later and I still have the pain. I weigh about 125 and am 5'2".
Dr Blake's comment: Tentative diagnosis is Tarsal Tunnel Syndrome. This is neuropathic pain, and needs to be treated with a nerve emphasis, some mechanical changes, and some anti-inflammatory measures.

I have seen a total of four doctors so far. I have done PT, tried custom orthotics (which I lost during my move back), tried a walking boot for 6 weeks, been on a couple strong NSAIDs, modified my activities, and tried ice and heat therapy at home on a sporadic basis.
Dr Blake's comment: This problem is helped with the mechanical support of the orthotic devices, especially if there is some varus wedge at the heel. Also, nerves love heat not ice, motion not lack of motion, no massage, and gentle stretching (like neural gliding). 

The orthotics caused more foot pain in other areas, so I am not sure they were made properly for my condition. The PT was done in Spain a year ago and consisted of 45 minutes of heat therapy, electric wave therapy, and massage every day for three weeks.

Six weeks in the boot this past winter was creating problems in my left knee and hip. They never gave me a leveler for the other side, but I did wear a high shoe which seemed okay.

Please help with your opinion! My current doctor who is an orthopedic surgeon and prescribed the boot is of the persuasion that PT and orthotics will not help the edema he sees on the MRI in my bones. I personally want to try a new PT routine and new orthotics before I resort to surgery, but that means I will have to move on to a new doctor yet again. Two doctors were in Spain and the other was here in the U.S. (podiatrist with a horrible bedside manner who said paying $400 for orthotics from his office was the only option).

I am so frustrated and feel like I have tried everything but I also think the timing and quality of the things I have tried could be reassessed and tried again. What do you think?
I don't want surgery if possible. It is my right foot and it will make me unable to drive.

Dr Blake's comment: Without a history of a fall or collision causing major injury, the need for surgery is typically small. Yes, starting again sounds the best. The bone edema could be residual for a stress fracture that has healed or is still healing, and the inflammation from the bone injury putting pressure on the nerves leading to the burning. Burning is classic nerve pain. You need to create your pain free environment however while you search out a new doctor. Typically sports medicine doctors, not necessarily podiatrists or orthopedists, are the best. If 6 months has passed from the first MRI, get another to assess the amount of healing. You may not feel any better until the bone edema is all healed. It is a reflection of bone trauma. Go back into the boot part of the day if you can not find another environment to keep the foot happy. See if warm water soaking works better than contrast bathes. If your skin can tolerate some massage, order NeuroEze online and massage 3 times per day, at least above and below the sore areas. Also do neural gliding 3 times per day, as long as it is comfortable. If warmth or contrast does not help, stay with ice packs. You can experiment with placing the ice pack over the area, or above it. Send me other info on what you have found works and does not work. Are you better in heels vs flats, barefoot vs shoes, etc? How long can you walk without limping? Send a photo of your foot with your finger pointing to the exact area. Hope this starts the forward progress. What exact diagnoses have you been given? Rich

Hi Dr. Blake,

Thank you so much for responding. I will do my best to answer your questions.
I have an accessory navicular in both feet (see photo of right foot with me pointing to general area of pain). I only realized they existed recently, because they never caused me any pain before, and I only present symptoms in the right foot. The pain changes places; sometimes it is under the arch, and other times there is a shooting pain up the post tibial tendon. Some days it feels like a rubber band about to snap with too much pressure, and other days it's that burning I described. I also have flat feet.
Dr Blake's comment: That definitely sounds more like an accessory navicular problem. Since it involves the posterior tibial tendon in the tarsal tunnel, you can get nerve pain or nerve symptoms being generated. 

It seems like switching shoes often helps. Barefoot is bad. I have spent more money on shoes in the past year than in my entire life! Dr. Scholl's inserts, MBT rocker bottom shoes (horrible for my condition), Clarks, sneakers, really expensive clogs, etc. The clogs (with a raised heel) are my favorite. However, I refuse to wear them in the summer as I still have some sense of fashion to maintain. I just bought some comfortable Clarks to get me through the summer that look like ballet flats but have a much better sole and support, with a wide toe. I'm also in love with Okabashi flip flops, and wear them around the house as much as possible.
Dr Blake's comment: If you can get comfortable, but stable orthotic devices, the design can be used in your sandals with a removable insole.

The MRI was done in January 2015 and we are now in May. My condition has not changed symptomatically since December 2013. My orthopedist believes that physical therapy will inflame the edema more, or be useless. He is also not a fan of orthotics, which I tend to agree with, because from what I've read online, they don't make your feet work hard enough and allow them to lazily conform to a mold. Some doctors believe they create dependency. What is your view on this?
Dr Blake's comment: I love orthotics for this problem. I believe you only need to do 2-3 minutes a day of strengthening to make up for any weakness from the bracing effect. And strengthening the posterior tibial tendon should be part of your program. You must understand, since you are still trying to get into a pain free environment for most activities, you are still technically in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, so any assistive aid is very appropriate now (especially when some are suggesting surgery).

So you think I should try using the boot again even though it didn't cure the condition in 6 weeks, just for comfort, while I search for a sports medicine doctor? The boot does cause problems in the left hip and knee if I wear it too long, but I will certainly do anything to get better! I will also mention that I am developing a bunionette on the right foot from compensating, as well as from wearing winter boots with a tapered toe. Not too happy about this!
Dr Blake's comment: See the video on Tailor's Bunion care.

I am currently taking Meloxicam and it doesn't seem to be helping after a month. I was on Indomethacin for a few weeks, and while I believe it did help reduce inflammation temporarily, the side effects were awful. You are correct in stating the foot likes heat better than ice.
Dr Blake's comment: At this stage you have both inflammatory pain and nerve pain. And they can trade off on a daily or weekly basis what gives you the current symptoms. Try to see if you can distinguish the various types of pain, and what treatments help them. 

My life has changed completely and I cannot play tennis, do Zumba classes, or walk long distances anymore. It has affected my social life and career as I must ask co-workers, family and friends to coordinate activity around my pain. Sometimes I push myself when I'm alone because I need to get things done (cleaning, vacuuming, etc). but I suffer the following two days recovering.
Dr Blake's comment: This is why I would err on getting and learning all forms of immobilization: various taping, different orthotic designs, Aircast PTTD brace, removable boots, AFOs, shoes, and power lacing. Read the posts on posterior tibial tendon dysfunction to see all these avenues like the one below.

The reason I have hope for recovery is that I have had a couple sporadic days with absolutely no pain. I did not change anything activity-wise, so I have no idea what alleviated the symptoms. I hope I am being reasonable by avoiding surgery. I am very anxious about it, but I also don't want to avoid it forever if it's really the best option. It seems that the body can heal itself in many cases given the right conditions, and want to exhaust all options before going under the knife, being out of work, collecting disability, etc. I am a very active person and while I have rested the foot a great deal, I won't pretend it's been easy to slow down.
I'd like to lose 10 lbs. because I think being a little lighter will alleviate some pressure, but I am not even overweight and don't want to have to maintain a low weight my entire life just for this reason (I.e., what if I get pregnant someday)? I think the weight is a contributing factor, not a root cause. I am having a hard time losing weight with the condition, ironically.
Thank you again for your time, Dr. Blake. I sincerely appreciate it!

Dr Blake's comment: Good luck. Here is my typical checklist for accessory navicular issues (with tendinitis and tarsal tunnel symptoms just part of the overal syndrome).

The top 10 treatments for accessory navicular syndrome:

1.  An MRI is very important to discover what the source of pain actually is: stress fracture, joint inflammation, or tendinitis. There is a joint between the navicular and its accessory bone.
2. Use Kinesio Taping or tape or classic low dye taping techniques intially 24/7 and then for extended activities.
3.  Ice pack the sore area 10-15 minutes 3 times daily.
4.  Go into a removable boot (such as an Anklizer) for 2-3 months if needed to calm the foot down.
5.  Strengthen the posterior tibial tendon starting initially with active range of motion like ankle circles.
6.  Check out the Aircast Airlift PTTD brace to see if it is helpful for you and can get you out of the boot faster.
7.  Custom foot orthotics are a must for a 2 year period. They must produce a good force against the navicular, but it may take time finding the right orthotic guy/gal.
8.  You can use Sole OTC orthotic devices with medial longitudinal Hapads initially until a good protective orthotic device is made.
9.  Create a pain free environment as soon as possible (level 0-2).
10.  If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.

Wednesday, July 1, 2015

Podiatry and Humor make for Great Healing

Please enjoy!!! Rich

Water Brace for Ankle Rehabilitation: Posterior Tibial Tendon Injury

This patient of mine is currently recovering from a posterior tibial tendon injury. Her MRI showed inflammation without tears, so we are moving her along in the rehabilitation process. We had discussed no kicking in the water at this point due to the added stress on the tendon, and definitely no fins of any form.

Hi Rich,

I apologize again for being late this morning, after asking you to
be on time.  Thanks so much for your patience and understanding.

Re: swimming (no fins) being stressful on my ankles

1.  Would this, or something like it, allow me to swim w/out putting
that float thing betw my legs?

2.  Would it work for water aerobics?  Can I go to water aerobics in another month or 2?
   (it does involve some jumping, etc) What if I use one of those wrap-around-your-waist float things and my
    feet don't touch bottom?

3.  Were you saying that I should NEVER swim w/out that float thing?

I made an appt for a month from now.  Hope it's not too much trouble to respond to these ???s.

Thanks again!


Dr Blake's response after reviewing the link:

Thanks, that looks great. It will help the biofeedback loop telling your brain that you are protected and that you can swim, while you still must avoid excessive kicking in the pool. Still go easy and ice for 15 minutes after swimming whether it hurts or not. Your MRI was too good to have any permanent restriction on activity, but it will take you 6-9 months to get that injured posterior tibial tendon super strong. Yes, you can begin water aerobics in 2 months, just start with brace and no weight bearing for the first month. And we will see how it goes.Hope this goes well. Rich

Saturday, June 20, 2015

Big Toe Joint Pain: Podiatry Today Post

I just got invited to host a monthly blog post for podiatrists in a magazine entitled Podiatry Today. It is another good source of information for podiatrists and lay patients alike. Hope it is helpful.

Correcting Children with Flatfeet with Orthotic Devices

Custom Made Orthotic Devices with Blake Design Improves Arch Structure in Developing Children

·        39 Flat Foot Children studied by x-ray evaluation over 6 years old (average age 10.3, range 6 to 14 years old) for a 2 year period to see if the arch developed with Blake Inverted Orthotic Design

·        Blake Inverted Orthotic Design is recognized worldwide as providing the most medial arch support

Orthotic Device cross section standard heel cup (right) and Inverted Technique (left)

Orthotic devices resting under Inverted molds (typically one foot more inverted than the other

Standard right arch and Inverted left arch
·        One study showed that if children were to spontaneously reduce their flat feet (grow out of it) it would be before 6 years old. Dr Ron Valmassy says it is predictable at any age, but 8 years old is the gold standard of knowing if they will grow out of it.
·        4 radiological angles (which measure arch collapse in the sagittal and transverse planes) and one standing angle (measuring frontal plane) were measured at the start of the study, 12-18 months into the study, and at 24 months.
·        Subjects were required to wear orthotic devices for 8 hours per day minimal
·        Exact Rx writing was used to individualize the custom orthotic devices based on the RCSP (Resting Calcaneal Stance Position).

This measurement, called the resting calcaneal stance position, changed from 8.0 everted to 1.9 everted with orthotic wear over the 2 years, and measures the frontal or coronal plane component. The ideal is 0 degrees or heel vertical measured exactly with a goniometer.

Inverted RCSP with goniometer.jpg

Here the exact angle is being measured with a goniometer.

·        2 of the 5 angles showed significant improvement, 2 of the angles showed improvement, and one was unchanged (the least predictive one generally)
·        Background Info: Blake Inverted Orthotic developed here at Center for Sports Medicine throughout the 1980’s. Dr Blake has lectured nationally and internationally about the technique. At one point, 17% of all custom made orthotic devices in Australia were this technique.
·        More Background: Bias of Pediatricians and Orthopedic Surgeons is that all children with flat feet will outgrow this, or at least there is no predictability in selecting children for orthotic devices. Dr Ron Valmassy developed the criteria in the late 1970s for predicting which children will not outgrow their flatfeet and also has lectured extensively.
·        Flatfeet: flexible and rigid. Flexible is the hardest to correct in adults and these were the ones chosen for the study (typically more ligamentous laxity than a rigid flatfoot). Flexible flat foot is much more common to see however in children, and can develop into rigid flat feet after the age of 22 when the adult ligament and bone structure is fully developed.

AP TCA is decreased as the arch gets better and the foot less splayed out (Angle 1)

Lateral TCA should get less as the arch improves (Angle 2)
Lateral TMA should get less as the arch improves (Angle 3)
CP should get greater as the arch improves (Angle 4)

·        RCSP changes  8.0 to 2.6 to 1.9  (less is good)
AP View TC Angle 38.4 to 38.1 to 29.6 (less is good) Angle 1 above
Lateral View TC Angle 47.3 to 49.8 to 47.3 (less is good) Angle 2 above
Lateral TM Angle 17.7 to 18.2 to 10.3 (less is good) Angle 3 above
CP Angle 11.6 to 14.7 to 16.0  (more is good)  Angle 4 above

Dr Blake’s comments:
·        Article used the Blake Design to customize the orthotic prescription typically not seen in foot orthotic studies (allowing the 5 to 1 rule of cast correction to heel eversion to create an equal and opposite force to control pronation)
·        The calcaneus is the best guide since it can be accurately measured in the sagittal and transverse planes (by the calcaneal pitch) and the frontal plane (by the RCSP) since it is trapped against the ground. The talus is notoriously a poor guide since it is influenced by the foot and ankle (and ankle positioning is not standard with these x-rays). 

Saturday, June 13, 2015

Walking vs Running Mechanics: Lecture in PowerPoint

This power point presentation is for my State Meeting in several weeks. So, it is written for a podiatrist of various degrees of knowledge on the subject, and geared for practical advice.

Wednesday, June 3, 2015

OESH Shoes: Unique Shoe to Know About for Wide Forefeet

All of these OESH shoes are zero drop (no heel lift), and very straight lasted with wide forefeet). This is unique, and many patients may fit into when the forefoot width of standard shoes is too narrow.

Tuesday, June 2, 2015

Help for bunions and hammertoes: Correct Toes

I have been looking for a product like Yoga Toes, that will be help to hammertoe and bunion patients, and that can be worn to walk in some shoes. One of my patients is wearing Correct Toes while walking in Keen (extra wide) athletic shoes. I hope it helps some of you. Rich

Monday, June 1, 2015

Arch Taping: Support the Foot Brand Excellent

The video above is a small introduction to a great taping technique for foot stability. So many foot problems are improved with taping, and this is one of the best new techniques I have seen in years. I first was introduced to the technique in July 2014. I have used the foot strapping in now 100 or so individuals with very good results. It runs about a dollar per day, and lasts 4 days or so. It survives showers and soaking, but not swimming pools. Go to their website. It is super easy to apply. I will try to make my own video soon. They sell in groups of 5, so you do not have to make too much of a committment before purchasing. Good Luck

Saturday, May 16, 2015 place for athletic shoes discounted

One of my patients told me that this was a wonderful place to get athletic shoes at a discount. Please check it out. It also has everything else, perhaps even the kitchen sink.

Foot Nerve Pain: You Tube Video Comment Reply

Hi Dr Blake, I have excruciating pain in between the 1st & 2nd metatarsal. (4 years ongoing). It only happens when I walk for long, try to run, carry heavy items or wear tight shoes. MRI scans showed nothing, XRays showed nothing. Could it be a neuroma? Massaging it helps alot. The cold also aggravates the pain. Anti inflammatory meds help as well as lyrica for nerves. My guess it is a pinched nerve or a neuroma.

Dr Blake's comment:
With the negative scan, this is typically an L4/L5 nerve root irriation or double crush syndrome. Neuromas are rare in this area. Look into neural flossing/gliding and topical NeuroEze. Have the nerves evaluated by a neurologist or physiatrist for radiculopathy. Definitely try to manipulate the weight bearing with Hapad Longitudinal Arch Pads and try restricting toe motion with toe separators, Budin Splints, spica taping. Ice Pack for 10 minutes twice daily for the next month to see if this is helpful. Hope this helps.

Saturday, May 9, 2015

Big Toe Joint Pain from Running: Email Advice

Hello Dr.,

I do not know if this email is still active, but I wonder if you could give me some advice.  I am a 27 year old active male who, for the last 7-8 years has had big toe pain in my left foot.  It seems to exacerbate on exercise and calm down when I rest it.  It doesn't seem to be getting worse, although it does tend to be quite tender after running.  I have no bone spurs that I can feel, and retain the same ROM as the other foot.  I had x-Rays about 7 years ago when I noticed it and the podiatrist suggested the usual hard sole shoes and orthotics, which I didn't follow through with.  Should I be treating this like a sore joint and avoiding exacerbating activities, or should I be looking into surgery?  If it is the latter, which surgery might retain maximal functionality of the toe ultimately?  I appreciate your time and your response.

Dr Blake's response:
     Thank you so very much for your email. In a situation like this, you have plenty of time to find 3-5 things that help you de-stress the joint and perhaps slow down the joint breakdown. You are way too young to do joint surgery, and there is no surgery out there that makes the joint better. You can make a toe straighter, you can remove bone spurs that get in the way of motion, you can fix or remove broken bones, but unless we had more info, you can not make the joint better by cleaning it out. 
     What typically makes big toe joint better are biomechanical changes (shoes, pads, orthotics, activity modifications), anti-inflammatory measures (icing, PT, contrast bathing, topical and oral meds), immobilization measures (cross training, plates, spica taping, stiff sole shoes, removable boots) and getting further information (xrays, MRIs, bone scans, CT scans).
     My goal for you would be to try one thing a month for the next 7 months (like icing for 10 minutes twice a day). Definitely use the KISS principle: Keep It Simple Stupid by using the least invasive things first. Find 3-5 modalities that help somewhat (10-20%) and make yourself a cocktail for less pain. Hope this works for you. Rich

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