Friday's Patient Problem of the Week: Measuring Range of Motion 2nd Metatarsal Phalangeal Joint

A patient presented post operative 2nd metatarsal phalangeal joint. The joint was very stiff and painful and she wanted advice on increasing the range of motion and minimizing the pain. As she walked, she felt that the bottom of the base of the toe would stay against the ground and cause pain. She felt that the toe would not move up as she walked through her foot. Even though the pain was on the bottom of the toe at the MPJ, she felt that the restriction to bending the joint was in the top of the joint. 

2nd MPJ with healed surgical scars, but too much restriction at the top of the joint. Patient started on joint mobilization (like with Hallux Limitus) and cross frictional massage with a Blaine Scar Treatment Kit.

http://youtu.be/bdRuO0QERpI

Tin Foil is used to give the patient a reference point before and then after treatment. With the toe bent upwards as much as possible, the tin foil is massaged into the skin to represent that area. About a 6 inch strip of tin foil is used and folded on itself to get some rigidity. 

Once the tin foil is removed for the skin, the patient can observe the angular relationship to the toe to the metatarsal (here before mob and massage). I can measure this as a 19 degree angle. 

After mobilization and massage, the angular relationship is remeasured and the patient can see how their treatment is working. Doing this multiple times a day (2-3) for several months (3-6) can give a consistent improvement. Remember no pain in this treatment. Here I measured the same patient at 40 degrees post mobilization and gentle cross frictional massage of 2 minutes. 

Thursday's Orthotic Discussion of the Week: Functional Foot Orthotic Devices and Rearfoot Posts

http://www.youtube.com/watch?v=7SjkTwynaQM&feature=share&list=UU6k8-p7cA93aIpg0pnxm1Jw

http://www.drblakeshealingsole.com/2011/12/extrinsic-rearfoot-posting-adding.html

Custom Shoemaker: Highly Recommended by a Very Discerning Patient of Mine

http://customshoemaker.com/home.html

Wednesday's Article of the Week: Leg Length Differences Following Hip Replacements

If you are going in for a hip replacement, try to get the most information you can about how you can avoid or minimize a short leg. I have found only a few hip replacements to have no residual short legs, and so it is standard of care to have a short leg after. But, this means, lifts for the rest of your life in shoes or added to the bottom of shoes. I have many posts in my blog on the topic of treating short leg syndrome. This wonderful article below kindly discusses the problem. With supposedly 80% of the population having a short leg, it does mean that at least 80% of these surgeries will leave a short leg and need for a lift guy/gal like me to help post operatively. This is complicated by the fact that any surgery will temporarily weaken the joint involved. When it comes to the hip joint, when that area feels week, it throws off the gait, and makes it feel either long or short. Standing AP Pelvic Xrays post hip replacement can tell you what side of the body to place the lift, and it may not be the side you feel is short.

http://www.ncbi.nlm.nih.gov/pubmed/15190563




http://youtu.be/WRD62QspZtw

Tuesday's Patient Question of the Week: Advice for Plantar Fascia Injections

Hi i have plantar fasciitis in both feet and have been told i need injections but i am terrified of needles. I was wondering how much it actually hurts, and whether you can return to work the following day?

One Image to give yourself if you are going to get an injection is that the injection is going to make you more beautiful inside and out. 

Dr Blake's comment:

Shots for Plantar Fasciitis are normally done from the side of the foot where the skin is softer. So, it would be more painful if injected from the bottom of the heel. I use Ethyl Chloride skin coolant to numb the skin before the actual injection, and that typically helps alot. You should ice for 20 minutes just after the shot and several more times that day. People go back to work after the shots, but no running for 2 weeks. You can inject long acting steroid into the bursae under the heel, but typically not into the plantar fascia itself. All these fine points are really up to the doctor, and most based on what he/she finds and is trying to accomplish. I have given heel shots that feel like a little prick to sharp pain, so have someone hold your hand, and definitely do not look. Bring music and earplugs so that you can relax before/during the shot. I pray you will not feel it at all. Look at the video and ask the nurse to see if some of these tips could be used. The Emla Occlusion is wonderful, but requires getting the medication and you coming one hour beforehand.  Rich



http://youtu.be/t1qGGtZMFzI

Monday's Image of the Week: When One Foot Being Longer can cause Chronic Symptoms

I am hoping one of these 3 photos clearly captures the longer left foot. These inserts were removed from the shoe to check why the left second toe was continually being irritated. He was sent home to check other shoes to see if this was a consistent pattern. This will help in my recommendations on shoe buying. With some situations, patients with this problem need to buy 2 pairs of  different shoe sizes and chose one from one pair and the other from the second pair. 

Sunday's Video of the Week: Why Jones Fractures have Poor Blood Supply

   © Kiankhoon | Dreamstime Stock Photos

The right foot is highly inverted as it strikes the ground right on the fifth metatarsal without much shoe protection.

  This is a wonderful video on the anatomy of proximal fifth metatarsal fractures. It wonderfully explains the poor blood flow to the area we call a "Jones Fracture" making it hard to heel. It does not explain that due to the attachment of major tendons and ligaments at the base of the fifth metatarsal (peroneus brevis, peroneus tertius, and 4/5 metatarsal base ligament attachments) the area to one side of the Jones Fracture  is very solid. The area just distal to these attachments, towards the toes, where you get the Jones fracture is a highly stressed area (more relative motion/stress with loading of the fifth metatarsal head). The area in front of an immobile area has more mobility, and in this area, can break easier and take longer to heal. 

     Podiatists also have many tricks to help these bones heal, and minimize or eliminate the need for surgery and/or non-weightbearing. Custom made functional foot orthotic devices can be made to off weight and stabilize the fracture (this has to be built into the design--you can not assume your orthotic device has this function). See some of my posts on orthotic modifications for supinators. Kinesiotaping of the midfoot can immobilize the fracture area and decrease the stresses.

 The use of removable casts with off weighting techniques (ample use of 1/2 inch adhesive felt with cut outs) or ZeroG removable boots with EvenUps can get a better result that the weakness of non-weightbearing. Exogen bone stimulators are vital is the healing of these fractures and are used for 9 months. Designing return to activity programs with the above minimizes the de-conditioning that can occur. From the day you broke your foot, you could be on a stationary bike for 1-2 hours with the weight in the heel. 

    What are other areas of concern? Of course with any bone injury, bone density and Vit D3 levels are important. Making sure you are getting 1500 mg of calcium and 1000 units of Vitamin D. Making sure that your shoes do not break down to the outside and you have become too inverted/supinated.

Remember that your treatment regimen is between you and your physician. The more you learn, the better questions you can ask, and ultimately, the faster you will heal. 

http://youtu.be/_CItUTjO_jA