This is a great review of taking care of ourselves with the Outbreak!!

https://boomerbenefits.com/coronavirus-medicare-and-telemedicine/

Foot Nerve Pain can come from the Back: And it is alittle confusing!

https://youtu.be/E0E60NpOSHg

As a podiatrist, I deal with pain all the time. The 3 types of pain with sometimes different treatments are mechanical pain (produced by mechanics or treated by mechanical changes), inflammatory pain (caused by inflammation or treated with anti-inflammatory measures), and neuropathic pain (caused by nerve problems or treated with neuropathic treatments). The article below is very good explaining how a disc herniation or bulge can affect the nerves into the foot, and that there is some innervation cross over. This cross over means that the same problem can actually affect 2 nerves, not one as my video describes. It is because at each disc level there is an exiting nerve and transversing nerve. For example, at L4L5 disc, the disc between the vertebrae lumbar 4 and vertebrae lumbar 5 has L4 nerve root exiting and L5 nerve root transversing (and will exit at the L5S1 disc). And, just to make matters even more confusing, a disc herniation on one side can give you symptoms on the other side. When I am talking to patients about their right foot pain for example, I always ask if they have sciatica or low back pain, and other spinal cord symptoms. So many patients that have nerve pain in one foot, have all their back symptoms on the other side. I wish I could tell you the percentage, but it is not rare. I hope this video, and article, will give you a better idea of how this process works, but it is so important in the treatment.

https://www.spine-health.com/conditions/spine-anatomy/radiculopathy-radiculitis-and-radicular-pain

Plantar Fasciitis Bothering You: Here some helpful tips.

Hi Rich,

How are you faring in this terrible and scary time?

I've developed plantar fasciatis  in my left foot (in addition to the other
leg ailments -sciatica and shin splints).   Would you be able to give me
some guidance?

Kind regards,

Dr. Blake's response: 

There is a tape to buy called Quick Tape. It is ordered at www.supportthefoot.com

You should buy 3 and wear one week at a time and see if it helps.

Try 5 minute ice roll with a frozen sports bottle. I will send you a  couple links. 

Be safe my friend. Rich 

Plantar Fasciitis:General Principles of Treatment

Plantar Fascial Treatment Protocol based on Implied Need

Can Journaling Help to Release Physical Pain? A Nice Podcast

     We all know that chronic pain can become unbearable. This wonderful Podcast from the Curable Company discusses how journaling your pain can allow you some control of it lessening its impact on you. I hope you are helped by this and please consider looking into the Curable app. Rich

journaling-and-physical-pain

Dr. Kevin Kirby on Force: Great Video Presentation

https://youtu.be/qeYWMjTXNf0

The First Patient with the Inverted Orthotic Technique

https://youtu.be/TNGR9XqvNEQ

Let us Be Together while we are Separate!! Enjoy!!

https://youtu.be/Vej5nc8WqKQ

Injury Rehabilitation: When is it safe to run or go back to my sport?

Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time as functioning improves. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. 

Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden, or non weight bearing on crutches or Roll-A-Bout/scooter

20 to 40% from beginning to bear weight with the help of crutches to no crutches needed (normally needs removable boot/cast). There will be some initial cross training.

40 to 60% Gradually feeling less pain with walking with or without boot (walking slow). This stage the patient is really finding what activities they can cross train without pain (typically bike, elliptical, swimming, some weights, many other forms of exercise).

60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball (many free throws!!), and flareups are common as the patient tests the waters.

80% Passed the 30 minute hard walk test without setback, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity. 

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can still be filled with flares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation. So you do not have to wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely.

The above is an excerpt from my book “Secrets to Keep Moving: A Guide from a Podiatrist”.

Turf Toe with AVN Sesamoid: Email Correspondence

     I have had a 2 plus month relationship with this patient after she first contacted me around January 3rd, 2020. I have given her advice and had her send her images on a CD to me. Below in red is a note I sent her in February. The original injury was early September 2019 playing ultimate frisbee in cleats. No acute incident happened. Late October 2019 X-ray which was negative except bi-partite fibular sesamoid. Late November 2019 MRI documenting AVN fibular sesamoid, intersesamoid ligament tear and lateral collateral ligament suspected tear. Podiatrist at that time wanted to do surgery, but she wanted another option. Shockwave for the sesamoid flared her up with significant swelling. She went on crutches, and started reading my blog early December for advice. She was able to calm it down with the crutches, contrast bathing, etc. 

Thanks for the update. Just went down and had a wonderful discussion with one of our radiologists who went over the joint with a fine tooth comb for me. Most of this we know, but she added a twist. Her findings were:

• Fractured fibular sesamoid with AVN 
• Stretched or torn ligament from the sesamoids to the base of the toe (places the sesamoids in the wrong position)
• Torn and partially healed ligament between the sesamoids (moving the fibular sesamoid laterally too far)
• Partially torn lateral collateral ligament with adhesions to the base of the first metatarsal causing chronic irritation (this is the part I did not appreciate)

So basically the sesamoid lost its blood supply (which we are trying to bring back with contrasts and bone stim), but it is also stuck down in the wrong position so motion of the joint is painful. 

Time will heal the ligaments more, so that part of the course is fine.

The questions are will the AVN come back (only another MRI in 6-8 months will tell us if our direction is solid). But even if it comes back, will it be stuck down (like a frozen shoulder is stuck in the wrong position and people can not comb their hair) too much, that PT will not be able to rehab? Alot of unknowns. I will help you with them. Watch my video on self mobilization for hallux rigidus on you tube under drblakeshealingsole self mob and start doing that twice daily. Rich

https://youtu.be/FBTeWbdGrzs

The Patient's Response today March 23rd, 2020.
Hi Richard,

It's been a month, and I wanted to give you an update on my situation! I apologize for not getting back sooner, but things have been completely crazy with the coronavirus situation. I'm adjusting to this new life. I hope you are doing well and that your business is not too impacted by the current situation! I imagine that your hospital is bracing for impact...

Dr. Blake's comment: Thanks for the good thoughts. I am in an outpatient clinic within the hospital so we are completely shut down and it may be for a long time. Trying to learn Zoom video so I can use Telemedicine some. Hard to give my patients orthotics and adjust them via the internet however. LOL. Hope you are well and practicing good social distancing!

So, here goes on the update - as a reminder, I'm the girl with the case of turf toe + AVN of the medial sesamoid. :-)

• Overall, I've been experiencing an incredible improvement that began towards the last week of February. The last 3-4 weeks have truly been a blessing and I'm starting to get my life back. It's strange that this would happen at a time where many are losing their lives, but that is the cruelty of life sometimes, I guess.
• I got off crutches and started to be able to walk for 10-15 minutes mid-February or so. Following that, I've been improving every day.
• I attribute a lot of my improvement to having gone to Physical Therapy over the last 3 weeks. He has truly helped me in actually pushing me to do a little more than what I thought I could. We do massages to decrease the swelling, but also strengthening barefoot on the ground and I even have graduated to doing small heel raises barefoot, which I am coping with very well!
• I have been able to take walks for longer and longer, (cluffy wedges have helped my toe mobility and gave me a further boost). I've finally managed to get back on my road bike using my clip-on shoes, which is just amazing. I used to swim a lot, but the pools have closed for the moment.
• I'm continuing the Exogen Bone Stimulator, along with PT, and revving up my walking and exercising. 

Dr. Blake's comment: I am so happy for you. By creating the 0-2 pain level, and gradually adding stress to the tissue, it sounds like it is responding well. So many of my patients need a PT which sees them at least once a week to gently but progressively move them along. Rich

My questions are quite straightforward at this point:

1. How slow or fast should my recovery go at this point? Am I doing too much? I'm trying to be really, really, careful, but I find that doing just a little more than what I'm used to helps bring me to the next threshold of recovery. Like, I need to feel a bit of pain, but not too much. Dr. Blake's comment: 0-2 pain which is very healthy is still pain. Yes, you will have pain as you do something that you think you are ready for but was not. You should take 2 steps forward, 1/2 step back at times. Each month should show improvement (sounds like you are much better than last month February). Just go with the rehabilitation gradually, do not think about time tables.
2. Is it possible that I am improving so much but that my bone is still dying? I will get a second MRI in May (at the 6-month mark) - what if my bone is still suffering from AVN? Will I need it removed even if my symptoms are almost none at that point?Dr. Blake's comment: The MRI is for some judgement of how the healing is going. Surgery must be matched up with disability. There is no reason to consider surgery if you have a non painful AVN. I am hoping the bone recovers. You made need another MRI summer of 2021. Your pain has always been from the injury, the inflammation, and probably nerve hypersensitivity. You are working on everything which needs gradual stress applied week by week. No more than 10% more each week, and you should be on the 48 hour recovery between the highest stresses. 

Thanks so much for all your help.

Kind regards and good luck with the current situation. My thoughts and prayers to you and your family. Stay safe and healthy! And you!

Self Quarantine Choir: Amazing!!

https://youtu.be/BumCkswUUDA

Sesamoid Transitioning Post from Boot to Real Life and Sesamoid Off Weighting Platforms

     This was a good post on thoughts for going from boot to shoes and orthotic devices. It is also good for the image of a sesamoid platform, you can used books also, to begin single leg work in re-strengthening. Rich 

transitioning-from-one-restriction-to.html

Foot Types, Asymmetry between Feet: Article by Dr. McPoil

     As I am researching for a book I am writing, I came across this good paper by the prolific writer/researcher Dr. Thomas McPoil. He discusses the variations that he sees which are similar to my findings over the years. Each one of these variations from ideal (or Normal as termed by Dr Merton Root) can and do cause symptoms due to the changes in gait that they cause. The findings were: 8.6% Forefoot Varus (this seemed low), 44.8% FF Valgus, 14.7% Plantar Flexed First Ray, 98% Tibial Varum (this seems high), and 84% Subtalar Varus. One of the important points that the paper shows that only 69% of the patients were symmetrical in deformity or variation. That is the patients showed over 30% that one foot was totally different to the other. This is found routinely in our clinic and is magnified by other reasons for asymmetry like: right or left handed, old injuries, running or walking styles, the affect of shoe gear on the force of abnormal motion on each side, etc. So, as podiatrist, we have a lot of work to do at evening out these asymmetries. Rich

https://www.jospt.org/doi/10.2519/jospt.1988.9.12.406

Tissue Stress Theory by Drs McPoil and Hunt

     This is a wonderful paper from 1995 that introduced a wonderful concept of the Load Deformation Curve to foot mechanics that was the centerpiece of a new theory of taking care of overuse injuries called Tissue Stress Theory. I believe the author spent too much time ridiculing the Root Theory to try to make his point, when the Tissue Stress Theory can stand on its own. Both theories are well founded, and can be used in treating patients. I use Root Theories all the time, and I use Tissue Stress Theory all the time. To me, they are different. Today I will not talk about Root, but talk to you about the basic concepts of the Tissue Stress Theory. I would read only the later part of the paper when the Tissue Stress Theory is discussed, unless you want to go to town on Dr. Root's Normal and Abnormal Function of the Foot Theories. Rich
PS. Dr. Root was a teacher who used the word "Normal" as "Ideal" or non injury producing, and "Abnormal" as "Pathological" or possibly injury producing. This has brought confusion to the biomechanics world at first glance, but once you understand that it seems easier to grasp.

https://www.ncbi.nlm.nih.gov/pubmed/7655482

Here are the Steps to using the Tissue Stress Theory, which when it was published in 1995, was a common treatment method for overuse injuries that are still used today.

1) Identify structures stressed (by history and symptoms)
2) Application of Examination Techniques to stress the tissue (can be done by PT or Podiatrist)
3) Determination if Mechanical Overload occurred
4) Reducing Stress to the Tissue Involved (Rest, Footwear, Orthotic Devices)
5) Healing the Tissues with modalities of ice, heat, ultrasound, etc
6) Restoration of Flexibility and Strength to the area

With this model, orthotic devices used may be temporary or permanent, OTC or custom
This was a big point in the article, that orthotics can be used as a temporary treatment (not a required lifelong treatment) and I think this is very good to bring out. Some patients need the orthotics only for the Immobilization Phase of rehabilitation, some need them permanently. It is up to the doctor/therapist/patient to decide in the long run. Rich

Are You Looking at the Tip of the Iceberg? A Metaphor used when treating Athletic Injuries

Are You Looking at the Tip of the Iceberg?

Each week I have patients that present with their first foot or ankle injury and I wonder whether I am looking at the Tip of the Iceberg of this and other future injuries. No matter how minor the injury appears, I wonder if it will be followed by another and another and another. What can I do as a healthcare provider to eliminate or at least minimize the onslaught of future injuries? How serious should I take these initial injuries which will heal relatively quickly? Should I always follow the KISS Principle and Keep It Simple Stupid when I think some of these injuries are definitely the Tip of the Iceberg? More pain is on the way for these athletes. What goes into the thought process of deciding who should get more treatment when relatively simple injuries present into my office? The treatment of any overuse injury (without an acute single episode) should always be directed at the one or two common causes, or the several possible causes for this individual patient with Achilles Tendonitis for example. The common causes of Achilles Tendonitis are:  
1. Straight overuse situation in which the Achilles Tendon is put in major stress (i.e. stair running for the first time, or working out too many days in a row, etc.)

2. Very tight Achilles Tendons.

3. Worn out shoe gear with lack of stability or cushion at impact.

4. Unstable shoes, or excessive wearing of shoe gear with

inadequate support (i.e. too much time in the flip flops, etc.)

5. Short leg with compensation of early heel lift.

6. Excessive pronation of the foot/ankle with excessive torque on the Achilles (as seen in the left foot of the photo above).

7. Excessive supination of the foot/ankle with lateral instability and over firing of the Achilles Tendon to stabilize the ankle joint complex.

8. Very loose Achilles Tendons from over stretching or patients with loose ligaments in general. This produces a weakness in the tendon. It is important to understand what the force/length curve of a tendon means.

9. Weak Achilles Tendons from many reasons (just returning to regular exercise program, following prolonged casting, aging process, genetics, dietary, etc.)

10. Achilles Tendonitis secondary to another problem (heel spurs, ankle injuries, sciatica, tibial stress fractures, etc.)

After performing an initial history and physical examination, and making the diagnosis if possible, the clinician will try to assess the reasons this individual patient developed their injury. It is the experience of the clinician that separates them from other health care providers in getting to the cause(s) of some injuries. Some “reversal of cause” treatment must be initiated in all cases. But for some patients, looking below the surface level of water, below the Tip of the Iceberg, is really what is crucial. What factors could lead, if not addressed, to either prolonged injury/treatment, or frequent recurrences of the symptoms. This is so crucial, but in a busy medical practice, often times not proactively explored. The patient and clinician only stumbles into the discoveries.

When a ship’s captain looks at the iceberg approaching, the captain scrutinizes the situation, assesses the severity, and then makes an appropriate plan. Health care providers, and proactive patients, can be slower than the sea captain at finally making these decisions, but must look at possible severity of the injury, and severity of the cause of injury, to come up with an appropriate plan. Since we can grade the severity of anything 3 typical ways—mild, moderate, and complex—let us look at these 2 factors in injury treatment from this angle. Perhaps then you can understand when under the Tip of the Iceberg danger may be lurking in the forms of prolonged treatment, possible incomplete healing, and frequent recurrences of the symptoms. After the initial assessment (history and physical), and perhaps after several follow up visits, the clinician will place the patient into one of 9 injury and severity categories. These are:

1. Mild Injury/Mild Severity of Cause

2. Mild Injury/Moderate Severity of Cause

3. Mild Injury/Complex Severity of Cause

4. Moderate Injury/Mild Severity of Cause

5. Moderate Injury/Moderate Severity of Cause

6. Moderate Injury/Complex Severity of Cause

7. Severe Injury/Mild Severity of Cause

8. Severe Injury/Moderate Severity of Cause

9. Severe Injury/Complex Severity of Cause

With the Severe Injuries, the treatment is usually prolonged enough that the patient and doctor/therapist gradually work at recognizing and correcting all possible causes of the injury along the way. It is the Mild and Moderate Injuries, that the KISS principle and Tip of the Iceberg principles must be reconciled. It is when the injury is classified as mild or moderate that the health care provider must decide when to look under the Tip of the Iceberg and explore the depths of moderate to complex causes. It is in the 4 categories below that I find most problems in dealing with these injuries. These are:

1. Mild Injury/Moderate Severity of Cause

2. Mild Injury/Complex Severity of Cause

3. Moderate Injury/Moderate Severity of Cause

4. Moderate Injury/Complex Severity of Cause

In these cases, I see the most patients for 2nd opinions. Why is the injury not healing? Why does the injury keep coming back? The mild and moderate nature of the initial injury makes the healthcare system relax and not look too deep into cause of injury, or not require enough followup visits. 

I will end this discussion with one example of this dilemma. Since I already used Achilles Tendonitis above, I will finish using an example of Achilles Tendonitis. The patient had pain in the Achilles for 3 months prior to seeing the initial doctor. The patient was a runner who pronated too much, rarely stretched the Achilles, when stretching only did Negative Stretching off a curb (which I do not encourage), was a vegetarian (not to pick on you guys too much!) but ate well, ran a lot of hills after moving from Dallas to San Francisco, and was told he had one leg shorter but never did anything about it. The initial treatment addressing the possible causes of the injury were Orthotic devices for the pronation, new motion control running shoes, power lacing, Achilles stretching 3 to 5 times a day, and running on flat ground, not hills until the symptoms got better. The doctor had categorized the patient mild injury/moderate cause of injury and had addressed the causes on the surface well. Was he/she just looking at the Tip of the Iceberg? What was below the surface that needed to be addressed? The patient after six months of treatment still was not much better in function. Running was still very limited. The initial treating doctor told him to stretch more and give it more time at their last visit (of 6 visits overall). This patient then sought a 2nd opinion. 

   On review of the injury itself, the right diagnosis had been made. The plan of treatment initiated was good, but never improved upon when the patient was struggling. Each of the treatments initiated were subpar in retrospect. The pronation was only partially corrected with the new Orthotic devices (but they were easy to modify in the office to greatly improve their function), the running shoe store had convinced him to not get a motion control shoe since he had Orthotic devices (and the doctor never evaluated his running after the first visit), the power lacing had been done incorrectly (and was also modified in the second office visit), diet counseling came up with non optimal protein intake (something that will help the patient forever), measurement of his flexibility showed him off the charts in over flexibility (too flexible means too weak and this was improved with 6 weeks of no stretching at all—he thought I was crazy when I proposed that one), and exact measurement of his legs showed over ½” short leg on the injured side (treatment with heel lifts helped him immensely). Within several weeks, he was feeling much better, and by 8 weeks was back running regularly with a better diet, heel lift for the short leg, sensible stretching routine before and after exercise, no negative achilles stretching, stable Orthotic devices, stable shoes, proper power lacing, and a gradual re-strengthening home program under a physical therapist with 6 one/month visits to up the ante. Yes, under the Tip of the Iceberg for this athlete was a considerable short leg, a considerable dietary problem, slightly harder to treat pronation, and an Achilles that could become over flexible too easily. His mild injury did not initially respond since the cause of injury was misread as moderate, when it really was complex. 

The Golden Rule of Foot: When treating athletic injuries, if the symptoms and function plateau, look under the Tip of the Iceberg to a deeper level of possible answers. 

The above discussion was an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

Excellent Short Video on the Magic of Social Distancing!

https://www.facebook.com/GuyVerhofstadt/videos/770246400049538/?t=2

Custom Orthotic Devices Important for Quality of Life

     I have to thank my friend Dr. Kevin Kirby who finds these wonderful articles. This article documented the great quality of life improvement with the group that wore custom devices. As a podiatrist, you see the pain relief daily in your patients due to custom orthotic devices, but sometimes you lose sight of the positive effect it has on their entire quality of life.

Gerontology. 2007;53(6):348-56. Epub 2007 Jun 22.

Intervention study to improve quality of life and health problems of community-living elderly women in Japan by shoe fitting and custom-made insoles.

Kusumoto A1, Suzuki T, Yoshida H, Kwon J.

Fighting the Virus: Poem by Rich Blake

I hope you will get pissed off as I and fight this invisible, deadly, but inherently cowardly foe!!               

  Fighting the Virus

                                     By Rich Blake

I have spent one whole day

     Not at work where I belong treating patients

But in Quarantine, self imposed of sorts, 

     To try and fight an invisible bug

It has the world in a frazzle

     Due to its strength to do damage

Yet, it picks on the helpless, the elderly, 

     Where I grew up, we would call that cowardly

So, this bug has really pissed me off

Fighting this incredible foe, yet such a small bug,

     A tiny virus

Has now become my Mission

     I needed one, so that our lives continued to mean something special

Life, each and every one,

     Young and very old is worth fighting for

Doesn’t that resonant in your heart

     Can’t you get behind that mission

I am so proud of the human race once more for what it is doing

     And I needed that faith in mankind restored

This challenge that is upon us

    Outweighs self, what our previous motivations were

We are the human race, 

    And we will do what it takes

This coward that picks on the helpless, the elderly,

    Will soon have no place to call home

Problems Developed by Abnormal Foot Supination

     My practice of Podiatry is fairly injury or pain centered. I use mechanical, inflammatory, and neuropathic pain treatments to help these patients get ahead of their pain, and prevent reoccurrences. The list below is in my head as I listen to patients complaints. You are trying to see a pattern in the problems that they present with related to their past problems. Here is the pattern of injuries related to abnormal supination of the foot that occurs after heel strike when the foot should be normally pronating to absorb shock and adapt to the ground. You will only get a strong feel of this correlation by eliminating the abnormal supination and seeing what symptoms resolve. Symptoms related to all 20 of the problems below can get better or completely resolve with treatment.
     There are many aspects to any treatment you prescribe. How you strengthen a patient? How long do you send them to Physical Therapy? What do their return to activities work out look like? It is a definite art with a lot of variation. However, in controlling abnormal supination, you either do it all or it will not work. One of my unbreakable rules of practice is that Abnormal Rear Foot Supination has to be completely eliminated. We are so used to dealing with pronation, the opposite problem, where as little as 10% correction can help someone at times. But, abnormal supination is not like that. It needs your full attention.
     I have attached at the end of the post a video on all the orthotic bells and whistles to stop this motion. However, there are so many treatments from peroneal strengthening, ankle brace temporarily, taping (video also attached), valgus shoe wedges, shoe selection, single leg balancing, etc. There are very few that actually need surgery, but some do to tighten ligaments. I hope if you have this problem, or treat this problem, this post will help you. There are many more posts on this subject by going into the search engine on my blog. Rich


Checklist for Supination Produced Problems
1. Hammertoes
2. Lateral Metatarsalgia
3. Tailor’s Bunions
4. 4th/5th Metatarsal Stress Fractures
5. Cuboid Pain
6. Lateral Ankle Instability
7. Peroneal Strain
8. Haglund’s Deformity
9. Medial Ankle Impingement
10. Fibular Stress Fractures
11. Proximal Tib-Fib Sprain
12. Medial Knee Compartment
13. Knee Arthralgias
14. Lateral Knee Collateral Ligament Sprain
15. Lateral Hamstring Strain
16. Iliotibial Band Syndrome
17. Femoral Stress Fractures
18. Hip Arthralgias
19. Sacroiliac joint inflammation
20. Low Back Pain

This list is an excerpt from my book: The Inverted Orthotic Technique: A Process of Foot Stabilization for the Pronated Foot

https://youtu.be/hMhrTmWXfDA



https://youtu.be/QIVbAB1t0Gc

Pre-Sesamoidectomy Advice Needed

Dear Dr Blake,

I have just come across your blog when researching the pros and cons of a lateral sesamoidectomy. 

I'm a former professional ballet dancer. I'd really appreciate it if you could give me some advice, as I'm trying to decide whether or not to go ahead with a sesamoidectomy over here in Europe where I now live. 

I never had much pain in the ball of my foot when I was dancing, but about a year after I stopped dancing professionally, I had consistent pain on the underside of my left big toe. I had a bunionectomy done in 2011. But afterwards I still had pain in the toe/ball of foot area. X-rays showed that the pins from the bunionectomy had come loose and were pressing into my lateral sesamoid bone, so I had surgery here in Europe in 2014 to have the pins removed. Once that healed, I was mostly pain free, apart from occasional periods when I'd get pain in the ball of my foot, but a local podiatrist would mobilise the joint and get the sesamoids sliding again, and that would help.
Dr. Blake's comment: Did they say anything about the joint position (like an elevated or plantar flexed first metatarsal) or your foot motion like over pronation? 

However, for about 9 months now I've had much more consistent pain in my lateral sesamoid area. I had an Xray done that showed a historic fracture in the medial sesamoid, but no fracture in the lateral sesamoid. I recently had an axial Xray taken, which showed that my lateral sesamoid is 'irregular', i.e. it's not smooth and round, the edge is a bit wavy. The surgeon (who is the same one who did my bunionectomy, and who has a very good reputation) said that I'm a candidate to have the lateral sesamoid removed. He didn't specifically say whether it is sesamoiditis or something else. The pain comes and goes, and I'm worried that the sesamoidectomy may cause other complications, and maybe the pain isn't bad enough to warrant having it done. I'm also wondering whether I should try a more concerted period of conservative treatment first.
Dr. Blake's comment: You absolutely must use all the means available to help save this sesamoid. The medial one is not perfect, and if you remove the lateral one it will get all the weight. Sounds like a potential problem.

Since December I've been wearing orthotics with a very stiff (fibreglass?) section under my big toe, to limit movement, and they help, but don't completely remove the pain. I can walk a decent amount when I'm wearing tennis shoes and orthotics, but the moment I try wearing a slightly nicer pair of shoes, the pain comes back, and I wouldn't want to walk more than 10 minutes. (I walk a lot here, as I don't have a car. I've been taking buses more recently because of my foot.) I don't dance regularly anymore, although I did take a contemporary class in December, but when I was pushing off the ball of my foot I felt a slight crack or something, and the sesamoid area was much more sore for a while after that. I don't think I could run or play sports with my sesamoid as it is. I'm frustrated with having limited my activities for at least 6 months, and I would love to have a 'quick fix', but I'm wondering if I should try a more concerted period of rest and immobilisation first, before resorting to sesamoid removal?
Dr. Blake's comment: First of all, an MRI would help us, but you can treat without. You are trying to create a consistent 0-2 pain level. Your orthotics limit big toe motion, but also increase pressure (which may be a problem). You should get a second pair that has more arch and frees up the big toe joint with traditional dancer's padding to off weight the sesamoids. Order Dr. Jill's dancer's pad both sides and both 1/8 and 1/4 inch. They can be used on the orthotic or on your foot. The hole for the sesamoid is alittle small so you will have to trim it. You want the dancers padding under the 2nd through 5th metatarsal heads. You want to be icing once daily and contrast bathes each evening. You want to make sure Vit D is fine, and getting enough calcium (usually 5 servings of food with calcium a day or you have to supplement. You want to get some Hokas to see if the Rocker helps you. You want to learn how to do spica taping. Take it 3 months at a time, meaning 3 months from now see how much better you feel. You should be at least 50% better, meaning you will probably need another 3 months. Personally, I would not do surgery unless I had an MRI and a CT scan, but that may be impossible in your situation. Keep me in the loop. Rich

Any advice you could provide would be greatly appreciated!

Thank you very much,

The patient later wrote:

Hi Dr Blake, 

I'm looking into getting some Hokas, as you suggested. I see there are two types of their 'meta rocker' sole: early stage and late stage. I think I want an early stage one, with the rocker behind the metatarsal heads. Is that right? I don't want to order the wrong type!

https://help.hokaoneone.com/hc/en-us/articles/207290609-What-is-a-Meta-Rocker-

Thank you,

Dr. Blake's comment: I am sorry for my indecision, but so much depends on your gait pattern. You are right early stage sounds right to put the stress behind the sesamoid for sure. No way you can try these shoes, but I guess we are all stuck at home. Rich 

PS Stay safe!!

Ice and Heat in Foot and Ankle Problems: New Video

https://youtu.be/oQD2CSAFRKk