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Monday, August 25, 2014

Blister Treatment: Email Advice

Hi Dr. Blake
I am a long time patient of yours. I doubled my running mileage and had slight pain in my second toe as I finished. When I got home I saw the toe was black. I taped it and this morning I noticed blood on the tape.
Should I make an appointment? Stop running for awhile (how long?) or pay no attention?
Your advice is greatly desired
Thanks


Bonnie (name changed), 
      The blood means that you got a blood blister. If you can find the opening keep antibiotic ointment over it for 5 days and cover with several band aids. Soak each evening for 30 minutes to 1 hour for the next 4 days in warm water with a tablespoon of salt. Leave air exposed while sleeping, and then recover before placing shoe on the next am. Do not stop activities unless you get sharp pain or limping occurs. Hope this helps. Rich

PS. The toenail may be loose at the cuticle causing the bleeding. If so, after the first few days, when the need to use soaking and antibiotic ointment is over, gently tape the nail down 24/7 with a bandaid to see if you can get the nail to restick to the nail bed below. If not, you will lose this nail, but a new one is growing as we speak to take it's place. It is also a great time to check the length of your shoes. Standing in your shoes with socks, at the end of the day (after 6 pm) you should have a thumb width from the end of the shoe to the end of you longest toe (in your case the first). If there is any question, go up a 1/2 size or at least learn power lacing to hold you back in the heel as you run. 


Saturday, August 16, 2014

Plantar Fascial Tears: Top 10


Plantar Fascial Tears

The top 10 treatments for plantar fascial tears:

1.  3 months removable boot or shoes to avoid toe bend
2.  EvenUp with opposite shoe if removable boot utilized
3.  Pain-free environment should be created by 2-3 weeks
4.  No plantar fascial stretches for 3-4 months
5.  2 to 6 week weaning process from boot full time into protected shoe gear with orthotic devices
6.  Orthotic devices should emphasize weight transference to arch and soft heel
7.  Gradual introduction to foot strengthening as long as pain is not produced
8.  Frozen Sport Bottle ice roll 2 times a day through arch for gentle stretch and anti-inflammatory
9.  Physical Therapy to strengthen and handle any sore areas typically at 3-4 months
10.  Deep Tissue Massage, like ART, is occasionally needed if the scarring process is too substantial

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Friday, August 15, 2014

Sesamoid Fracture: Email Advice

Hello,

     I was hoping to get some advice from you. I had a stress fracture in my sesamoid bone almost 3 years ago when I was running 45 miles a week. I was in a boot for 8 weeks, took about 1.5 years off of running. I tried running on and off again with orthotics, but the orthotics actually made it worse and I could never run more than a few miles a week.
Dr Blake's comment: There are so many factors that can be considered in making orthotic devices for a patient suffering with sesamoid pain (under the big toe joint). Unfortunately, there can be a lot of art in the process, which can drive patients and health care providers crazy. But, in the end, if everyone is willing to stick with it, a proper device can be designed. These factors/components are:
  1. Amount of arch to use
  2. Amount of stiffness across the ball of the foot 
  3. Amount of dancer's pad to use to off weight sesamoid
  4. Amount of varus cant at the heel (inversion) to center the weight as you push off 
  5. Amount of softness
  6. Amount of stability needed from the shoes versus orthotic devices

     I finally started running consistent mileage in March of this year. I was only running about 12 miles a week and only running every other day. I ran a 10k race and had no pain. I decided to start training for a half marathon. I only made it a few 6 miles runs and my foot pain is back. I was careful to progress slowly and only went up by 10 % each week. I'm assuming it's sesamoiditis or could it be that my fracture never really healed? (I know the blood supply is poor to the area).
Dr Blake's comment: If you do not have the right orthotic in my mind, you are doomed to re-aggravate the sesamoid again and again. Once injured, it can heal, but the original injury shows that it is a vulnerable spot in your body (weak link in the chain!!). I am hopeful that this setback will get you on the road to finding the right orthotic for you. That is paramount!!

     I'm not sure if I should be considering removal of the sesamoid or if it's normal to have flare ups and I should just accept this and when it happens, rest, ice, strengthen calves, etc? My hip has also started to hurt so I can tell that my gait is altered. 
Dr Blake's comment: Removal of the sesamoid without the proper orthotic post op, which is the same orthotic you would use pre-op to hopefully avoid surgery is not a great option. It is done so so often, but there is a reason why your sesamoids are a weak spot. We do not know why it is vulnerable, but it is. You need to find out from your treating docs why it is vulnerable--plantarflexed, over pronation, hallux limitus, etc. 

I should mention that in the past I tried ice massage, contrast bath, orthotics, dancers pads, minimalist shoes, turf toe taping, and that it actually feels better when I'm barefoot (which is different from most people it seems). 
Dr Blake's comment: You bring up a good point. Our biomechanics are different in every environment--shoes, shoes and orthotics, barefoot, etc.  Many problems are related to motion or shock absorption or stiffness. It is up to you and the treating docs/physical therapists to decide how safe you are in various environments with various activities. Some activities are better barefoot, some with shoes, some with shoes and inserts. I hope this helps. Rich
Any information you could give me would be great.

Thanks,

Thursday, August 14, 2014

Lipitor and its Link to Diabetes

Diabetes is on such a rise in the United States with all it's harmful complications. Unfortunately, for those of you who need Lipitor for high cholesterol you may not have a choice. But, it is worth a talk with your internist. 

http://www.hngn.com/articles/38841/20140812/lipitor-causes-diabetes-in-women-pfizer-faces-lawsuits.htm

Wednesday, August 13, 2014

Complex Regional Pain Syndrome: Lessons learned so far

Lessons learned from the treatment of Complex Regional Pain  Syndrome

Dr Rich Blake (podiatrist)
Saint Francis Memorial Hospital, San Francisco, CA

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I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots, and hopefully I can help with direction and technical issues. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, you are scared. The doctors and therapists who treat you are scared for you. The quicker the diagnosis is made and appropriate treatment is started, the better the response, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling co-morbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

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The Mainstays of Treatment are:
·       Identifying Source of Pain
1.      MRI/CT Scans
2.      Bone Scan
3.      Diagnostic Injections (local or into the back)
4.      Nerve Conduction Studies
5.      Lab Tests
           §         Sed Rate
           §         CBC
           §         Free T4 and TSH
           §         Vit B12 and D3 Levels
           §         HgbA1c
           §         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle
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1.     Mechanical Means
           §         Roll A Bout Scooter
           §         AFO (Ankle Foot Orthotic)
           §         Crutches
           §         Tibia Wt Bearing Brace (Freedom Brace or Zero G Types)
           §         Activity Modification
           §         Custom Made Orthotics to stabilize an injured area (Hannaford based orthotic with memory
                      Foam best to start). Some patients can take no arch pressure initially and need some
                      Version of taping to get support.
           §         Taping (Kinesiotape or Support the Foot, but no complete enclosure)
 
2.     Oral Medications
          §         Anti-Seizure (ie Lyrica)
          §         Anti-Depressant (ie Nortriptyline)
          §         Others through Pain Management Specialists
          §         Low Dose Naltrexone (1-4.5 mg/day)
          §         Sublingual Ketamine for flare-ups


3.      Topical Medications/ Applications (gels and lotions best for ease of application)
          §         Warm Compresses
          §         Non Painful Massage
          §         Parafin Wax (Target sells, but heat must feel great)
          §         Chinese Herbs
          §         Lidoderm Patches (especially for sleeping, can be above the sore area)
          §         Neuro-Eze (OTC applied 3 times daily—buy online)
          §         50% DMSO cream 99.9% Pure (mixed with other medicines as below)
          §         Multiple Compounding Medications which include (usually not all of these):
                     ü      Ketamine 10%
                     ü      Clonidine 0.2%
                     ü      Gabapentin 6%
                     ü      Baclofen 2%
                     ü      Nifedipine 2%
                     ü      Lidocaine 2%

4.     Alternative (only in category, very main stream for this condition)
          §         Biofeedback (Thermal to increase circulation)
          §         Hypnosis
          §         Meditation (30 minutes to 1 hour per day)
          §         Acupuncture (can be to opposite limb or ear)
          §         Graded Motor Imagery (laterality flashcards and mirror therapy)
          §         Somatic Experience technique
          

·       Nutritional (next 3-12 months)
1.      Alpha Lipoic Acid 300mg 2x/day
2.      Acety-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B1 (5-30 mg/day)
5.      Vit B6 50mg/day
6.      Vit B12 1000mg/day
7.      Vit E (up to 1,600units/day)
8.      Vitamin C (500 mg/day for 45 days)
9.      Vitamin D 3  (1000 units/day)  --have blood level drawn and get to 45-50 level
10.    Thyroid Natural Supplements

·       Rehabilitation of Limb Function
1.      Lower Extremities (keep strong as long as pain free) Physical Therapist must be skilled in Neuropathic Pain treatment, not just musculo-skeletal.  There are times to Honor Pain and times to Push through Pain, that can change from day to day.
2.      Core (support feet and legs from above with less pressure on feet overall)
3.      Cardio (improve overall circulation and health)
4.      Whole Body (must address physical, emotional, spiritual sides together)
5.      Swimming in a Warm Water Pool is one of the best forms of rehab out there for CRPS
6.      Patient must learn how to avoid triggers (sometimes cold drafts, loud noise, etc).
7.      Patient must have thorough understanding of the concept of neural tension and how to protect the sciatic nerve (or how not to irritate).
8.     Neural Gliding or Flossing 3 times a day with Spine Neutral
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·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal
1.      Part Time Work
2.      Volunteer
3.      Projects

·            Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration
                   ü      American Chronic Pain Association
                   ü      American Academy of Pain Management
                   ü      Reflex Sympathetic Dystrophy Syndrome Association
                   ü      How To Cope With Pain blog
Psychological Workup/Treatment for Biofeedback/Depression/Anxiety

·        Other Important Treatment Options
1.     As the symptoms from the CRPS calms down, focus again may be necessary on the original injury which could serve as a trigger for flares.
2.    Sympathetic Blocks are crucial in the first year, and their effectiveness wanes more and more as time goes on.
3.    Consider Ketamine Infusion and Calmare Pain Therapy (if there are centers in your area) over the more aggressive Spinal Cord Stimulators. Both of these require initial 10 day commitments, but have great potential. 
4.    Neuro Prolotherapy injections are a great help to patients. 

Monday, August 11, 2014

Achilles Tendinitis: Email Advice regarding strengthening and running

Hi Rich;
I'm not up to 100 stretch sessions yet but I'm getting close (at which point I will make another appointment with you).


In the meantime, I just wanted to keep you abreast of what's going on.

I've been running every other day and doing the stretching regularly and leg strengthening exercises faithfully. I am now up to 50 straight leg both legs/25 bent legs, as well as 50/25 on each leg separately. I do, however, break the individual legs into sets. 25 straight leg on my right, 25 on my left, second set of 25 on my right and left, the 25 bent knees on both. My calves really start to burn at about 21 but I have the strength to power through them. I feel like they're really helping me with some burst energy when I run,which is good news.
Dr Blake's comment: I am having this patient each evening do two sided calf raises both straight and bent knee to warm up, and then straight and bent knee single leg calf raises to tolerance (pain in the calf/achilles, or burning. She has slowly worked up to this level. Sounds like she is successfully squeaking in a few more after the burn. She is also doing more since she is breaking them up into 25s for the straight knee. The goal in rehabilitating achilles is to build up to 50 one side straight knee, and 25 one side bent knee. 

This past weekend, I deviated from the "run only every other day" by running two days back to back. I ran 7.5 miles on Saturday at a relatively fast click (for me) and then a little slower on Sunday for 6 miles. I found after yesterday's run that my achilles reminded me that I needed stretching (we sat in the car a while) so I made sure to stretch whenever I could.
This morning, I felt the normal tightness in my achilles, but after my regular morning calf stretch routine it feels completely fine.
Question: I have a half-marathon coming up in 7 weeks and I would like to start being able to incorporate two things:

Running 4 times a week rather than 3
Running longer runs.
I want to get a sense from you whether those would be OK. The 7.5-miler was a test; I felt fine afterwards but I made sure to ice and stretch afterwards.
No crazy big miles for any of the runs but I would like to be able to run at least a couple of 12 milers in the next 5 weeks. Do you think that's reasonable?
By the way, I have started taking a yoga class once a week and I find that it is very helpful.

Thanks.

Dr Blake's comment:

     Sounds great, but you can do the 1/2 marathon better with every other day runs when you are recovering from an injury. That gives you 4 times one week, and 3 the next. It will honor the recovery phase better, and when you are increasing mileage (especially the long runs), it makes a big difference. Hope it makes sense. Keep up the hard work. With 7 weeks to go, run 8 miles the first weekend, 9 miles the next, 10 the next, 11 the next, and 12 the next. You will be more than ready.  Rich

Friday, August 8, 2014

Inverted Orthotic Technique: Email Discussion

Dear Dr Blake,

I am a Bachelor of Podiatry student at the University of Newcastle in Australia. I am in my second last year of the degree and we are presently making your inverted devices.

I just have a question regarding one of the indications or criteria for your devices. In two lots of our notes it states 'NCSP of 8 degrees  or greater'. I don't understand why this would indicate a Blake inverted device, it doesn't seem to  fit with the other criteria. I was hoping you would be able to explain this particular point to me.

Regards,

Dr Blake's comment:

     Thank you so very much for your question. I am happy to answer all questions to this topic so dear to me. Fire away. We will have to look closely in our conversation at what is being said to make sure you and I are on the same page. The way I read what you are saying is that one of the instances of ordering a Blake Inverted Orthotic is if the NCSP (neutral heel position) is 8 degrees inverted or greater. And this is definitely one of the criteria, for it stands for a Highly Inverted Rearfoot Varus. With this foot type, using Root criteria and technique, you must now measure the RCSP (relaxed heel position) and see if it goes to vertical, pronates to the everted side, or stays inverted. When you attempt to control this foot with the Root Technique, you are just trying to stabilize even if the foot can be held near 3-4 inverted (close to neutral position). And it is hard to do this, with typically the foot is held close to vertical. If you think about the importance of neutrality, where the foot and ankle line up, you are actually no where close with the foot pretty pronated (even when inverted slightly). Problems can develop when the patient pronates farther than the device wants them to go. Say you want them to stay around 3 inverted. The patient has a 8 degree inverted NCSP, but the device is made around a pronated 3-4 degree inverted position (the highest inversion in Root Biomechanics). Typically being this far from neutral allows too much instability in the subtalar and midtarsal joints, and the foot can not be held at 3-4 degrees inverted (unless that is the end of the range). 

     In the same scenario, you are using the Blake Inverted Technique to not go from an everted position to vertical, but from vertical to an inverted position (same direction). A 40 Inverted Orthotic Device in a patient with a high degree of Rearfoot Varus, that really can not get to the everted side easily, typically holds the foot 8 degrees inverted (very close to neutral).  My starting point is 35 degrees Inverted, and for a new practitioner probably 25 degrees, but the positioning of these orthotics are so much better than Root since they hold the foot so much closer to neutral. 

     Okay, fire away with more questions now that I have confused you more. Rich

Tuesday, August 5, 2014

Foot Anatomy and Complexity

The Complexity of the Foot   

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    The foot is complex, exciting, puzzling, informative, painful at times, and demanding our respect. 28 little bones per foot, over 100 ligaments, and a bunch of muscles and tendons make this an area the whole profession of Podiatry was formed to help. Countless sports have foot injuries as the #1 area involved, like ballet. Yet, most of the problems can be treated simply, which does not mean without thought. The thought comes from the vast array of problems, which have to be individualized to the patient uniqueness. And it can take awhile to understand each patient with their goals, pain level, activity levels, and demands of work and day to day activities. 98% of the problems seen by specialists in feet are conservatively treated. Sometimes I wish I only could see problems that had to be fixed instantly (as with surgery) to rest my tired brain. But, I am a shadow dweller, a subtlety finder, an explorer, an investigator, an artist more than anything. So the complexity of the foot is a perfect match for someone like me, and there are many more of me. Just look for members of the AAPSM and you will find us loving the 4 major and 1 minor articulation of the cuboid bone for example.

Sunday, August 3, 2014

2nd Metatarsal Fracture: Email Advice

Hi Dr. Blake,
On July 8, 2014, I was filling my car up with gas with the automatic trigger on when the gas nozzle rocketed upwards and then nose dived onto the top of my right foot.
Because the swelling was so severe, the radiologist in the urgent care center did not detect the break on the x-rays taken there.
When I first visited my orthopaedic a few days later, he relied on the urgent care center x-ray and validated the contusion diagnosis.
After noticing that my second toe had lifted and was curving a bit towards my third toe, I returned to my orthopaedic and asked that he take x-rays.  After review, he immediately found that the metatarsal was broken.
One doctor says have surgery.  Another says not to.
I train 5 days a week with a trainer and have run 39 marathons so full use of my foot is critical to me.  I also enjoy running stairs.

I've attached the x-ray that indicates the break and a picture that I took of the hit within minutes at the gas station.
What is your recommendation?

With a heartfelt thank you for honoring Dr. Roy Corbin,
Sharon (name changed)



Dr Blake's response: 

Hey Sharon, how did you know Roy? He was an unbelievable person. I get great joy, and sadness, looking at him every time I open my blog. What a loss!! You definitely have a bad break, which takes a long time to heal conservatively, and yours will heal crooked. I would have that rebroken and fixed once the swelling is gone. With your athletic goals, I would not take a chance at poor healing. The 2nd metatarsal takes the most pressure at the start of push off before the weight is transferred to the big toe. You need this stable and strong. It will heal in 6-8 weeks with surgery and 6-8 months possibly without surgery, even if you get a bone stimulator to use. But, you will need to be off running alot longer than that. I hope this helps. Let me know any thoughts or what happens next. Good Luck. Rich

And the patient's response:

Hey Dr. Blake,

Thank you very much for sharing your expertise.
Dr. Donald Baxter, the famous doctor regarding Baxter's nerve entrapment, examined me last week as I live in Houston, Texas.  He generously spent 45 minutes with me but, at the end, was a bit conflicted so we agreed that the best plan of attack was to seek other experts' opinions.  We were leaning towards surgery but figured waiting another week would not hurt.
I came across your video regarding how to pull back and wrap the second toe.  After watching that video and studying other videos and analyses of cases that you have posted, I felt like an old friend so I emailed you!
Sadly, I did not know Dr. Roy Corbin.  However, since you dedicated your blog to him, I Googled his obituary so I could better understand and appreciate your inspiration.  Alas, after reading such a beautifully written obituary, I do.
Please know that you continuously honor Dr. Corbin by not only dedicating your blog to him but also by helping patients near and far.  Most significantly, you honor him with your thoughts of him and heartfelt actions because of him.
I look forward to updating you later this week.
With my kindest regards,

Top 10 Treatments for Achilles Tendinitis: A Starting Point


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Golden Rule of Foot:  Look at the Achilles Tendon Wrong and it will be sore for 9 months.

Introduction to Achilles Pain

    Treating achilles tendon problems can be very challenging and frustrating. So, it is so important to understand the basic rules of rehabilitation so you can get ahead of the problem as soon as possible. If I was to tell you two things to take to heart regarding achilles injuries, they would be “do not ignore achilles pain for it is not like other injuries, and begin working on controlling the swelling the day before it hurts”. Swelling is the deal breaker with achilles since it cuts off the normal circulation to the tendon and stops any chance of healing in it’s tracks.

    It is so important to know how to stretch the achilles tendon safely. I love the 3 positional achilles stretches I also teach for plantar fasciitis to be done 5 times daily, as long as there is no pain. Stretching the achilles tendon should give you instant and temporary help where you feel better. If this is not the case, you may have an over stretched tendon, a nerve problem, or a partial tear of the tendon (plus a few other things).


The top 10 treatments for achilles tendinitis are:

1. Stretching 3-4 times per day (see chapter 3)
2. Icing 2-3 times per day (see chapter 3)
3. Heel lifts in all flat shoes, or an elevated shoe like Dansko clog or heels/cowboy boots
4. Orthotic devices if over pronating or over supinating
5. Use activity modification to avoid “bad pain” (see post on Good Pain vs Bad Pain)
6. Begin calf strengthening as soon as pain free
7. If cannot walk, you need a removable boot with EvenUp on the other side and probably MRI
8. If symptoms are significant or persist, use PT or acupuncture, but consider an MRI to really see the 3D images.
9. Calf massage with massage sticks (always emphasized if you go to PT)
    10. Avoid activities that are too explosive or over stretch the tendon, or modify activities like
          staying on the seat of the bike in spin class, or not lifting your heel on the elliptical

Below is a few further thoughts on achilles stretching. These are all enclosed in the posts on stretching principles and achilles stretching.

Achilles Stretching Technique

    Proper Stretches for the Achilles Tendon are a vital part of every pre and post activity, and especially with injuries to the achilles, calf, plantar fascia, and hamstrings. There are two muscles, gastrocnemius and soleus, that make up the achilles tendon. These two muscles can be stretched separately by first having the knee straight (gastroc stretch on the left photo above), and then having the knee bent (soleus stretch on the right photo above). It is the back leg that is being stretched. The soleus stretch is being done incorrectly (on purpose) to demonstrate that the heel should be on the ground the whole time. With both stretches, it is important to keep the heel on the ground. Hold each stretch for 30 to 60 seconds, or 8 deep breathes. Deep breathing gets oxygen into the stretch, a good yoga principle. Do not bounce, called ballistic stretching. It is never good to jerk the muscle or stretch through pain. You want that good ache feeling. Try to stretch several times a day to actually gain in flexibility, even on days you do not do your normal activities. When non-athletes complain of cramping in their calves, often low potassium or dehydration is blamed. Have them try stretching 2 or 3 times a day and many will experience complete elimination of the cramps.

Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)




A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. The photo above shows a very powerful achilles and plantar fascial stretch. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch, called Negative Heel Stretching, can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of Foot: Avoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas which will be handled in other posts.




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