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Sunday, September 23, 2018

Stage ll Posterior Tibial Tendon Dysfunction: Give Conservative Care a Try


Dr. Blake, 
 This is the original post back in March 2018 when the patient contacted me. I referred her eventually to Dr. Matt Werd in Florida. 
I wanted to share with you a follow up on my progress with physical therapy. 

I am seeing Dr. Werd and he was very helpful in prescribing PT. Not only that but of all the doctors I have seen for this condition (4 so far), he has by far spent the most time with me analyzing my symptoms and going over the diagnostics and various alternatives. 

I had 5 months of PT. I was very blessed in finding an experienced therapist. I can tell you that it was not easy. It was sometimes painful and discouraging. However, I stuck with it daily, sometimes an hour or more of exercises every day. I had a couple of setbacks but am so thrilled with the results now. I am walking without pain, have full range of motion and full strength. I can easily do 50 single foot heel rises! Although it wasn't easy, I can also say that it was much easier for me to do PT than the alternative of surgery (with the post-op of being non-weight bearing, on painkillers all while trying to take care of my children.) I would have done surgery if absolutely needed but was so glad to have an alternative. 

I'm so thankful to God to lead me to this path. Thank you so much for your help along the way!

Sincerely,

P.S. Do you have any advice for me how to keep my foot healthy (exercises to do? any to avoid?) Dr. Blake's comment: This is your weak spot, but over the next year you will get it stronger and stronger. I pray that you are doing the posterior tibial theraband work level 6 2 sets of 25. Did you go through them? If you did, you need to do twice weekly to maintain the strength and make sure the tendon stays strong. Focus on activities until April that you can do with orthotics like hiking. I would wait another year before starting a walk-run program. Modified Yoga with orthotics on would be wonderful. I hope this gives some direction. You want to keep it strong forever so it will have minimal effects on your overall life. 
https://youtu.be/w3FXx4OFqec

Big Toe Bone Spur: Email Advice

Hello Dr. Blake,

I am very glad to say that searching on the Internet trying to find information about the problem I have I came across your blog. Thank God you have opened my eyes and gave me a better understanding of what I'm about to do.

I am about to have cheilectomy in my right big toe because I have developed a spur, which annoys me a lot when jogging. This is what my doctor here in Athens, Greece has suggested to me.
I am wondering if the simple movements on self-mobilization you are proposing for the big toe joint in your videos, might help and alleviate me from the burden of having the surgery.
Best Regards,

Dr. Blake's comment: 
     Yes, the conservative treatment can prevent or delay the course of surgery on the big toe joint. It is at least valuable information in the postoperative setting to see what helps take the pressure off the healing joint. Give yourself 3 months to see if it works. Self-mobilization is only one thing to try. My blog has been treatments for Hallux limitus which these spurs fall under. Try to skip the eyelet above the spur to help in any shoe you get pain. Try to place padding just to the bump, not over it. This is called proximal padding. I use 1/4 inch adhesive felt, but any soft material can be used in an inch square shape to tape down. Try spica taping to restrict the motion of the big toe joint. Try dancer's padding to off weight the whole joint from the bottom. Ice the area for 5 minutes twice daily for the next month to see if some of your pain is inflammatory, and not just mechanical. You can also experiment with shoes with bigger toe boxes depth-wise, or shoes with rocker to decrease toe bend like Hoka One One. Hope this experimentation helps you. Rich
PS. My wife and I have been to Athens, Mykonos, Delos, Paros, Naxos, and Santorini. Can not wait to go back in a couple of years. We want to see Crete and Rhodes for sure. Beautiful area. 

Friday, September 21, 2018

Nerve Pain: Possibly Treating the Wrong Area

Hi Dr. Blake,


I too experienced severe pain/side effects after my first alcohol injection. It has now been 7 weeks after my last injection (7 in total) and I'm STILL in pain - as a result, from the shots. I didn't have this type of pain, or in this location prior. Here is a summary of my story leading up until this point:
  • Stubbed/fractured/broke/ right pinky toe Nov 2016 (was pain-free prior)
  • Went to podiatrist May 2017 who suggested tape and increase vitamin D dosage due to deficiency
  • Toe seemed to make progress into Nov 2017 but then healing plateaued and eventually worsened
  • The orthopedic surgeon said they couldn't help since X-rays/MRI showed no damage(Normal results - Morton's Neuroma was NOT shown)
  • Podiatrist suggested 9 laser treatments on the bottom/side of the pinky toe (not the neuroma since this wasn't diagnosed at the time). All 9 were performed by 2 physical therapists and no long-term relief was evident.
  • Podiatrist performed an ultrasound and diagnosed me with Morton's Neuroma. Found interesting since the pain I was experience was not where the 2 neuromas were located. I did not have the typical symptoms listed for MN at that time and the diagnosis didn't match MRI...but he convinced me this was causing my issue.
    • Podiatrist suggested 7 ultrasound guided alcohol injections on my right foot. (30% in both neuromas per session).
    • The 1st shot had horrible side effects: increased pain, numbness, tingling. Caused common symptoms of Morton's Neuroma, which I hadn't experienced prior.
    • 2nd shot provided relief to some of those symptoms.
    • Started noticed an improvement in injection 4/5. Feeling optimistic!
    • The pain started to come back slightly after injection 6
    • Injection 7 was now 7 weeks ago. The pain came back both in my pinky and neuroma. There was visible external bruising after this injection which has subsided but I'm still in pain.
  • Dr. Blake's comment: The initial reaction is unfortunate, but probably one in 5-6 patients, and always resolves. The series should stop at five to rest the tissue. Not sure why you kept going. Actually, from your explanation, many neuromas never hurt ever, so why wake up a sleeping dog? 
  • I'm now in more pain today than I was prior to treatment! (although less so specifically in my pinky toe...and the pain comes and goes more frequently than prior)
    • Prior to injections, I did not have any typical Morton's Neuroma symptoms (no burning, tingling, etc.) But now I do, in addition to my chronic toe pain.
    • After injection 7, my right foot now physically looks/feels swollen underneath my toes. I'm not sure if this is the neuroma, pools of alcohol from the shot, or hematoma. 
    • Dr. Blake's comment: I hope you are in a removable boot to rest the tissue for the next month. Sometimes 5 minutes of ice frequently is best, and sometimes several warm water soaks of 30 minutes each twice daily is very smoothly. The MRI taken should tell you if the swelling is anything to worry about, but swelling from pain is normal with this type of problem. It is telling you to quit irritating me!! 
      • My podiatrist didn't have an answer for me and said this has never happened before. He Rx Lyrica to reduce the pain but I didn't feel good on it and the pain relief was minimal
    • I got a new MRI. And my podiatrist says it looks like one neuroma shrink over 50% and the other is marginal compared to the other...But again, I'm not in more pain since starting the injections.
    • I've had pain every day of my life for almost 2 years. I thought these alcohol injections were going to be the answer but now things are worse.
    • Dr. Blake's comment: Definitely get the MRI report to read. You can send me the report because you need to know if there is anything else to be concerned about. Probably not. This pain should cool down over the next month if you do not keep irritating. Do you know the alcohol percentage used? I just do not think from what you say you are treating the right thing. I am not saying to switch either yet. Please wait the next month, go in a boot. Try to topically cool it down with ice or soaks. 
I've attached an image of my current pain/discomfort. The skin is still sensitive in that area when touched.




My podiatrist has presented some alternative "plan B" options (laser treatments on the neuroma or stem cell, amnion-chorion membrane injection) but these are not covered by insurance, costly, and I'm afraid it would only provide short-term relief if any. Based on my MN support groups - most people said this was a waste.

Please share any thoughts and suggestions you have regarding my case.

Thank you for your time.

Dr. Blake's comment: I need to know if you are off-weighting the area with Hapad or Dr. Jills products. My blog has many examples. You should be massaging three times a day Neuro-Eze cream (online product) and doing neural flossing until the new symptoms better. Get in the boot and relax this. Rich


The patient responded:





Hi Dr. Blake,

Thank you for your quick response! 

Some follow up information/questions:
  • I was told they were 30% alcohol sclerosing injections with the intent to shrink the neuromas. 
    • I was given 2 injections in my right foot for each of the 7 sessions. I have attached images of the injection areas. As you will see, this was not near my original source of pain (pinky toe).

  • Dr. Blake's comment: This is a lot of irritation. The highest percentage that I have gone is 20%, which is what I have found podiatrists in the UK are using. Plus, giving it in 2 places at once is more chance of irritation. This may be fine, but no more shots, especially since it was done for MRI findings, and possibly not for the reason you needed to be treated. 
  • I kept going with the injections because my doctor suggested all 7 for my case. I felt maybe 80% relief after the 5th injection so it made sense to continue on my doc's advice thinking it would get me to 100% relief instead of reversing and causing more/new pain.
  • Dr. Blake's comment: With any injection series, and probably for most treatment protocols, you try to get the patient to 80% better, with the remaining 20% allowed to father time. 
  • "Many neuromas never hurt ever, so why wake up a sleeping dog?" - Only because my doctor believed the MN diagnosis was the cause of my chronic pinky pain.
  • Dr. Blake's comment: If you give a 5-hour lasting local anesthetic into the neuromas first, and for that 5 hours the pain in the pinky toe disappeared, then addressing the neuromas in some way would make sense. 
    • If my chronic wasn't wasn't from MN - what else could have been causing it? Perhaps RSD/CRPS?
    • Dr. Blake's comment: When you stub your toe, and then have chronic pain and negative xrays and MRIs, you may have some version of CRPS although the injury could just be missed in the films due to its superficial location. Besides the laser treatments by the PTs, you really have not had a thoughtful approach to where you hurt. Once the pain goes away from all these shots, you may have to investigate various options like joint mobilization, ultrasound as a treatment, acupuncture, off weight-bearing padding. Just sending me a photo of what types of padding minimize your symptoms would be a good start. 
    • Is it possible for these injections to cause more long-term harm than good? (My fear is that my chronic pinky toe pain has turned into chronic foot pain)
    • Dr. Blake's comment: In December, as long as you have had no more shots, a new MRI will be done if some of the injection pain lingers. 
  • No one has recommended a removable boot until this post. Happy to give that a try. Is there a specific brand/model you would recommend? Dr. Blake's comment: yes, anklizer by Bird and Cronin is a good one or the short style (just going above your ankle) by Aircast.
    • Is this something my doc could Rx and be covered by insurance, or am I better off just buying on my own online? Dr. Blake's comment: Your doctor's office will know. They are around $60-70 self-pay.
    • In the meantime, I've spent most of my time at home in slippers with custom Rx orthotics. When I'm out, I'm in wide sneakers with the Rx orthotics as well
  • I've tried both hot Epsom salt baths and ice without luck... In the past the bath would make the sensation further "radiate" and the medical ice pack would cause a "burning" sensation. But if you suggest one over the other I can try to do that more consistently.
  • Dr. Blake's comment: We have to assume you may have an internal burn. The general rule is no ice on a burn, so some warm compresses are probably best. Try a warm slightly damp facecloth on the area when you sit and wrap saran wrap around for 30 minutes at a time. The saran wrap allows the heat and circulation to get deeper. Whatever you do, you should at least immediately feel better. 
  • I have a copy of the full digital MRI on CD. Happy to send this to you to review if you suggest a certain file type. (can your computer read a .iso CD image file or anything else you recommend? I can also try taking some screenshots from it)
  • Dr. Blake's comment: I am not sure which ones. Can you have a disc burned and sent to me at Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109? Any screenshots as photo images are fine also. 
  • I do not have a copy of the report. I will request this next week. When I asked my doctor about the results, this is what he told me:
    • "The MRI shows only mild residual neuroma remnants following the injections. No other major boney or soft tissue pathology. Dr. Blake's comment: Hooray!!!
    • [The size of the neuroma is not indicated on the MRI Report] When I looked at it myself, it looks to be 6 MM or less which is small and over 50% of the one neuroma and marginal on the other as compared to the original ultrasound I did on April 2nd which showed:
      • Findings body of the report. We noted a 14.0 mm ovoid hypoechoic ill-defined nodular density seen on sagittal view in the right 2nd interspace. And also a 6.9 mm ovoid hypoechoic ill-defined nodular density is seen on sagittal view in the right 3rd interspace. No evidence of bursitis, capsulitis, or plantar plate tear in the right 1st, 2nd, 3rd, 4th, or 5th MTPJ's."
  • I was Rx a couple of different topical anti-inflammatory cream. I was told to use these simultaneously but they failed to provide relief. Dr. Blake's comment: Makes sense, your pain is nerve pain, get one for nerve pain and also try Neuro-Eze. 
    • I have not tried or heard of "Hapad or Dr. Jills products" . Which would you recommend for my case? Dr. Blake's comment: Both companies sell online. You could ask the podiatrist which one offloads the area best. I would try a small longitudinal medial arch Hapad support as a metatarsal support. But we have these right in the office. 
    • I haven't heard of neural flossing. I found an older blog of yours with a video. Is this what you recommend I do in my situation, or is there another type of neural flossing suggested for MN? Yes!!
  • What are your thoughts on Dr. Blake's comment: I think acupuncture right now makes sense as long they do not stick the sore area. You have a nerve problem, and acupuncture addresses that. 
    • MLS Laser treatment?
    • Amnion chorion membrane injection?
    • Acupuncture?
    • Nerve decompression surgery?
I rather not seek any other type of treatment if you think I simply need more time to heal...but my doc said my symptoms should have resolved 4-6 after the last injection and it's now been 7. Maybe the boot would have helped but I've been fairly inactive during this time.
Dr. Blake's comment: You can not use time, because everyone is different. That being said, get in a boot, start treating the nerve pain without increasing pain, be nice to yourself, see how you are in 3 weeks. I want a report. 

Thanks again,

Wednesday, September 19, 2018

Peroneal Tendinitis: Email Advice



Hi Dr. Blake,

I developed bilateral peroneal tendinitis from overuse earlier this year (lots of walking). Despite a reduction in sports and addition of light physical therapy, the tendinopathy slowly worsened to the point where I couldn't walk without significant pain. This happened over several months. The pain was mostly behind my lateral ankles, sometimes extending up into my calves.

I finally took off a couple of weeks from work, saw a podiatrist, and was referred to physical therapy for more aggressive treatment, including mobility and functional exercises, stretches, and ASTYM. During this time I was able to start walking every other day with only mild pain on rest days. I'm not sure if the PT was helping, but the rest days definitely were.

On my first day back at work I had soreness in my feet and intense pain behind my left lateral malleolus that night, which had never happened before (typically I had no pain when in bed). The next two days at work were similar, though not quite as bad. I then took off another week and was recovered on my first day off, followed by having no pain at all when I returned to work days later.

However, I relapsed after a few days. I was still performing my physical therapy exercises and increased my previously band-assisted heel raises to bodyweight. This had aggravated my tendons before, and I think this was what precipitated the relapse. By the end of every day, I was incredibly sore in my lower legs and feet and had trouble performing ADLs (activities of daily living) at home. I could barely rest and recover on weekends for each following week.

I continued to work for another month with minimal walking (less than a mile/day total) and standing. During this time I started developing early PTTD (posterior tibial tendon dysfunction) in my right foot, probably from compensating for peroneal pain by overpronating.

Finally, I took a full month off work. Most of the pain subsided within a few days. I gradually started resistance band inversion/eversion exercises every other day with some walking and seated heel raises. I've been off for three weeks now. My lateral ankles have been feeling pretty good, but my right posterior tibialis is now limiting me. It seems to get easily irritated by very short walks or from standing. Custom orthotics are uncomfortable and seem to provide too much support, which stresses my peroneals. I'm also still getting dull aches/soreness in my ankles and lower legs following any physical therapy exercise. I'm not sure if this is from becoming weak from minimal walking, or some kind of sensitization?

I'll be following up with my podiatrist next week and will also see an orthopedic surgeon for a second opinion later in the month. Until then I'm really not sure of the best course of action in terms of rest and strengthening.

Thank you for reading! It's been over 6 months since this all started, and writing this out is somewhat cathartic. It takes a lot to stave off a feeling of complete hopelessness.
Dr. Blake's comment: Please do not lose hope as the universe is not picking on you. This is an all too common scenario of injury, inadequate rehabilitation, progressive weakness with new pains developing, and improper timing of events. First of all, I am going to any pain like the PTTD that is not along the course of the peroneal tendons is just compensation and will get better. What do you do at work? Is there something that forces you to use the outside of your foot a lot (called supination)? Rest for weeks and months does not normally help unless you are using the time off work to get the 5 treatments below accomplished. 
     Any tendinitis has to be treated concurrently with 5 treatments. The mnemonic is BRISS--biomechanics, rest or activity modification, ice or anti-inflammatory, strengthen, and stretch or flexibility work. For the peroneal tendons, the number one biomechanical task is to control supination (movement to the outside), and number two is to overall stabilize the ankle with braces, boots, taping, high top boots. There are a lot of options in getting achieve this stability. From the sound of things, you have to get in an orthotic that is stable and does not supinate you. You can find my video of orthotic modifications for the supinator, although I am not sure you supinate normally or only with high arched orthotics. But, you can not get better if you supinate. 
     Rest is activity modification since rest in general in these cases can really work against us in allowing weakness, nerve sensitivities, and tightness to settle in. You have to keep your body strong if you have to limit walking to elliptical, swimming, cycling, floor programs. This is even if you have to do it with tape, orthotics, braces, or boots. Typically straight rest is a killer if you get my point. We are trying to get the pain down to consistent 0-2 while we slowly increase activities, and gradually get stronger. The sad fact is one day off normal activities, especially physical activities at work, after one month can take 2 days to regain that strength. 
     Ice or anti-inflammatory is to be used after activities if you flare them up, but physical therapists have a lot of tricks to cool tissues down, as do acupuncturists. Oral NSAIDS like Advil are used after workouts not before to allow you to workout. 
     Strengthen is key. You want some activities to mimic work related, most functional, but also isolate the peroneal tendons. My blog has peroneal tendon theraband exercises to isolate the peroneus brevis vs longus, since one may be more involved. 
     Stretch is achilles mainly. The achilles, when tight, is a powerful supinator as you lift your heel. You have to check with the physical therapist or podiatrist to see if you are tight, but I would start doing normal achilles stretches three times a day. 
     I hope this helps. You have your work cut out for you, but you seem to respond to things well and should get over this. Keep strong, but do not push through the pain.

Tuesday, September 18, 2018

Injury to Fibular Sesamoid in Rock Climber: Email Advice


Hi Dr. Blake!
I've been reading your blog and thought I'd try and see if you respond to my questions. I'm desperate for answers and I've seen 2 DPMs and 1 Ortho surgeon with foot/ankle specialization. Each of their prognoses is different and so is their proposed treatment. I'm going to get one more opinion from an ortho too but if you have any insights, I'd love to hear them.  I'm a 34 yo female construction manager, rock climber, dancer (ballet growing up, lots of Latin dancing in heels as an adult). I hate running so I'm not as concerned about losing my ability to compete in triathlons.

Summary of the condition:

  1. initial injury occurred in rock climbing in late March 2018. There was no impact, but I was standing in a precarious position for over 45 mins standing over a chasm and didn't have much room to move. My weight was mostly evenly distributed between my feet but my toes were hyper-extended and all the weight was on the balls of my feet. I was in instant pain in my left foot that felt like a hit a pressure point. My foot became instantly numb and remained that way for the rest of my 6 hours climb and hike down the mountain. the feeling in my foot came back the next day but my toes stayed numb for 6 weeks. I did not go to the doctor because I had no idea I could have broken a bone by just standing on my foot. It's common for climbers to complain about toes going numb so I just rested for a few weeks and didn't think much of it.  (Dr. Blake's comment: The numbness is either from compressing a nerve for too long as you describe or from the intense swelling internally from a fracture or sprain, that pulls pressure on the local nerves. Or, a combination of course). 
  2. Fast forward 3-4 months to July 2018 (I've been continuing to run, lunge, climb, and wear high heels to work all day).  I should also say that I drive a standard transmission vehicle with a stiff clutch and sit in traffic constantly for work. By the end of July, my left MTP joint would be swollen, most of the pain was on the side of my MTP joint, not on the ball of my foot. Eventually, I started having numbness in my toes again and finally went to a podiatrist. (Dr. Blake's comment: I am assuming the numbness went away and these months were not painful, and you did not have to limp.)
  3. Aug 3, 2018, I was diagnosed with a lateral sesamoid fracture. I wore a boot and unna wrap for 4 weeks while my DPM was taking x-rays every 2 weeks telling me it was healing. 
  4. By Aug 28, 2018, my pain was increasing not decreasing and the ball of my right foot is now hurting because of me trying to offload the left foot. The DPM Xrays both feet, says the left fracture is still healing and the right foot shows no signs of fracture. The DPM put me in the iWalk crutch and ordered an MRI of both feet since I was still having pain. 
  5. I've had J pads in the boot on the left foot and orthotics also with a J pad on my right foot because I was starting to have pain in that foot now. (Dr. Blake's comment: I am sure this is Dr. Jill's Gel Dancer's Pads or something similar).
  6. After the MRI I saw an orthopedic surgeon (who recently operated on my mom's foot with success) and a leading podiatrist in the state. Both of these doctors agreed that the Xrays showed NO signs of healing and that the original DPM was wrong. MRI indicates no sign of healing and is inconclusive as to whether or not it's a bipartite sesamoid or a nonunion fracture.  There are signs of AVN and edema. (Dr. Blake's comment: Yuck!!)
  7. Here's where I'm confused:
    1. Ortho surgeon says he doesn't know if it's a fracture or bipartite but it doesn't matter because it's not healing and shows no sign after almost 6 months (the last 1.5 was immobilized). he says surgery is inevitable but he'll wait as long as I want. He gave me a cortisone shot and suggested within a week I transition to regular hiking shoes until I'm ready for surgery. he doesn't want me to stay in a boot that will cause muscle atrophy and all other sorts of problems while I decide on surgery. My question is, is 1.5 months enough time in a boot to be sure it won't heal. and if it's not a fracture, is there another cure than surgery? (Dr. Blake's comment: Sorry this is confusing. These time frames do not apply to sesamoids or a lot of other injuries. The wait with sesamoids can be a one year process, and sometimes more.)
    2. DPM #2 says it's fixable with 6 months in a boot and exogen bone growth stimulator. Do I really wait 6 months in a boot with an expensive contraption waiting for the bone to heal (what if it IS bipartite?). Will the exogen doing anything for bipartite sesamoid? (Dr. Blake's comment: I agree sort with the DPM #2. I will look at the images you sent below to comment on the bipartite aspect).
  8. I have an active lifestyle but more importantly, I have to walk at work a lot. I can't afford to waste 6 months in a boot for a bone to heal that isn't even broken.  I also can't afford to have sesamoiditis in my right foot as a result of offloading for multiple months on the other foot. What do you recommend? (Dr. Blake's comment: Work can force people's hands at having the surgery, since the prolonged rehabilitation may not work for them. That is one of the huge reasons patients will have some foot surgery.)


Additional Questions:

  1. No one has commented on the right foot having a bipartite sesamoid or not. It was not specifically mentioned in the radiologist's interpretation but when I look at the Xray it looks possibly bipartite to me. I've been researching this a lot and I've seen that 90% of bipartite sesamoids are bilateral and occur on both feet. Can you see from my Xrays if both my right and left foot of bipartite lateral sesamoids? 
  2. Should I be considering selling my car? From what I read about surgery, it'll be a long time until I could press the clutch with my left foot again. Maybe I should buy an automatic transmission. (Dr. Blake's comment: Whether you end up in surgery or not, switching from manual to automatic makes sense right now. Can you rent one for a week to convince yourself?)
  3. I'm worried that if I get a sesamoidectomy that my fibular sesamoid will fracture too. Should I worry about that? (Dr. Blake's comment: This is at the root of why we try to avoid the first surgery if possible. It is a rare occurrence because people are so protective of their remaining sesamoid. But, with rock climbing positions, who knows? Make sure your Vit D is at 55 with low normal at 32 or so, halfway on the normal scale. You would not want transient Vit D deficiency to cause a fracture.)
  4.  I don't know who to believe the orthopedic surgeon or the podiatrist? How do you choose? (Dr. Blake's comment: First of all removing the sesamoid is technically simple, but the decision to do the surgery is not at all. Also, who is going to provide you will the best post-op course, orthotics, taping, etc? )
  5. How long is too long to wear this boot? (Dr. Blake's comment: My golden rule of thumb is 3 months with the bone stimulator for 9 months total. The transition from boot to shoe can be tricky with the need for orthotics, perhaps rocker shoes like Hoka One One, taping, padding, bike shoes with stiff soles, etc.)

I've attached my L and R foot Xray from 8/28/18 and summary of the MRI interpretations, in case you have time to look at these. (Dr. Blake's comment: Please send me a disc of the MRIs to Dr. Rich Blake, 900 Hyde Street, San Francisco, Cal, 94109. Please email me at rlb756@gmail.com when you think I got it. I want to see how inflamed the sesamoids are). 

Thank  you in advance for your time!

Jaime
This does look like a lateral or fibular sesamoid stress fracture with irregularities where the junction between pieces area. Bipartite usually look more symmetrical and rounded borders. To me, it is the incredibly long first toe and metatarsal that makes this prone to injury. Yes, removal of the one sesamoid could set up problems for the other.
Here the lateral sesamoid looks more like it is bipartite, which shows you have the bone overlap from the first x-ray distorted things. If it is bipartite and began to hurt with prolonged hyperextension, I wonder if you have a turf toe situation. Has anyone mentioned that?

I read this as mild injury to a bipartite sesamoid junction leading to a mild reaction of the tissues. Maybe once I see the views the mild level will look more like moderate. The biomechanics of Turf Toe, where you hold the toe on the ground, and you stress various things, like the bipartite junction to cause injury or one of the muscles or ligaments (not noted) makes sense here. If you switch to turf toe protocols, it may make more sense then sesamoid fracture protocol. The treatment can be some the same and some different. Create that 0-2 pain level consistently.

More obvious bipartite. A CT scan should be ordered for your left. Again, the long first metatarsal and toe (called Egyptian Foot in ballet)  which takes more stress than normal. 

 Again more bipartite looking with the two parts of the sesamoid with smooth borders and unequal in dimensions

Sesamoids look different on MRIs. They are wrapped up in ligaments and tendons, and unless they are abnormal (as in your left side) they look normal. Your workups have been good. Until I see your films, 3 months in the boot, with an EvenUp on the other shoe to keep the weight normal. If it is Turf Toe, spica taping is key, and probably advancing gradually to bike shoes with embedded cleats. 

  1. Should I cut back on my glass of wine or a beer most evenings? No, unless it causes you to stumble.LOL

Thursday, September 13, 2018

Transitioning from one restriction to less restriction: Email Advice

Hi there Dr. Blake,

 I found your blog while looking for the best way to transition out of a walking boot back to my shoe.  I fractured my Medial sesamoid in my Right foot in March while on the elliptical due to high arches and over-pronation.  Started as a stress fracture which I thought was a soft tissue injury so I treated it that way.  Rest, Ice, NSAID’s, elevation.  No improvement after 2 weeks, so I went to our podiatrist here and she found my fractured sesamoid (my what?).
Into the boot, I went for 8 weeks with icing 3 times a day, NSAID ointment for topical use and elevation at night.  Things looked great at follow-up so back into my shoe.  2 weeks later, it was swollen, red and angry again.  Back into the boot and a knee scooter for non-weight bearing for 2 months.  At follow-up, the x-rays showed the bone was knitting with remodeling on the bottom of the bone. 
   There has been general discomfort in the MTP joint for a month, just achiness and occasional tingling in the sesamoid area.  This is Sept. 11 so 5 months out and I will have the knee scooter until the 21st.   I’m concerned about just going into the boot or my shoe and re-breaking it again.  I do not want to have it surgically removed. 
   If you have any suggestions or anything, I’m open to trying it.  Thank you for your time!
Sincerely,

Dr. Blake's comment: Thank you for the email. Improper transitions, like our US sprinters dropping the baton in the Olympics, can be devastating. You have done a lot to help the sesamoid heal in the last 4 months so I will assume it is healing just fine. Sesamoids are very sensitive as they heal, and with high arches and overpronation, you are going to be putting a lot of stress on a sensitive bone for a while. So, the question is how to minimize that stress on the bone. My blog is full of information on the following: dancer's padding, Hoka One One Shoes for rocker, avoid toe bend in general, spica taping initially to help stop toe bend, get some Dr. Jills Dancer's pads for even sandals as they come in 1/4 inch size, while you are waiting for a good pair of orthotics to be made, use the dancer's padding in an anklizer boot. You may need to use crutches initially also since you have been using a knee scooter and putting no weight down. That typically makes the joint more swollen and sensitive as you begin weight bearing. Contrast bathes nightly should help reduce the inflammation. I would get Neuro-Eze from Amazon and rub in nonpainfully for 3 minutes three times a day. You also need to strengthen your foot again with metatarsal doming, single leg balancing, heel raises. I have a post explaining how to build a well or depression to float the sesamoid while still doing exercises.

I hope this helps. Rich
PS. Why no Exogen Bone stim? 

Achilles Tendon Taping with Leukotape and Coverlet


This is a video I found that uses leukotape for the achilles tendon injuries. It is solid. I would cover the skin with coverlet so that the leukotape does not rip up the skin. I commonly actually go a little higher up the leg and split the top piece once or twice to fan out the tape. But, overall, wonderful video. Leukotape is the strongest tape I know. The photo below is meant to show the upper part of the tape split into two sections. Therefore, the part on the achilles is one piece, the part below is split to go around the heel bone and the part above is split to grab more of the leg (typically it makes it more comfortable and more powerful). Rich


https://youtu.be/oytJehRhweg



Sunday, September 9, 2018

Sesamoid Pain in a Rock Climber: Email Advice

First of all, thank you for you wonderfully helpful blog and for your tremendous generosity in spreading your knowledge to help others. 

I have read through a lot of your blog and videos regarding sesamoid injuries, and have a couple questions about my particular situation. I am an avid rock climber -- and it is a pursuit I would like to continue at a relatively high level (weekend warrior) as much as possible. 

Last November (2017) I noticed a pain in the ball of my left foot. The appearance of the pain was fairly sudden, although I do not remember it occuring with a specific move; however, I do believe it occurred while climbing. The pain would really only be present when putting significant body weight on that portion of my foot (big toe or sesamoid area), or when I would try to bend the toe forward or backward to a large degree. It bothered me primarily while climbing but was generally not bad while walking. I never noticed any swelling or discoloration. I figured it was a minor tweak and didn't pay much attention. For unrelated reasons, I ended up having to take three months off from climbing (Jan - Apr 2018, though I still played some recreational tennis occasionally), and when I returned to climbing, the pain was not any better when that part of the foot was weighted, so I finally went to see a podiatrist. To be clear, the pain was generally only present when standing with most of my bodyweight on a very small chip of rock using just that portion of my foot/toe -- not while walking normally

Xray did not show anything, so was given diagnosis of sesamoiditis, and since the toe really only bothered me while climbing, it was suggested that I try some over-the-counter 3/4-length orthotics inside my climbing shoes (not very realistic) and sent on my way.

The toe did not bother me much for a couple months (although the pain during specific climbing moves was always there), but after a week-long climbing trip, it flared up significantly to the point where there was some pain/soreness even just while walking/standing. Upon returning to the podiatrist, an xray showed "small lucency to the medial sesamoid with concerns for fracture" so the podiatrist said there might be a small fracture there but basically suggested there was nothing really to be done, and that given that my symptoms were mild and intermittent, I should just modify my levels of activity to avoid overly stressing that area ("let pain be your guide").

It is true my symptoms are mild and manageable for every day activity. I can walk with no pain. However, for climbing, I would like to heal the bone to the point where there is no pain when I weight that area. Reading up a bit more about sesamoiditis and sesamoid fractures, I am wondering:

1/ Is it still advisable to go through the immobilization phase (given that the initial injury was 10 months ago, and that current pain levels are in 0-2 range)? I'm hoping the answer is no, but is an immobilization phase important for healing (even if the potential fracture occurred months ago)? If so, what level of immobilization? Tall boot? All the time / even when sitting at a desk or in bed?
Dr. Blake's comment: So many injuries do not heal unless placed back , even 10 years later, in the Immobilization Phase. However, we would need an MRI to know how inflamed the bone is, and really if you have something to gain by resting. Many of my patients go into the small anklizer boot for 4 months, for all activities other then their main sport, to give themselves a chance of healing. You already have the 0-2 pain level down, so hard to know if you will gain anything. How is your overall bone health? Has your Vitamin D been tested lately? Have you had a bone density? Good diet? 

2/ If it's OK to skip the immobilization phase, what would you recommend now? Contrast baths and runners pads/orthotics, no climbing on that foot, no tennis for some (what number?) weeks, then reintroducing those activities? (Given my low levels of pain, it doesn't seem like my podiatrist will be up for doing an MRI or bone stimulation.... or even custom orthotics...)
Dr. Blake's comment: Yes, I can tell you have been reading the blog!! Thank you!! All of these should be used. Contrast bathing once to twice daily as a deep bone flush is the most important. Common sense says you should pick on the bone less, so Dr. Jill's Dancer's Pads stuffed into the rock climbing shoes is also key. Orthotics have too much bulk and the main part in the front to protect, so just go with the dancer's padding protection. Really, the MRI is important to tell us what we are dealing with. It can be the structures next the sesamoid that are injured changing the treatment plan. You hurt with rock climbing, so I do not care if you do not hurt walking, unless you want to just be a walker. Some patients only hurt running, and they would fire me as their podiatrist if I told them to stop running forever and just walk. Get my point? The MRI is also baseline in case we need them again. Get them and send them to me if you want my read. 

3/ Any suggestions on how to best go back into climbing/tennis and over what length of time? I feel like both of these sports are situations where there might be sudden severe weighting on the pain spot (not repeated weighting like in running), and I don't want to risk re-injury, but I also wonder how to know when I've healed. Currently I'm not playing tennis and am avoiding any left-forefoot-weighting (and generally minimizing use of left foot) in climbing and basically having no pain, so I'm not sure how to tell when things have improved to the point where I can start weighting the left forefoot and/or playing tennis.
Dr. Blake's comment: This is exactly why we get the MRI. A very positive MRI today may mean that the sensitivity you feel loading the sesamoid may be there for up to 2 more years. Let's find out now, and it saves so much anxiety for the next 2 years. I find with negative x-rays, a positive MRI for bone swelling, you do contrast bathing daily, 9 months of bone stimulator, protect the bone with dancer's padding, and we see where you are at next June. That is the next time you really think about it. You wear the boot four hours a day to rest the overall tissue. You modify activities and cross train to stay as healthy as possible. Hope  this thought process is helpful. 

Thanks in advance!

Sunday, September 2, 2018

Sesamoid Pain post injury: email advice


Hello Dr. Blake
I am a 30-year old woman suffering from sesamoid complications in both feet. I came across your blog while desperately searching the internet for some help. My situation is somewhat unique and I would greatly welcome your advice.

On June 20th, 2018, I rolled my right ankle while doing yard work and obtained a mild eversion sprain.
 This was the 5th time in my life I have sprained that ankle so I am fairly familiar with the proper treatment.
 I rested as much as I could for three days and used ice and compression.
 There was no bruising and very minimal swelling. 
After three days, I did contrast baths once a day for a week and started range of motion,
 theraband, and balance exercises. I did not wear a brace (kicking myself for that now).
 I remember having some mild discomfort in the ball of my foot under the big toe at that point,
 but nothing that seemed too far out of the ordinary. I visited a podiatrist at 3 weeks post-injury
 and he was satisfied with my strength and range of motion and told me to keep doing what I was doing.

Fast forward a month to the end of July 2018 - I was still unable to walk normally 
and was now experiencing a lot of pain in the ball of my right foot, under the big toe. 
My podiatrist put me in a CAM walker boot on an as needed basis.
 I wore this out of the house for about two weeks but found that the stiff angle put pressure 
on the ball of my foot, and I was worried about losing flexibility in my ankle.
 During the time in the boot, I started feeling some intermittent pain in the ball of my left foot.

On August 18th, the pain was present and consistent in the balls of both of my feet (2 weeks ago).
 I do not have any relief while resting or elevating my feet, and I also am experiencing tingling 
and tightness in the painful spots and throughout the arches of both of my feet.
 I also have fasciculations in both arches while resting.
 Doctor ordered an MRI of the right ankle and an MRI of the forefoot - both came back showing mild
 inflammation. He decided to put me on a 12-day prednisone taper (60 mg to start) and 
I have one day of 10 mg left. I do not think the prednisone helped at all. 

I have started physical therapy since this all seemed to spring up after the acute ankle injury. 
I have never had issues with my feet before. The physical therapy team assessed me 
and decided that my hip strength is to blame. Basically, they are saying that my weak hips 
cause my feet and ankles to turn outwards and splay all over the place while I'm walking,
 causing an unsteady gait and thus the pain in the feet. I am working on hip strengthening, 
calf stretches, and some mild nerve flossing exercises. They also instructed me to walk with 
my stomach tight and focus on keeping my hips in a straight line. 
I've only had two physical therapy sessions so far.

The doctor also recommended Hoka running shoes for me because of the rocker forefoot. 
After wearing those for 2 days, I started feeling and hearing a popping sensation in my left ankle
 (the good ankle!) and I can feel what I think is a peroneal tendon moving over the ankle bone
 when I invert my foot. I also have an extremely sore spot on my lateral leg
 above the ankle now. I exchanged the Hokas for Altras two days ago and
 the popping is less consistent. The physical therapist said that should resolve itself,
 but if not I will have to see the doctor for this new injury as well. I am particularly worried about this. 

I am desperate to get some relief. Do you have any suggestions for me? 
I am particularly concerned by the constant nerve pain I seem to be having and am unsure 
what medications or course of treatment might be best for me. 
I'm functioning at 20% of my normal capacity and I'm basically at my wits end.

Thank you,
Linda (name changed due to witness protection)

Dr. Blake's comment: These are not that abnormal symptoms post injury to raise any warning flags 
of something serious. You got injured, your body compensated, other things hurt, and you will get 
better. You did not injure your sesamoids when you sprained your ankle, but your biomechanics change 
and stress is placed on other body parts. This sucks, I know, but you will work through it. The MRIs showing 
only mild inflammation, and the prednisone not helping, really points to your back (or nerves). The treatment 
should be activity modification to maintain 0-2 pain level, nerve flossing, neuro-eze OTC medication 
online, contrast bathing, real focus on normal gait (no favoring), ankle brace if you feel unstable (I doubt it), 
some sesamoid protection with dancers padding and arch support, sciatic nerve evaluation (what is you back 
history?). Keep me in the loop. Rich







Monday, August 27, 2018

Dr. Blake's CV

I have been asked many times for this information so I thought I would place it on my blog. Rich   

CURRICULUM VITAE

RICHARD L. BLAKE, D.P.M.

Business Address            Orthopedic and Sports Institute
                                        Saint Francis Memorial Hospital
                                        900 Hyde Street
                                        San Francisco, California 94109

Personal Data                   Date & Place of Birth:   January 9, 1954, San Francisco, CA
                                        Spouse:  Patricia A. Blake
                                        Children:  Stephen P. Blake, Christopher R. Blake
                      

Secondary Education        Riordan High School, San Francisco, CA

Undergraduate Education City College of San Francisco, 1972-74
                                        University of California, Berkeley, 1974-76, 1981

Graduate Education          California College of Podiatric Medicine, San Francisco, CA, 1976-79

Residency Programs
          First Year Medical-Surgical Podiatric Residency, 1979-80
          First Year Biomechanics Fellowship, 1979-80
          Second Year Biomechanics Fellowship, 1980-81

Degrees
          Bachelor of Science, Basic Medical Sciences, California College of Podiatric Medicine, June 1977
          Doctor of Podiatric Medicine, California College of Podiatric Medicine, June 1979
          Master of Science in Podiatric Biomechanics, California College of Podiatric Medicine, June 1981




Academic Biography
          Associate Professor, Department of Biomechanics, California College of Podiatric Medicine, 1981-83
          Clinical Instructor, Department of Biomechanics, California College of Podiatric Medicine, 1981-84
          Clinical Assistant Professor, Dept.  of Biomechanics, California College of Podiatric Medicine, 1983-89
          Adjunct Clinical Professor of Podiatric Orthopedics and Biomechanics, 1987
                    Barry University School of Podiatric Medicine
          Director, Sports Medicine Class, California College of Podiatric Medicine, 1991-92, 1984-89
           Professor, California School of Podiatric Medicine, Sports Medicine Lectures, 2011-2018

Fellowships
          Fellow, American College of Foot Orthopedics, 1979-81
          Fellow, American Academy of Podiatric Sports Medicine, 1983-present

Society Memberships
          American Podiatry Association, 1979-present
          California Podiatry Association, 1979-present
          American Academy of Podiatric Sports Medicine, 1982-present
         

Current Appointments

                Professor, California School of Podiatric Medicine, Sports Medicine, 2011-present
          Consultant, Podiatry Tracts, 1992-present

Past Appointments
          Consultant, Krames Communications, 1991-94
          President, American Academy of Podiatric Sports Medicine, 1992-93
                  President-Elect, 1991
                  Board Member, 1987-90
          Chairman, Annual Meeting, American Academy of Podiatric Sports Medicine, 1993
          Consultant, Motion Analysis Corporation, 1988-92
          Special Editor in Sports Medicine, Journal of the American Podiatric Medical Association, 1984-92
          Director of Podiatry:    City of San Francisco Marathon, 1991 (Co-Director)
                                             Golden Gate Marathon, 1984
                                             Golden Gate Marathon, 1983
                                             San Francisco Marathon, 1982
          Medical Coordinator:   City of San Francisco Marathon, 1990
                                             City of San Francisco Marathon, 1989
                                             San Francisco Marathon, 1983
          Board Member, YMCA Health Advisory Board, California Division, 1988-1989
          Examination Chairman, Fellowship, American Academy of Podiatric Sports Medicine, 1988, 1989
          Team Podiatrist, Gymnos USA Gymnastics Center, San Rafael, CA, 1985-87
          Medical Editor:  Strider Running Magazine, 1983
                                   Dolphin-Southend Running Club Newsletter, 1981-84
          Team Podiatrist:    Greater San Francisco Track Club, 1981-83
                                        Terra Linda High School Cross-Country Team, 1981
                                        Lowell High School Cross-Country Team, 1981
                                        City College of San Francisco Cross-Country Team, 1981-82
                                        Marin Catholic High School Cross-Country Team, 1982

Awards
          President, American Academy of Podiatric Sports Medicine, 1992-93
          Chairman, Annual Meeting, American Academy of Podiatric Sports Medicine, San Diego, CA, 1993
          Biomechanics Award, American College of Foot Orthopedists, June 1979
          1st Prize, Outstanding Paper in Foot Orthopedics, American College of Foot Orthopedists, June 1980
          Honored Guest/Plaque Presentation for Work With Runners, Dolphin Southend Running Club, Jan. 1984
          Richard Schuster Biomechanics Award, American Academy of Podiatric Sports Medicine, 1995

Podiatry Blog: www.drblakeshealingsole.com  March 2010 to present

Podiatry YouTube Channel:  drblakeshealingsole   July 2010 to present



Publications

Who Gets Injured?” Running Times Magazine, March 1979

A Survey of 1,500 Athletes -- Injury Questionnaire”, Yearbook of Podiatry, 1981-82

A Study of Ankle Joint Height Changes with Subtalar Joint Motion”, Journal of the American Podiatry Association, Vol.71, No.3, March 1981

Running Gait Evaluation”, Journal of the American Podiatry Association, June 1981

Runner’s Knee Examination”, Journal of the American Podiatry Association, July 1981

Etiology of Atraumatic Medial Knee Pain”, Journal of the American Podiatry Association, October 1981

“Low Back Pain in a Runner:  A Case Report”, Journal of the American Podiatry Association, November 1983

Theraband Strengthening Exercises -- How I Do It”, Podiatric Sports Medicine Journal, Fall 1983

Functional Foot Orthoses for Athletic Injuries”, Journal of the American Podiatry Association, July 1985

Inverted Functional Orthosis”, JAPMA, Vol. 76, No. 5, May 1986

Treatment of Flexible Flatfoot - A Panel Discussion”, Jour of the American Pod Med Assn, pp 46-49, Jan 1987

Conservative Treatment of Acute Inversion Ankle Sprains -- A Follow-Up Study”, Syllabus - National Meeting of American Academy of Podiatric Sports Medicine, Boston, MA, May 1988

Athletic Injuries -- Orthoses vs. Surgery”, Current Therapy in Pod Surg, 296-301, B.C. Decker Publishing, 1989

Inverted Orthotic Technique”, Syllabus - National Meeting of American Academy of Podiatric Sports Medicine, Phoenix, AZ, May 1989

Common Sports Injuries and Their Treatment”, Foot and Leg Function Newsletter, Langer Biomechanics Group, New York, May 1989

Walking Case Studies - Calcaneus to Vertical Angle”, 1990 Syllabus, American Academy of Podiatric Sports Medicine meeting, Miami, Florida, May 1990

Treatment Flowsheets”, Footprints Newsletter, Florida Podiatric Medical Association, December 1990

Achilles Rupture Protocol”, Newsletter, American Academy of Podiatric Sports Medicine, Winter 1990

Sports Injuries - A Podiatric Approach to Prevention and Treatment”, patient education booklet, Krames Communications, released March 1991

Conservative Management of Closed Tendon Achilles Ruptures”, Australian Podiatrist, March 1991

Tibial Stress Fracture Flowsheet”, American Academy of Podiatric Sports Medicine Newsletter, Spring 1991

Effect of Rearfoot Posting on Rearfoot Motion as Demonstrated by Motion Analysis”, Syllabus, Annual Meeting, American Academy of Podiatric Sports Medicine, May 1991

The Myth of Running Limb Varus”, Journal American Podiatric Med Assn, Vol. 81, No. 6, 325-327, June 1991

TL-61® versus Rohadur® Orthoses in Heel Spur Syndrome”, Journal of the American Podiatric Medical Association, Vol.81, No.8, August 1991

Achilles Tendon Rupture”, Journal of the American Podiatric Medical Association, Vol.81, No.9, Sept 1991

Foot Orthosis for the Severe Flatfoot in Sports”, Jour American Podiatric Med Assn, Vol.81, No.10, Oct 1991

Muscle Strengthening for Chondromalacia Patellae”, Australian Podiatrist, December 1991

Biomechanical Analysis of Running with 25° Inverted Orthotic Devices”, Journal of the American Podiatric Medical Association, Vol.81, No.12, December 1991

Limb Length Discrepancies”, Journal of the American Podiatric Medical Association, Vol.82, No.1, Jan 1992

"The Os Trigonum Syndrome", Journal of the American Podiatric Medical Association, Vol 82, No. 3, Mar 1992

"Extrinsic Rearfoot Posts", Journal of the American Podiatric Medical Association, Vol.82, No.4, April 1992

"Achilles Peritendinitis: A Literature Review with Case Report".  Journal of the American Podiatric Medical Association, Vol. 82, No. 9, September 1992

Common Running Injuries Seen in a Podiatric Sports Medicine Practice - Part I”.  Medicine, Exercise, Nutrition and Health, Vol. 1, No. 6, Nov/Dec 1992

The Inverted Orthotic Technique:  A practical discussion of an orthotic therapy”.  Journal of British Podiatric Medicine, Vol. 48, No. 2, Feb 1993

Common Running Injuries Seen in a Podiatric Sports Medicine Practice, Part 2”.  Medicine, Exercise, Nutrition, and Health, Vol. 2, No. 1, Jan/Feb 1993

The Motion Analysis System for Dynamic Gait Analysis”.  Clinics in Pod Med & Surg, Vol. 10, No. 3, July 1993

Effect of Extrinsic Rearfoot Posts on Rearfoot Position”.  Journal of the American Podiatric Medical Association, Vol. 83, No. 8, August 1993

Walking and Hiking Injuries: A One-Year Follow-Up Study”.  Journal of the American Podiatric Medical Association, Vol. 83, No. 9, September 1993

Correlation Between Limb Length Discrepancy and Asymmetrical Rearfoot Position”.  JAPMA, Vol. 83, No. 11, Nov 1993

Developing a Treatment Plan for Athletes”.  Podiatry Management, February 1994

Update and Rationale for the Inverted Functional Foot Orthosis”.  Clinics in Podiatric Medicine and Surgery, Vol. 11, No. 2, April 1994

The Inverted Orthotic Technique: It’s Role in Clinical Biomechanics”.  Co-authored with Heather Ferguson, MS B App Science (Pod-Australia), Clinical Biomechanics of the Lower Extremities, Mosby-Year Book, Inc., Chicago, 1995, chapter 22, pp 466-497

A Podiatrist’s Guide to Shoe and Shoe Insert Modifications”, Podiatry Management, October 2011, pp 131-136

Keys to Pain Management in a Sports Medicine Practice”, Podiatry Today, Volume 28, Issue 4, April 2015

Maximalistic Shoes: A Closer Look into the Biomechanics”, Podiatry Today, July 2017.


Speaking Engagements


“Running Injuries”, California College of Podiatric Medicine, Biomechanics Seminar, San Francisco, 1979

Biomechanics III Class, California College of Podiatric Medicine, San Francisco:
1979 (3 lectures), 1980 (7 lectures), 1981 (6 lectures)

“Athletic Taping”, California College of Podiatric Medicine, Biomechanics V Class, San Francisco, 1980

“Sports Injuries in Children”, California College of Podiatric Medicine, Pediatrics Class, 1980

“Evaluation and Treatment of Limb Length Discrepancies”, American Pod Association, Annual Convention, 1981

Biomechanics I Class, 4 lectures, California College of Podiatric Medicine, San Francisco, 1981

“Iliotibial Band Syndrome”, “Athletic Rehabilitation Injuries”, plus 4 workshops on “Knee Examination”, and 1 workshop on “Gait Analysis”, California College of Podiatry Medicine, Super Seminar, San Francisco, Mar 82

“Sports Injuries in Children”, California College of Podiatric Medicine, Pediatrics Class, San Francisco, 1982

“Rehabilitation of Athletic Injuries”, Western Podiatry College, Hawaii, May 1982

“Knee Pain in Relationship to Foot Function”, National Podiatry Convention, Chicago, IL, August 1982

“Rehabilitation of Athletic Injuries”, Calif College Pod Med, Sports Medicine Class, San Francisco, Feb 1983

“Update on Athletic Shoes”, plus 4 workshops on “Knee/Hip Examination”, California College of Podiatric Medicine, Super Seminar, Las Vegas, NV, 1983

“Physical Therapy for the Athlete”, Western Podiatry Congress, Reno, NV, June 1983

“Athletic Rehabilitation”, Los Angeles Podiatry Student Lecture Series, January 1984

“New Concept in Running Orthoses”, San Francisco-San Mateo Podiatric Society, January 1984

“Modifications for Functional Foot Orthoses, Part I and II”, “Knee Examination”, “New Concept on Running Orthoses”, “Taking a Negative Cast for Post-Operative Patients”, American College of Foot Surgeons, Annual Meeting, Las Vegas, NV, February 1984

6 Lectures on various sports medicine topics, Sports Med Class (Chairman), Calif College Pod Med, Spring 1984

“Sports Medicine Injuries”, American Academy Podiatric Sports Med, Natl Convention, San Francisco, July 1984

“Knee Rehabilitation”, “Physical Therapy Concepts”, “Evaluation of the Knee and Hip”, California College of Podiatric Medicine, Super Seminar, Las Vegas, NV 1985

“Ankle Sprains - Diagnosis and Treatment”, “Overview of Ballet”, California College of Podiatric Medicine, Sports Medicine Lectures to Junior Class, 1985

“Exercise and Your Heart”, American Heart Association, Sports Medicine Injury Prevention Symposium, May 85

“Lower Extremity Biomechanics as Causes of Injury”, SF Ortho Society/Golden Gate Phys Ther Assn, June 1985

“Functional Orthotic Control of the Severe Pes Planovalgus”, NW Pod Found, Annual Sem, Seattle, Oct 1985

“Functional Orthotic Variations”, Northwest Podiatric Foundation, Kauai, HI, October 1985

“Sportsmedicine -- Implications to Podiatry”, California College of Podiatric Medicine/American Academy of Podiatric Sports Medicine Student Chapter, October 1985

“Podiatrist’s Role in Sports Medicine”, JFK University, Graduate School of Professional Psychology, Sports Psychology Program, Orinda, CA October 1985

“Podiatry and Sports Medicine”, Riordan High School, Alumni Boosters Club, San Francisco, October 1985

“Biomechanics and Sports Medicine”, Chicago Pod Society, Study Group, 11 lecture hrs, Chicago, Nov 1985

“Knee Injuries in Athletes”, YMCA, San Francisco Embarcadero Branch, November 1985

“Rx Writing”, “Workshop on Casting and Bioevaluations”, “Basic Biomechanics”, Root Laboratory, 3-day seminar, San Diego, CA, November 1985

“Causes of Athletic Injuries”, California College of Podiatric Med, Sports Med Class, San Francisco, Jan 1986

“New Concept in Sport Orthoses”, workshop on “Ballet Injuries”, American Academy of Podiatric Sports Medicine, Seminar, Houston, TX, May 1986

“Podiatry for the Physical Therapist”, Golden Gate District Phys Therapy Assn, 2-day Seminar, Sept 1986

“Current Concepts in Sports Medicine”, podiatry stall of Hillside Hospital, San Diego, September 1986

“Biomechanical Principles in Sports Medicine”, Union Mem Hospital, 2-day Seminar, Baltimore, MD, Oct 1986

“Contraindications to Aerobics”, YMCA, Oakland, CA, November 1986

“Foot Care for the Elderly”, Saint Francis Mem Hospital, Healthwise Senior Program, San Francisco, Jan 1987

“Foot and Ankle Sports Medicine Injuries”, Natl Acad Ortho Nurses, Shriner’s Hosp, San Francisco, Jan 1987

“Rearfoot Analysis with High-Speed Cinamatography”, Root Laboratory, Functional Orthotic Seminar, Sacramento, CA, January 1987

Causes of Athletic Injuries”, “Treatment Modalities in Athletic Injuries”, “Biomechanics of Athletic Injuries”, “Foot Injuries in Sports Medicine”, “Ankle Injuries in Sports Medicine”, “The Ankle Sprain in Sports Medicine”, California College of Podiatric Medicine, Sports Medicine Course, San Francisco, January/February 1987

“Conservative Treatment of Ankle Sprains”, California College of Podiatric Medicine, Department of Surgery, Podiatric Trauma Course, San Francisco, April 1987

“Knee Injuries in Sports Medicine”, “Hip Injuries in Sports Medicine”, “Leg Injuries in Sports Medicine”, “Prescription Writing for Functional Foot Orthoses in Sports Medicine”, Sports Med Course, San Francisco, April/May 1987

“The Changes in Rearfoot Motion with High-Speed Cinematography with the Inverted Orthotic Technique”, “Prescription Writing for Functional Foot Orthoses”, Amer Acad Pod Sports Medicine, Chicago, IL, May 1987

“Sports Medicine and Biomechanics”, San Diego Podiatric Society, 4-1/2 hour presentation, San Diego, CA, September 1987

“Stretching Techniques and Principles”, “Functional Orthoses Prescription Writing”, California College of Podiatric Medicine, Palm Springs, CA, October 1987

“Knee Injuries”, American Academy of Podiatric Sports Medicine, Student Chapter, San Francisco, October 1987

“Biomechanical Examination and Demonstration”, Root Laboratory, Auburn, CA, October 1987

“Podiatric Sports Medicine”, Barry University School of Podiatric Medicine, 4-1/2 hour presentation, Miami Shores, FL, November 1987

“Clinical Biomechanics”, Union Memorial Hospital, 2-day Sports Medicine Seminar, Baltimore, MD, Nov 1987

“Introduction to Sports Medicine”, Calif College of Pod Medicine, 2-hour presentation, San Francisco, Jan 1988

“Inverted Orthotic Technique”, Cleveland Clinic, spon by Ohio Pod Med Students Assn, Cleveland, Feb 1988

“Causes of Athletic Injuries”, California College of Podiatric Medicine, San Francisco, Feb 1988

“TL-61 vs. Rohadur for Heel Spur Syndrome”, “Inverted Orthotic Technique - 5-Year Update”, Root Lab Seminar, Sacramento, CA, February 1988

“Inverted Orthotic Technique”, California College of Pod Med, Sports Med Course, San Francisco, March 1988

“Treatment of Common Athletic Injuries”, 3-hour pres, sponsored by CCPM, Lake Tahoe, CA, March 1988

“Conservative Treatment for Ankle Sprains”, Calif Coll Pod Med, Sports Med Course, San Francisco, April 1988

“Ankle Sprain Research Study -- 208 Consecutive Ankle Sprains Conservatively Managed”, “Ankle Sprain Treatment Workshop”, American Academy of Podiatric Sports Medicine, Boston, MA, May 1988

“Causes of Athletic Injury”, “Inverted Orthotic Technique”, “Chondromalacia Patellae”,  College of Podiatric Medicine and Surgery, University Osteopathic Medicine and Health Sciences, Junior Class, Des Moines, IA, Nov 1988

“History Taking and Generalizations in Sports Medicine”, California College of Podiatric Medicine, Jan 1989

“Clinical Applications of Motion Analysis”, Root Seminar, Sacramento, CA, April 1989

Intermediate Lower Extremity Biomechanics Course, sponsored by Northern District Virginia Physical Therapy Association, May 1989:  “General Concepts in Biomechanics”, “Extrinsic Forces to the Foot”, “Common Running Pathologies”, panel discussion; “Common Foot Injuries and Their Biomechanicsl Basis”, “The Inverted Orthotic Technique”, “Gait Evaluation” workshop, “Suspension Neutral Position Casting”, workshop

Graduation Address, University of California at Berkeley, Department of Phys Education, Berkeley, May 1989

American Academy of Podiatric Sports Medicine, Phoenix, AZ, May 1989:  “Evaluation and Treatment of Ankle Sprains”, “Inverted Orthotic Technique”, “Current Concepts in Sports Orthoses”, panel discussion with Drs. Burns, Wernick and Schuster; “Ankle Sprains”, panel discussion with Drs. Lowe, Taylor, Ross and Subotnick

California College of Podiatric Medicine, American Podiatric Technique - Series V, Australian Podiatry Group, June 1989:  “Examination of the Knee”, “Examination of the Hip”, “Inverted Orthotic Technique”

Pennsylvania Physical Therapy Association, Seven Springs, PA, November 10-12, 1989:  “Common Generalizations in Clinical Biomechanics”, “Overview of Clinical Anatomy of the Foot and Anatomy” “Pronatory and Supinatory Gait Patterns”, “Compensatory Biomechanics Extrinsic to the Foot”, “Principles of Orthotic Prescription Writing”, “The Inverted Orthotic Technique”

“Inverted Orthotic Technique”, California College of Podiatric Medicine, Student Chapter American Academy of Podiatric Sports Medicine, San Francisco, November 1989

Australian Academy of Podiatric Sports Medicine Conference, Adelaide, South Australia, January 18-22, 1990:   Keynote speech, “Biomechanics of the Foot and Leg”, Follow-up of keynote speech, “Biomechanics of the Foot and Leg”, “Kinesiology”, “Muscle Testing”, “Muscle Testing”, demonstration; “Podiatric X-ray Evaluation”, “The Gait Cycle”, “Orthotic Therapy”, “Orthotic Materials”, “Evaluation of the Injured Athlete”, “Biomechanical Assessment”, “Prescription Writing”, “Motion Analysis FootTrack Computer Video System”,
2 workshops; “Dress Shoe Orthotic Casting”, workshop

“The Sport, Equipment, and Inherent Injuries -- Running and Walking”, California College of Podiatric Medicine, Sports Medicine Course, San Francisco, February 1990

Golden Gate District Physical Therapy Association, “Podiatry for the Physical Therapist”, February 1990: “Common Office Taping, Strapping and Padding”, “Impression Casting” workshop; “Gait Evaluation” workshop

“Introduction to Motion Analysis Computerized Video Gait System”, AAPSM, Miami, Florida, May 1990

“Orthotic Devices in Athletes”, California College of Podiatric Medicine, Student Chapter, AAPSM, Aug 1990

“General Approach to Decision Making in Athletic Patient”, Sports Med Course, Calif Coll Pod Med, Jan 1991

“Current Advances in Podiatric Sports Medicine”, Veterans’ Hosp, Fort Miley, San Francisco, Jan 1991

“Physical Examination of the Athlete”, Sports Medicine Course, CCPM, January 1991

“Current Biomechanical Concepts in the Rehabilitation of the Athlete”, San Diego Pod Med Society, Jan 1991

“Muscle Strength and Flexibility Testing”, Sports Medicine Course, Calif College of Pod Med, January 1991

“Orthotic Prescription Writing, Part I”, Sports Medicine Course, California College of Pod Medicine, Jan 1991

“Orthotic Prescription Writing, Part II”, Sports Medicine Course, California College of Pod Medicine, Jan 1991

“General Physical Therapy Principles”, Sports Medicine Course, California College of Pod Med, February 1991

“Common Foot Injuries”, Sports Medicine Course, California College of Podiatric Medicine, February 1991

“Role of Rearfoot Posting on Foot Function”, “Treatment of Chondromalacia Patellae”, “Introduction to Motion Analysis”, California College of Podiatric Medicine’s “Super Seminar”, Las Vegas, Nevada, March 1991

“Common Foot Injuries, Part II”, “Common Ankle Injuries”, Calif College of Pod Med, San Francisco, March 1991

“Common Ankle Injuries, Part II”, California College of Podiatric Medicine, San Francisco, April 1991

“Common Leg Injuries, Part I”, California College of Podiatric Medicine, San Francisco, April 1991

“Common Leg Injuries, Part II”, California College of Podiatric Medicine, San Francisco, April 1991

“Common Knee Injuries and Rehabilitation”, California College of Podiatric Medicine, San Francisco, May 1991

“Proper Selection of Walking Shoes”, Institute of Sports Med, R.K. Davies Med Center, San Francisco, June 1991

“Foot Manipulation”, Mt. Zion Hospital physical therapy staff, San Francisco, August 1991

“Inverted Orthotic Technique”, American Podiatric Technique, St Francis Memorial Hosp, San Francisco, Aug 1991

“Biomechanical Control of Runners”, California College of Podiatric Medicine, Sports Med Club, Sept 1991

“Introduction to the Athletic Patient”, “Physical Examination of the Athlete”, “Treatment Generalizations of the Athlete”, California College of Podiatric Medicine, Sports Medicine Course, Spring ‘92 Junior Class, Jan 92

“Achillis Tendon Rupture - Protocol for Conservative Care”, Utah Podiatry Association/American Academy of Podiatric Sports Medicine, 1992 Snowbird Ski Seminar January 1992

“Prescription Writing for Foot Orthoses”, “Physical Therapy Techniques in Sports Medicine”, California College of Podiatric Medicine, Sports Medicine Course, February 1992

“Overview of Common Leg Injuries”, California College of Podiatric Medicine Sports Medicine Course, Mar 1992

“Overview of Overuse Injuries”, “Gait Analysis”, “Principles of Stretching”, “Principles of Strengthening”, “Proper Shoe Selection”, “Causes of Athletic Injuries/Treatment of Acute Inujuries”, Course entitled The Amateur Athlete: From Start to Finish, Stanford Hospital Nursing Continuing Education Program, March 1992

“Common Orthotic Modifications”, Allied/OSI Lab, Indianapolis, March 1992

“Ankle and Leg Injuries in Sports”, Student Athletic Trainers’ Course, Univ. of California, Berkeley, April 1992

“Common Leg Injuries, Part II”, Sports Medicine Course, California College of Podiatric Medicine, April 1992

"Running Biomechanics", California College of Podiatric Medicine, April 1992

"Conservative Treatment of Complete Achilles Ruptures", Annual Meeting AAPSM, Houston, May 1992

"Motion Analysis Evaluation for Knee Pain", "Tibial and Fibular Stress Fractures", "Sesamoiditis", "Peroneal Tendinitis", Sports Medicine Symposium, Western Podiatry Congress, San Jose, California, May 1992

"Rehabilitation Principles", Residents Lecture, V.A. Hospital, Fort Miley, San Francisco, September 1992

“Inverted Orthotic Technique”, IPMSA Mid-Winter Seminar, Scholl College of Pod Med, Chicago, Jan 1993

“Treatment for the Supinator”; “Inverted Orthotic Technique”; Achilles Ruptures Protocol”; Limb Length Discrepancy”; and “Heel Pain - Diagnosis and Treatment” Oregon Podiatric Medical Association, Winter Meeting, Bend, Oregon, February 1993

“Common Causes of Athletic Injuries” Los Angeles Coll Chiropractic Med, Postgrad Div, Oakland, May 1993

“Orthotic Modifications for the Severe Pronator”, “Evaluation and Treatment Protocol for Heel Pain”, “Conservative Protocol for Complete Achilles Tendon Ruptures”.  Annual Meeting, American Academy of Podiatric Sports Medicine, San Diego, California, June 1993

“Biomechanics of Shin Pain” American Podiatry Technique, CCPM, San Francisco, July 1993

“Athletic Overuse Injuries and Treatment”, CAQ Board Review Course, ACSM, San Francisco, Aug 1993

Kansas/Oklahoma Podiatric Medical Association, Annual Meeting, Wichita, Kansas, September 1993:
        “Motion Analysis: Clinical Pearls”
“Treatment of the Abnormal Pronator”
“Treatment of the Abnormal Supinator”
“Lower Leg Athletic Injuries”
“Prescription Writing for Athletic Orthotics”
“Gait Evaluation for Prescription Writing for Athletic Orthotics”

“The Inverted Orthotic Technique: A 10-Year Review”, First World Congress and Third European Congress of Podiatry, Brighton, England, October 1993

“Podiatric Management of Foot Disorders”, Samuel Merritt College, Physical Therapy Program, Nov 1993

“Six-Month Conservative Protocol for Heel Spur Syndrome”, course on Endoscopic Surgery for Plantar Fasciitis, California College of Podiatric Medicine, San Francisco, February 1994

Ontario Society of Chiropody, Toronto, Ontario, Canada, February 1994:
“Heel Spur Syndrome”
“Achilles Tendinitis”
“Biomechanics” (panel discussion with Dr. Sheldon Langer and Jeff Cuszak)
“Knee Examination” (2-hour workshop)
“Orthotic Prescription Writing” (2-hour workshop)

“Biomechanical Considerations in a Marathon Runner”, John Weed, D.P.M. Memorial Seminar, South Lake Tahoe, Nevada, April 1994

American College of Foot Orthopedics, Biomechanics Seminar, San Diego, CA, May 1994:
“Inverted Orthotic Technique”
“Treatment for a Supinator”
“Motion Analysis: Clinical Applications”
“Limb Length Discrepancy”
“Prescription Writing for Functional Foot Orthotic Devices”

“Inverted Orthotic Device”, California College of Podiatric Medicine, Sports Medicine Course, May 1994

“Six-hour Biomechanics Workshop”, at the annual meeting of the American Academy of Podiatric Sports Medicine, Scotsdale, Arizona, June 1994

Regional Meeting, Seattle, Washington, June 1994
          “Treatment of Plantar Fasciitis”
          “Inverted Orthotic Technique”
          “Modifying Athletic Shoes”

“Inverted Orthotic Technique”, teleconference with 30 podiatrists in New Zealand, August 1994

“Modifying Athletic Shoes”, American Podiatric Medical Assn Annual Meeting, San Francisco,  August 1994

“Inverted Orthotic Technique”.  4th Annual Applied Biomechanics Seminar, CCPM, San Francisco, Oct 1994

“Inverted Technique”  Student Chapter of California College of Podiatric Medicine, AAPSM, November 1994

“Management of Biomechanic Pathology in the Athlete”  American Academy of Podiatric Sports Medicine’s Sports Medicine Day, San Francisco, March 4, 1995

“Plantar Fasciitis”  Sports Medicine Club, California College of Podiatric Medicine, April 1995

“Inverted Orthotic Technique” Sports Medicine Course, California College of Podiatric Medicine, April 1995

“Treatment of Plantar Fasciitis”, Sports Medicine Symposium, Memorial Hospital Association, Modesto, CA, April 1995

Regional Meeting, American Academy of Podiatric Sports Medicine, San Francisco, April 1996
          “Heel Pain Management”
“Limb Length Discrepancy”
“Inverted Orthotic Devices”
  6 Workshops on “Gait Evaluation”

“Inverted Orthotic Device” Sports Medicine Course, California College of Podiatric Medicine, San Francisco, May 1996

“Biomechanics Workshop”; “Podiatric Sports Medicine 1995” American Academy of Podiatric Sports Medicine, Orlando, Florida, June 1995

“Inverted Orthotic Technique” American Academy of Podiatric Sports Medicine meeting, sponsored by Student Chapter of California College of Podiatric Medicine, San Francisco, September 1995

“Gait Evaluation”, “Conservative Management of Heel Pain”, “Common Running Injuries”  National Meeting, American Academy of Podiatric Sports Medicine, Kansas City, Missouri, October 1996

“Heel Pain Management” Sponsored by American Academy of Podiatric Sports Medicine and Student Chapter of California College of Podiatric Medicine, San Francisco, February 1997

“Pearls of Biomechanics”, “Inverted Orthotics”, Limb Length Discrepancies”, “Sports Injuries” Annual Scientific Seminar, British Columbia Association of Podiatrists, Vancouver, BC, February 20-23, 1997

“Inverted Orthotic Technique and Kirby Skive”.  Sports Medicine Class, California College of Podiatric Medicine, San Francisco, California, April 1997

“Knee Injuries” American Podiatry Technique Course for International Podiatrists, California College of Podiatric Medicine, San Francisco, July 1997

“Inverted Orthotic Technique and Basic Biomechanical Principles” Mercy Hospital Residents’ Lecture Series, San Diego, November 1997

“Practical Advice on Maintaining Flexibility” Fifty-Plus Fitness Association and the San Francisco Bay Club, San Francisco, May 20, 1998

“Right Fit: Orthotics and the Athlete”; “The Wide World of Orthotics”.  Annual Meeting, American Podiatric Medical Association, Boston, August 1998

"Orthotic Modifications in Sports Medicine Practice" Sports Medicine Class, California College of Podiatric Medicine, San Francisco, California, October 1998

"The Inverted Orthotic Technique"  Student Chapter, California College of Podiatric Medicine, American Academy of Podiatric Sports Medicine, April 1999

"Rehab Protocols for Overuse Injuries" Sports Medicine Course, California College of Podiatric Medicine, San Francisco, March 21, 2000

"Orthotic Prescription Writing for Sports Medicine" Sports Medicine Club, California College of Podiatric Medicine, San Francisco, October 2000

"Inverted Orthotic",  Biomechanics Student Club, California College of Podiatric Medicine, November 2000

"Foot and Ankle - Mechanics, Injuries, Shoe Selection"  Sports Medicine Course, Dept. of Family and Community Medicine, School of Medicine, University of California, San Francisco, November 30, 2000

"Orthotic Devices for Athletes" Student Chapter, American Academy of Podiatric Sports Medicine, San Francisco, March 2001

"Orthotic Therapy for Athletes" California College of Podiatric Medicine, Mare Island, Vallejo, California,
April 2002

“Biomechanics” Sports Medicine Course, JFK University, Walnut Creek, California, November 2002

“Sports Injuries and Rehabilitation” CSPM Student Chapter, American Academy of Podiatric Sports Medicine, St. Mary’s Medical Center, San Francisco, February 2003

Workshop:  “Casting for Orthotics/Orthotic Prescription”.  American Academy of Podiatric Sports Medicine in conjunction with California School of Podiatric Medicine’s program entitled “Sports Medicine of the Lower Extremity”, Samuel Merritt College, Oakland, California, March 15, 2003

“Inverted Orthotic Technique”, Richey & Co Labs, Charlottesville, VA, July 2007, 2 Day Seminar

“Shoe Modifications” and “Treating the Negative Addiction in Athletes”, Western Podiatric Seminar, Disneyland Hotel, Los Angeles, June 2008

“Variations in Orthotic Therapy”, Department of Biomechanics, Samuel Merritt College, San Francisco, CA, November 2008

“Biomechanical Guidelines”, Orange County Residency Program, Los Angeles, Ca, Feb 2009

“Sports Medicine Principles”, Keynote Address, Georgia Podiatric Medical Association, Atlanta, GA, Feb 2009

“Top 30 Biomechanical Principles”, A Day In Sports Medicine, California School of Podiatric Medicine, April 2009

“Sports Medicine Introduction”, 6 hour lecture presentation, California School of Podiatric Medicine, Samuel Merritt College, January 2011

“25 Common Shoe and Shoe Insert Modifications in a Sports Medicine Podiatry Practice”,  2011 Continuing Medical Education Lecture Series, California School of Podiatric Medicine, Samuel Merritt University, Co-Sponsored by the American Academy of Podiatric Sports Medicine, April 16, 2011

 “Sports Medicine Introduction”, 6 hour lecture presentation, California School of Podiatric Medicine, Samuel Merritt College, January 2012

“Orthotics for the Athlete”, California School of Podiatric Sports Medicine, Samuel Merritt University, March 2013

“Sports Medicine Introduction”, 6 hour lecture presentation, California School of Podiatric Medicine, Samuel Merritt College, January  2013

“Introduction to Gait Evaluation”, California School of Podiatric Medicine, Samuel Merritt University, March 2013

“Orthotic Modifications for RX Writing”, American Academy of Podiatric Sports Medicine, Samuel Merritt University, September, 2013

“Introduction to Sports Medicine Principles”, 4 hour lecture presentation,  California School of Podiatric Medicine, Samuel Merritt University, Oakland, California, October 2014

“Walking versus Running Mechanics: What are the Differences?” June 2015,  Anaheim, CA, The Western Podiarty Conference

“Running Shoes: Science and Controversy” June 2015, Anaheim, CA, The Western Podiatry Conference

“Management of Soft Tissue Injuries” 3 hour presentation, October 2015, California School of Podiatric Medicine, Samuel Merritt University, Oakland, California

“Gait Evaluation Workshop” October 2015, California School of Podiatric Medicine, Samuel Merritt University, Oakland, California

“Biomechanics and Podiatric Sports Medicine”, Two workshops, Samuel Merritt University Motion Analysis Research Center, 1st Annual MARC Symposium, November 2015,   Oakland, California

“Walking vs Running:What’s the Difference?”, Samuel Merritt University, 1st Annual MARC Symposium, November 2015,  Oakland, California

“Introduction to Sports Medicine Principles” 6 hours of presentation, Fall 2016, Samuel Merritt University, California School of Podiatric Medicine, Oakland, California

Biomechanics Workshops, 12 total, October 2016 through April 2017, 2nd Year Students, California School of Podiatric Medicine, Samuel Merritt University, Oakland, California

“Knee, Hip, and Low Back for the Podiatrist”, October 2017, Samuel Merritt University, California School of Podiatric Medicine, Oakland, California

Physical rehabilitation/ return to activity guidelines- how to work with physical therapy, stretching, cross training”, November 2017, Samuel Merritt University, California School of Podiatric Medicine, Oakland, California.

“Orthotic Devices: Custom, OTC, How to Choose Modifications”, February 2018, Building Blocks for Running Seminar, UCSF Benioff Children’s Hospitals, UC Berkeley, California.

“The Runner’s Foot Examination”, 2 one hour workshops, February 2018, Building Blocks for Running Seminar, UCSF Benioff Children’s Hospitals, UC Berkeley, California.

Biomechanics Workshops, 12 total, October 2017 through April 2018, 2nd Year Students, California School of Podiatric Medicine, Samuel Merritt University, Oakland, California


“Inverted Orthotic Technique”, 3 hour Workshop, OOLAB, Hamilton, Ontario, Canada, May 2018

“35 Years Experience with the Inverted Technique”, Keynote Address, Ontario Conference of Chiropody, Markham, Ontario, Canada, May 2018

“Principles of Athletic Rehabilitation”, Ontario Conference of Chiropody, Markham, Ontario, Canada, May 2018


“Using Biomechanics in Clinical Practice”, Ontario Conference of Chiropody, Markham, Ontario, Canada, May 2018