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Wednesday, October 22, 2014

Sports Medicine 2014 Lecture Quiz

Here are the questions for the 2 sports medicine lectures by Dr Richard Blake at the California School of Podiatric Sports Medicine October 2014.

1.     What are the 3 Phases of Rehabilitation that patients progress through with any injury? 
2.     When a patient reaches full function, but is still experiencing 0-2 pain, they are considered how much  better?    


3.     When a patient has a sore foot and you can design a foot pad to off weight the area, what is this part of the rehabilitation process called?

____________________ Bearing

     4.  What are the 3 types of pain that patients can experience?

     5.  Gait Evaluation can be the key to the mechanical cause of an injury. What are 5 common categories seen in gait that could be tied to an injury?


     6.  With the "Weakest Link in the Chain" concept, one patient can over pronate and get knee pain, another over pronate and get plantar fasciitis, and another shin splints. What would be 2 other causes of plantar fasciitis other than over pronation that could make it the weakest link in the chain?


     7.  In a sports medicine practice will you see more acute injuries or overuse injuries?
     8.  List 3 common causes of a stress fracture in a runner.


      9.  What do the initials for the KISS principle stand for and how does apply to a patient with pain for 2 weeks in their foot?

A)     K---
B)     I---
C)     S---
D)     S---

     10.  What does PRICE stand for?

A)   P---
B)   R---
C)   I---
D)   C---
E)    E---

     11.  When is pain BAD (versus GOOD)?

     12.  When there is a partial tear of a tendon, what is the grading and is it a sprain or strain?            
                   _Grade __________________________

     13.  Can Achilles Tendon Ruptures be successfully treated without surgery?

     14.  Any time you are dealing with a broken bone what vitamin deficiency should be considered?

     15.  What injury may involve Gerdy's Tubercle?

     16.  What ankle motion is most effected in a High Ankle Sprain?

     17.  Can you stretch the achilles tendon better at the MT junction or at it's attachment?

     18.  How do you strengthen the soleus differently from the gastrocnemius?

     19.  How do you strengthen the peroneus longus differently from the peroneus brevis?

     20.  What is the time difference of an acute vs subacute vs chronic injury?
A)   Acute---
B)   Subacute---
C)   Chronic---

     21.  If a ballerina tends to sickle her foot en pointe (supinate), how can she develop a fibular stress fracture?

     22.  In evaluating leg pain for compartment syndrome, what is the normal resting pressure of a leg compartment?

     23.  In treating runner's knee, what quad muscles needs strengthening and which one stretching?

     24.  When evaluating heel pain, try to initially decide if it is plantar fasciitis. What should be in the differential?


     25)  What area is primarily injured in Turf Toe?

     26)  What are the 3 common positive effects of wearing high heel shoes?


     27)  When watching someone walk, which leg may be longer when dominance to the left side is seen?

     28)  What are 11 common injuries seen related to excessive supination (start at the forefoot and work upward)?


     29)  What are 15 common injuries seen related to excessive pronation (start at the forefoot and work upperward)?


      30)  As you progress from the Immobilization Phase, through the Re-Strengthening Phase, into the Return to Activity Phase of Rehabilitation, a gradual Walk/Run Program can be vital. What is level 5 and level 10 of a 30 minute program?

                    Level 5---

                    Level 10---

     31)   Following an low ankle sprain, what determines how long you wear an ankle brace?

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

     33)  A runner with medial knee pain for 5 days and excessive pronation in gait. What would be 5 KISS type treatments that may resolve the situation that you could recommend at the first visit?


     34)  Athletes in the Return to Activity phase are moved from one drill set to another, each adding time and complexity of movement. The goal is to move towards the skills they need for complete return to their sport. As the complexity increases, and the pain returns, how long in general should you wait to try that activity again?

     35)  What is cast disease?

     36)  When should you start a patient strengthening following an injury?

     37)  Cross Training is vital to keep strength, cardio, emotions, and  flexibility. Would an injured ballet dancer with knee pain get better cross training with running or swimming?

     38)  We are doctors of motion!! Movement is one of the secrets of a quality life. Treat all your patients like athletes in regards to keeping them moving, as long as you do not risk harming them. What would be one difference in treating an 80 year old vs a 40 year old?

     39)  When dispensing a new pair of orthotic devices, why is it important that you watch them walk in them before allowing them out the door? 

     40)  Thank you for allowing me to teach you some things. What does BRISS stand for and how would you use it in posterior tibial tendonitis? 

                      A)   B---
                      B)   R---
                      C)   I---
                      D)   S---

                      E)   S---

Diet for Reducing Nerve Pain's_diet.htm

Sunday, October 19, 2014

Painful 2nd MPJ: Email Advice

Hi Dr. Blake,

I've been reading your blog and was hoping you may be able to offer me some suggestions/advice.  I was diagnosed by my podiatrist ( through Kaiser) that I have capsulitis (2nd Metatarsal).  He also pointed out that I have an unusually long 2nd metatarsal bone and my arch was normal.  I have had 2 cortisone shots.  The first was over a year ago and the 2nd was about 3 months ago.  They both took away the pain on the ball of my foot/toe for about 2-3 months, but the pain is back.  I was trail running about 4 to 5 miles, 5-6 days a week, although I have scaled back to a couple days a week because the days are shorter.  I supplement with a stationary bike.  I also do occasional hikes.  I seem to notice more discomfort/pain following the hikes, maybe due to longer periods on my feet and/or a different stride?
Dr Blake's comment: Definitely, stride and foot placement can be very variable for different sports/activities. For example, many of my patients are surprised when they can run long distances, but can not walk one street block without pain. Of course, there are also many variables in the terrain with hiking and trail running. Sometimes, runners/hikers can walk up but not down, or soft surface is okay, and rocky terrain not. 

I have also tested different orthotics along with metatarsal pads.  I'm not sure if any of this is helping, although the metatarsal pads may be helping a bit and seem to make the most sense.
Budin Splint with Met Pad for a Painful 2nd MPJ

Combination of 2 different Hapads to off weight sore area

Longitudinal Metatarsal Small Hapad to off weight sore metatarsal

Example of various combinations of pads needed to alleviate pain

With a painful 2nd MPJ, you can get relief with the Budin splint over the 2nd toe, over the 3rd toe, or over the 2nd and 3rd toes combined. Experimentation needed. Start with light tension. 

Dr Blake's comment: Definitely metatarsal pads are a direct help by off weighting. Daily ice massage for 5 minutes 3 times is helpful. Try to purchase some single loop Budin splints to immobilize the 2 and/or 2/3 Metatarsal Joints. Also try to off weight the sore area with 1/8th inch adhesive felt you can purchase from

After doing some more of my own research, I have read up on taping.  The last couple of days I have taped my 2nd toe down by putting tape on the bottom of my foot and wrapping around the 2nd toe which holds it down.  The other taping technique that I read was to tape my 2nd toe to my 3rd toe in order to stabilize.  Do you feel that I should be doing either of these, or possibly both of these taping methods at the same time?  I haven't tried running with the tape yet, but was next.
Dr Blake's comment: The Budin Splint would do just that when looping over the 2nd and 3rd toes combined. When running with the budin splint, it typically has to be a little looser than just walking around. I do have patients who prefer tape to budin splints. 

I have also noticed that my 2nd toe seems to be drifting towards my big toe.  I'm not sure if that is do to inflammation.  I noticed this before I had the last cortisone shot as well, but it appeared to go away after the shot.
Dr Blake's comment: Usually the injury you are describing is a version of a plantar plate tear to the base of the joint. The tear is never directly centered, so if it involves the part of the ligament closest to the big toe, the toe will drift towards the 3rd toe and vice versa. The toe typically moves upward and a hammertoe develops. 

I have actually seen 2 podiatrists through Kaiser and have received completely different advice from both.  One of them actually supplied me with heel pads, anti-inflammatory pills, and suggested using the insoles that came with my shoes and not using orthotics.  In all of my own research, I haven't seen heel pads as a recommended approach.
Dr Blake's comment: I agree, heel lifts and even orthotics can be in the wrong direction if they transfer weight into the forefoot (the injured area). Here is one of my videos on hammertoes explaining met pads, met doming, and stretches to be done.

Help?!  Any advice/recommendation is appreciated.

Bill (name changed)

Recurring Sesamoid Fractures: Email Advice

Dr Blake,
I have had 3 different sesamoid fractures in 1 1/2 years.  One on left foot, one on right foot, then this morning my podiatrist told me my left was fractured again in the same place.  I was given clearance the first time so this is a new break.  I'm thinking this is due to a very high arch putting excessive pressure through my sesamoids. 
Dr Blake's comment: Definitely high arches can place more pressure on the sesamoids due to the downward positioning of the first metatarsal (more downward than in a flat foot). Designing orthotics for sesamoid injuries is difficult at times due to this situation. Sometimes the best orthotic is more on the line of the full length Hannaford style which evens the playing field better. 

 There was not any act in which would have caused this.  It slowly began to hurt and swell.  It got worse and by the second week I was at my podiatrist receiving the news that it was fractured again. 
Dr Blake's comment: It can be very difficult to make this call. The original injury probably caused some irregularity in the appearence of the sesamoid. This irregularity can look like a separation of fragments, even though there is solid internally healing. Also, Golden Rule of Foot: It is hard to break a bone in the same place a second time. This is due to the fact that bones typically "double heal" or get twice as strong as they were originally. So, a word of caution about rushing ahead on any surgery. 

 My dr suggested removing one of the pieces as he does not feel it will heal completely or if it does that the fracture is likely to happen again given the way this one happened.  They are putting me on the schedule to have a partial sesamoidectomy.  I'm fine with this as I do not want to fight this breaking for no apparent reason for the rest of my life. 
Dr Blake's comment: I have only seen only partial sesamoidectomy in my life, so I am not a judge. It did not help the problem, but my comment is not anyway scientific. I would be thinking complete removal of the involved sesamoid, or no surgery until the biomechanics of your high arches were addressed. Without the biomechanics being adequately with inserts so that you feel you have no to minimal pressure on the sesamoids, you will have one surgery, then another, and then perhaps more. 

 I have a few questions given my story.
Is it normal to break a sesamoid in TWO DIFFERENT FEET?
Dr Blake's comment: Yes, and it points to a biomechanical predisposition that you want/need to correct. And yes, there are also surgical treatments for this predisposition, if the predisposition can be eliminated. Typically, non surgical avenues can be explored with complete success. 

Is it normal to break the same sesamoid twice?
Dr Blake's comment: No, but it may have never healed completely in the first place, or the underlying predisposition never corrected. That could be foot biomechanics, shoes, diet, Vit D deficiencies, running style, etc. We look at all causes of bone injury, attempt to reverse/correct all these factors, and this is why it is hard to break the same bone twice. That being said I do have my failures also when I did not recognize a problem, say Vit D deficiency, or the patient did not say on track at correcting the problem, or I forgot to tell the patient their need for the corrective orthotics was a life long committment, or the correction of the problem was difficult to do and we hoped the bone would not break again. 

Would you suggest a different option?
Dr Blake's comment: See above, definitely do three things:
  1. Treat this sesamoid fracture conservatively like you treated the first one
  2. Have the biomechanics of your high arch feet, and all causes of bone weakness addressed.
  3. Get a bone stimulator to use for the next 6 months (I love Exogen since it is 20 minutes per day)

How long can I expect to be back to a normal gait, and pain level?
Dr Blake's comment: Of course this depends on surgery or no surgery.

It is extremely swollen and painful now.  How can I relieve some of the pressure?  I am in a walking boot and ice twice a day and take naproxen to help inflammation.
Dr Blake's comment: Definitely add crutches or in boot accommodations to float the sesamoid to achieve a 0-2 pain level with your protected weight bearing. You should add the Exogen bone stimulator, and do daily contrast baths for deep flushing. You should have you internist look for Vit D deficiency and perhaps a bone density test should be ordered. 

Should I get a second opinion?  I am very comfortable in the surgical route given my dr has been working with me for a year and a half.
Dr Blake's comment: Yes, I love our foot surgeon, Dr Remy Ardizzone, but I always think patients should get a 2nd opinion, and not from someone in the same group. I would look at the member list of the AAPSM (American Academy of Podiatric Sports Medicine) for a referral near you. This does not mean you have to switch. You just want another smart person to give you an opinion. I tell my patients never to tell the 2nd opinion doc what the first doc says. Make it a true 2nd opinion. Just tell them your scenario, and that you wnat there advice on what to do from here. 

I have read about pt after these surgeries on your site but should it be the same for me with a partial instead of a full? 
Dr Blake's comment: Again, I claim lack of valuable knowledge.

Could I have a deficiency causing weak bones?
Dr Blake's comment: Yes!!!!

I'm a very active 31 yr old male with a 4 year old who loves to play sports.  I just want to be back to functioning without extreme pain.
Dr Blake's comment: As a father of 2 boys, I feel your pain and understand. I hope this helps you. 
Lawrence (Name changed due to witness protection)

Wednesday, October 15, 2014

Biomechanics 3: Sports Medicine Summary 2014


First of all: Go Giants!!!

The following information will form the core of my 2 lectures at the California School of Podiatric Medicine at Samuel Merritt Universitty in Oakland California October 2014. Each lecture is 2 hours in length. The links to my blog and the questions in red are for your advanced learning. If you can go through it all by yourself, or in groups, you will have a good understanding of some of the basic concepts of sports medicine.

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

These include:
  • Introduction to Sports Medicine
  • General Definitions of Injuries 
  • Specific Discussion of Injuries 
  • Generalization on Gait and Role of Mechanics on Injuries 
  • Podiatrist as Part of a Sports Medicine TEAM 
  • Further General Rehab Thoughts 
                                                                  Introduction to Sports Medicine

Sports Medicine vs Normal Orthopedic Medicine

Sports Medicine: Team Centered with everyone equal weight over the course of the treatment
Normal Orthopedic Medicine: Doctor Centered directly treatment

Sports Medicine is an incredibly fun way to practice medicine. The goal is to keep the athlete going without risking damage. With most surgeries in sports medicine elective, many alternatives to surgery (at least as a stop gap) exist. Sports Medicine approaches for some injuries have eliminated many surgeries, and some would have been career ending. In essence, it is a Team approach where the patient, doctor, therapist, coach are all very active participants. It is not Top Heavy, with the traditional doc directing the treatment completely. It is not drug oriented and not surgery oriented. The patients are a lot more informed, and have most of the work to do. A typical sports medicine patient is spending a lot of time trying to get better with the following treatment areas:

  1. Strengthening
  2. Stretching
  3. Anti-Inflammatory (icing, contrasts, etc)
  4. Shoe Changes
  5. Shoe Inserts
  6. Physical Therapy
  7. Gait Changes or Sport Technique Changes
  8. Other Areas like Acupuncture, Chiropractic, Bodywork, etc
  9. Herbal Remedies over NSAIDs
  10. Second/Third Opinions

3 Phases of Rehabilitation 

But, to get us going in our discussion let us talk about some generalizations based on a patient presenting with heel pain. First of all, you want to always place a patient, new or returning, into their appropriate Phase of Rehabilitation: Immobilization Phase, Restrengthening Phase or Return to Activity Phase. This is huge, and can change from visit to visit based on reflares, etc. 
     Here are 3 patients with heel pain. 
  1. Heel hurts at 3 miles into running and a lot each am.  Which Phase?
  2. Heel hurts with every step all day long.  Which Phase?
  3. Heel hurts in bed, when doing certain exercise, and sometimes not at all.  Which Phase?
Which of these 3 patients can continue to run?
Which of these patients most likely needs an MRI?
Which of these patients is most likely to have neuropathic pain?

Magic 80% Rule

The 80% Rule (also known as the 80/20 Rule) directs the rehabilitation of an athlete as it is the ideal balance between the pain scale

Concepts of Protected Weight Bearing in the Immobilization Phase and Good Pain/Bad Pain

This is where podiatry excels. When patients have pain with weight bearing, you need to get that pain to a 0-2 level. This is considered Good Pain, and the goal of most treatments. It must be achieved, and maintained during the rehabilitation process for ultimate success. Protected weight bearing with pads, orthotics, shoegear, removable boots, wedges, etc, can be the difference between success and failure. A situation may demand a removable boot, but you must make sure that the boot achieves what it is designed to do, driving down the pain into an acceptable Good Pain level. The more weight bearing without pushing the pain into the Bad levels (3-10) that less swelling, the better muscle, ligament, and bone strength is maintained, the faster the overall rehabilitation. Non weight bearing an injury is necessary at times, but always try to have protected weight bearing as the drug of choice.

3 Types of Pain

It is important that you also need to deal constantly with the 3 types of pain, and there different treatments,  that can be difficult to figure out. These are:
  1. Mechanical
  2. Inflammatory
  3. Neuropathic

Role of Gait Evaluation to look for Mechanical Causes or Aggravating Factors

Some patients will present with one, two, or all 3 types of pain all at once. It could have started Mechanically Induced, but developed an inflammatory and neuropathic side. Podiatry is wonderful at dealing with the mechanics on the lower extremity that causes injuries, but you need to know where the stresses go when you fit into one of these categories which can be screened on a good Gait Evaluation. I am always looking for an mechanical cause or aggravating factor that I can change to help a patient. 
  1. Over Pronation
  2. Over Supination
  3. Poor Shock Absorption
  4. Tight Muscles
  5. Weak Muscles
  6. Limb Length Discrepancy
  7. Miscellaneous Abnormalities (for example, pre and post hip replacements, or varus thrust at the knee)
Weakest Link in the Chain 

I personally continue to work on the mechanics, while seeing if inflammatory treatments help. Neuropathic problems, like double crush and radiculopathy, are probably the most misdiagnosed. It is important to understand the concept of "Weakest Link in the Chain" for one patient who over pronates injures the plantar fascia, another the posterior tibial tendon, and another develops "Runner's Knee". The mechanical fault is the over pronation, but some one or two other factors have lead to the pain showing up in the foot, ankle, or knee.

The Law of Parsimony

The parsimony principle is basic to all science and tells us to choose the simplest scientific explanation that fits (all) of the observed evidence. Amazing how often this is ignored in medicine. We go after looking for a zebra when 5 horses stand in front of us. Learn how this law applies to every injury you treat.

  • Achilles Tendinitis: Tight Achilles Tendons
  • Plantar Fasciitis: Over Pronation
  • Metatarsal Stress Fracture: Poor Shock Absorption
  • Morton's Neuroma: Tight Shoegear
Role of Physical Examination Findings

What is the significance if there is swelling, ecchymosis, limping, stiffness, weakness? The body gives us many clues to help treat a patient. Do not ignore these signs. While you may want to wait for the results of some test, always treat what you find. Many injuries heal within weeks of onset, but the resultant weakness, gait changes, swelling, stiffness, etc, can lead to months and months of more problems. And when you see signs of any inflammation, be aggressive at attacking it. I love icing and contrast bathing to bring down swelling. Physical Therapy and Acupuncture are also great helps for you in this area, along with NSAIDs and herbal remedies like tumeric, and avoiding inflammatory foods (like tomatoes, peppers, etc)

Overuse 95% of Injuries in Sports Medicine 

Most injuries you will treat are overuse as a sports medicine specialist, different than acute, and very important to make sure you know which one it is. Acute can have one cause, overuse I always look for 3 causes. So, in your podiatry training, you need to learn the top 5 overuse causes of any injury. For example, when you make the diagnosis of a stress fracture in a runner, what are 5 common causes in this overuse situation.
  1. Overtraining
  2. Poor Shoe Shock Absorption or Stability
  3. Deficient Vitamin D or Calcium in their diet
  4. Poor surrounding muscle strength for protection
  5. Biomechanics that set up the injury (ie. supinators get fibular stress fractures and pronators get tibial stress fractures).
KISS  (Keep It Simple Stupid) and Implied Need

We are in an age of high tech, but KISS is typically the starting point of treat. It probably is not the big money maker for a practice, so ignored too often. There is also a concept of Implied Need, sometimes real, sometimes not, but typically should be honored. Implied Need can come from the patient or doctor. If we were to categorize injuries by need, they would be mild, moderate, or severe. 
So much depends on your experience, but your patients can help you. Is this an injury that KISS applies or should we pull out the big guns right away, or something in between.

Because of KISS, I am a big believer in learning the simply tools that can help. Many believe I am an expert on custom made orthotics, but because so many of my patients need KISS principles, I am also need to be an expert on OTC arch supports. 

Levels of Complexity in all Treatment and all Problems  

So, before we get into the solid aspects of the lecture, try to learn topics in 3 levels: Simple, Moderate Complexity, Complex. Most sports medicine doctors know the complexity of surgery, but only the simple forms of teaching strengthening, flexibility, orthotic therapy, rehabilitation. Each aspect of treatment has these various levels that you will need to learn. I learned early on in sports medicine, a simple change in one treatment variable can be the difference between success and failure. 

Pros and Cons of Protocols

I abhor protocols. I have seen terrible protocols set by insurance companies, and I ignore them. If an insurance company, or HMO, does not cover a treatment option that is valid, they should tell there patients. I inform my patients if their insurance company will not cover something I think is important or crucial to their getting well. You have to be brave to fight the insurance battles. However, you will have initial protocols to treat things, you just need to be able to change them when the patient is not responding.

Golden Rules of Foot

I would be remiss to not mention the Golden Rules of Foot. These are the Rules I learn by. I accept that they can give me some element of tunnel vision in some cases. But, Golden Rules are different then other rules, they are not to be broken. They are on that level. If I can teach anything to students of deep meaning, it is to develop your own Golden Rules. Typically, they are not merely guidelines, but solid rules of the podiatry landscape. I have 100 of them or so. After practicing medicine for 35 years, that means I developed 3 a year. They should be from your medical soul.

One example: Golden Rule of Foot: In treating heel pain, the orthotics prescribed should be borderline obnoxious in the arch to transfer weight adequately. 

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

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

Acute Injuries --- Generalizations: When is an injury acute, sub acute, or chronic?  
  • Happened within last 2 weeks (if not, they are sub acute up to 2 months, and chronic after 2 months)
  • Understand Good History Taking (have a consistent system of questions).
  • Understand PRICE       What are the goals of PRICE?

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

Chronic Injuries--what most of your patients will be dealing with. Injuries over 2 months old.   What is a Plateau in Symptoms?
  • Understand Magic 80% Rule              What does 80% better mean to an athlete?
  • Understand Good Pain vs Bad Pain Principle
  • Understand the KISS Principle

Sprains  What is the difference between sprains and strains?
  • How are they subdivided?
First Degree--ligaments stretched (no obvious ecchymosis on exam)
Second Degree--ligaments partially torn (some ecchymosis) Why do 2nd degree sprains hurt more than 3rd degree sprains at times?
Third Degree--ligaments torn completely (significant ecchymosis on exam)

Why can some ankle sprains, without breaks or tears, take 2 to 3 years to heal?
  • The ligaments do not repair on their own!!            Why are most ankle sprains not casted acutely?
  • Strength must replace loss in ligament integrity       What is the Romberg's Test for ankle instability?

When balancing on one foot, how long do want to do it for?

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

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

 What do the initials stand for in tendinitis treatment?

Overuse Injuries      What are some possible etiologies?
  • The general concept is the the tissue injured is stressed higher than its breaking point (tissue threshold) and it either strains, sprains, breaks (like bones), or gets irritated (like nerves).
  • Always think and investigate 3 causes of any overuse injury    What are 3 common causes of plantar fasciitis?  What are 3 common causes of achilles tendonitis? What are 3 common causes of metatarsal stress fractures?
  • How we overuse something, and cause it to hurt, can be varied, but usually predictable (see the Law of Parsimony)

What is the Law of Parsimony? How does it fit into the KISS Principle?

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

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

 What is the daily recommended dose of Vit D3?

 When do you place a patient with a stress fracture in a removable cast?

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

 What are the 6 basic types of strengthening exercises? What type is a calf raise on one foot?

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

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

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

With limb dominance seen in Short Leg Syndrome, which side tends to get the ilio-tibial band strain?

What areas do you avoid while stretching the IT Band with an Ethafoam Roller?

Lateral Ankle Sprain:
  • Probably the most common traumatic injury affecting the foot and ankle (so master this one).
  • When a patient presents with an ankle sprain, decide if it is a high ankle sprain, low ankle sprain, rearfoot sprain, or midfoot sprain. What is a High Ankle Sprain?
  • Understand the mechanism of injury, and the force of the injury, to understand the possible problems created by the injury (including fractures).
  • An inversion sprain without a fall is better, an inversion sprain without rotation is better, an inversion sprain without coming down from a jump is better, an inversion sprain without someone landing on you is better. It is all about forces. Understand the forces generated by any sprain to predict severity.
  • There is no right or wrong on xrays or MRIs. If it is black and blue, it means something tore or broke, so xray at least. If you think a tendon is torn, MRI immediately. If the patient still can not walk in 2 weeeks after a sprain, even with a removable boot, get an MRI.
  • Followup on ankle sprains is every 2 weeks. They should get better and better. If the patient plateaus, change something in the rehab, get a test, something.
  • With the average ankle sprain, receiving average treatment, some symptoms of pain occur for 3 and 1/2 months, and swelling for 4 and 1/2 months. Return to running with an ankle brace can occur as early as two weeks. But, no limping is allowed. How long do you use just ice?
  • As will be stressed in the links below, it is so important to restrengthen the ankle for around 3 months to avoid reinjury. Usually the next ankle sprain is worse. While restrengthening, you must get a brace to stabilize the ankle in vulnerable activities.

What is one example for getting an MRI after a common ankle sprain?

 How is the Peroneus Longus strengthened differently than the Peroneus Brevis?

 What is the reason some exercises should be done with your eyes closed?

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

What is the 3 areas of treatment for plantar fasciitis?

 How do you strengthen the soleus differently than the gastrocnemius?

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

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

 What are the 11 common factors that can make an area the weak link in the chain?

 What are the 10 common treatments for shin splints?

 What are the 4 basic types of shin splints?
What is Compartment Syndrome?
  • The compartments are fascial enclosures which house several muscles. There are 4 compartments in the foot and 4 in the lower leg. The fascia which covers the muscles can be too tight for the amount of muscle hypertrophy or swelling within the compartment. As pressure builds up within the compartment, the fascia does not give enough, and the blood circulation in the compartment is restricted (the walls of the vessels are compressed due to this pressure).
  • Acute Compartment Syndrome, normally produced by a blow to the outside of a compartment, is caused by the swelling in the compartment, and is a medical emergency. A compartment release is crucial to save the muscles from dying.
  • Chronic Exertional Compartment Syndrome can be a diagnostic nightmare. Injuries in the foot or leg that seem to have a solid limit of activity (the pain can only run 3 miles before the leg pain gets bad) may be compartment syndrome. Compartment syndrome has always been a surgical treatment, but with deep tissue work, there is a promise in the future of conservative management.
  • Diagnosis of Compartment Syndrome is needle catheter in the compartment to measure the pressure. Normal resting pressures are between 0-4 mmHg. Pressures that climb above 40 mmHg and stay there after activity is stopped is considered compartment syndrome. What do you think happens to the muscle strength in a compartment that has a release?
Patello-Femoral Pain:
  • Also called Runner's Knee, Biker's Knee, Dancer's Knee
  • Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc...
  • Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation.

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

 When stretching the right quadriceps, it is best to use your right or left hand?

 What is Malacious Malalignment Syndrome and how does it relate to knee pain?

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

 2 months of treatment for plantar fasciitis and the patient is not getting better, should surgery be considered next?

 True or False. After a plantar fascial tear period of cast immobilization, there is no need for physical therapy?

 What are 3 common adjustments made to sleeping splints?

 What are the 2 most important aspects of an orthotic device for heel pain from plantar fasciitis?

What is the common denominator in all 3 stretches demonstrated?

What is the difference between counting as you stretch, and taking deep breathes?

 If you ice for 5 minutes, how long does it take to have your soft tissues thaw out?

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

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

 What type of tape is typically used to limit first toe dorsiflexion?

 Can a Budin Splint be used for a first toe injury?

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

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

 What are the 5 common categories of mechanical problems seen in gait?

 What are 3 common knee symptoms sometimes related to excessive pronation?

What are 2  foot injuries associated with excessive supination?

 If the right shoulder dropped lower than the left in gait evaluation, what leg is normally longer in an adult?

 Is squinting patellae associated with genu varum or genu valgum?

 When dispensing a new pair of orthotic devices, why is it important to evaluate their gait?

 What are 3 positives of high heel fashion shoes?

Where should your center of gravity be while running?

 What is limb dominance seen in gait?

 How is a decrease in limb dominance achieved?

 What are the 11 common injuries related to excessive supination?

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

As you treat injuries from different sports, gradually learn about that sport. If a ballerina comes in with an injury, learn alittle each time about her sport. What are the main producers of pointe shoes?

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

5) What are other General Rehabilitation Thoughts

What are the general concepts in Injury Rehabilitation around return to activity?
  • Since most athletic activities are based around running, a good understanding of the walk run program is crucial.

 What are the 10 levels of a Walk/Run Program?

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

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

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

 What is Cast Disease?

What are the general concepts around footwear considerations?
  • Footwear is podiatry. And one person's best shoe ever, hurts another. Analyzing the qualities of shoes can and is as important as analyzing the patient's biomechanics.

 What is to practice Excessive Happiness?

 What are 11 reasons that the treatment plantar fasciitis can be different in all the patients you see?

 Why must the patient be encouraged to follow up with the doctor/therapist so that they are aware of their progress?

 What are the 2 categories of injury based on severity? And how is there overall success of treatment different?

 If you restart running, but pain returns, how long in general should you wait to try running again?

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

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

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