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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. $15 has been donated in April 2017. I am very honored and grateful. Dr Rich Blake


Dr Blake's Book to Learn the Secrets of successfully helping your problems

I would love you to consider purchasing my book from Book Baby publishing. The printed book goes for $79.95, but the ebook is now available for $4.99. I hope it helps many people. Thank you. Rich (eBook) (print)

Book image not available.


Saturday, April 22, 2017

Strengthening the Hip External Rotators: The ClamShell with Resistance

As a patient walks or runs or bikes or skis (or any straight line repetitive motion activity), following the heel contact, the knee should internally rotate slightly, and then the strong external rotators begin to correct and pull the knee strait. If the external hip rotators are too weak, this does not happen. As the body moves over the knee as you move forward, the knee is out of normal alignment and pain ensues. Here is another of the common exercises used to strengthen this important muscle. 

Here the runner is maintaining good knee position

Here the runner's left knee is too internally rotated

Thursday, April 20, 2017

Discussion on Avascular Necrosis of the Sesamoids: Email Advice

Hi Dr. Blake,

I hope all is well ! I read over your blog and focused on the AVN posts, which were helpful.

About a year ago, I started noticing a dull pain in the ball of my left foot, but nothing unbearable. This must have been from walking around in a bad pair of shoes for a week. The dull pain did not at any point between April 2016-December 2016 get any worse.

 I did however decide to go see a podiatrist in December to see what was going on. He put me on two different anti-inflammatories separate times and took x-rays (normal results). In January, after not having felt an improvement, he ordered an MRI. This is when we discovered that I have AVN of the fibular sesamoid. He put me in a post-op shoe for a few weeks, which did not help at all. In fact, it made the pain worse. I decided to get another opinion so I went to see another podiatrist who gave me a cam walker to wear for 6 weeks. She also suggested a bone stim. I wore the boot every day, but felt pain when I was walking in it.
Dr Blake's comment: Both the shoe and  walker typically stop you from bending the big toe joint but put extra pressure on the toe. So you need some form of dancer's padding to float the sesamoids even in these contraptions. Definitely if someone mentions AVN, because of the high risk of surgery if the bone stim not work, you have to use the bone stim for 9 months. 

 After 5 weeks, I realized that it was also aggravating the problem and starting hurting other parts of my foot (assuming this is because it forces you to walk in an unnatural way). I switched to sneakers with Hapad dancer’s pads and have been wearing them for the last two weeks. I found a third podiatrist who recommended orthotics. I just received my custom orthotics today and after putting them in, I feel a bit of pain when I walk in them (the same amount as when I wear the dancer’s pads). Not sure what to think of this...I also ordered an exogen bone stim, which will arrive tomorrow. Following the doctor’s suggestions, I will be using the stimulator once a day for 20 minutes for 3-5 months. 
Dr Blake's comment: This is a hard call. You have pain from 3 sources: mechanical (being off weighted by the hapad and/or orthotic, inflammatory (do the twice daily 10 minute ice pack, and once daily contrast bathes), and neurological hyper-sensitivity (try Neuro-Eze, pain free massage). Everything needs to be perfected. Look at each component since a littel change in anything can potentially make a big difference. Can you tolerate a bit more arch? How about a little more dancer's padding. If you are not immobilizing, perhaps a hike and bike shoes for several hours per day to rest the area better. Sometimes just go anti-inflammatory program, or consistently wearing spica taping. 

I am very worried that the pain is only going to get worse with the orthotics. If I feel pain when I walk in the orthotics, does this mean that it will not subside? My last hope is the exogen. I really am trying to avoid surgery at all cost because I have heard awful stories. Unless the pain gets unbearable, I do not even want to consider it. 
Dr Blake's comment: The real reason not to do sesamoid surgery initially is that in the long run it can effect the joint, and the lower leg biomechanics. We try to leave in what was originally there. But, it is a very successful surgery, and not too difficult to heal from. So, when a few of my patients need it from time to time, I do feel I let them down alittle, but I am happy they can gain relief. Whatever they have learned before surgery, in trying to prevent surgery, they can use post operatively to protect the joint. You would need to find a surgeon skilled at this surgery with good results, expectation to get back to full pre-injury activity, with a little sesamoid protection of the other one. 

Do you have any recommendations as to what I can do? Nothing seems to be working and it’s starting to put me down. I used to love running, but I haven’t been on a run in 2 months because I am worried I will worsen the situation.  Even before I started wearing all these shoe-alternatives, I would go on runs a few times a week and the pain was stable. I am so confused!!! I feel as though I should never have gone to see a podiatrist and ignored the problem because now the pain is worse. Are there any exercises I can do that will help?
Dr Blake's comment: You have to give this time. One year from now until you are feeling very fit is not uncommon. Avoiding the bend of the joint for the next 6 months is a start with the hike and bike shoes, spica taping, carbon graphite inserts, or just stiff shoes and orthotics. Just try to create a consistent 0-2 pain level in what you do. Bike, swim, and elliptical without lifting your heels are common exercises. Keep your foot strong with metatarsal doming, single leg balancing, inversion and eversion resistance bands, and FHL strengthening with theraband as long you only work the plantar flexion range. A physical therapist should be able to give you a good program, but protect the sesamoid also. Definitely this should include 9 months of the bone stimulation twice daily, and icing twice per day, and contrasts at least 5 evening a week for a deep flush of the stagnant blood flow trapped in the sesamoid. 

I live in NYC and am still trying to find the right podiatrist. Do you have anyone in mind?
Dr Blake's comment: Contact any of these 3 pods to get a name of someone good near you: David Davidson, Robert Connenello, and Karen Langone. 

I would appreciate any suggestions you can give me because I have been feeling hopeless.

Thank you for taking the time to read this.


Below is the report for my MRI that I got done in January:

Study Result


History: 23-year-old female with left forefoot pain for 4 months. Evaluate for sesamoid injury.

MRI of the left foot

Technique: Routine multiplanar imaging of the left forefoot was performed on a 1.5T MR scanner according to standard protocol.

Comparison: None available.


A skin marker has been placed along the plantar-medial aspect of the forefoot at the level of the tibial hallux sesamoid.

There is a homogeneous low signal of the fibular hallux sesamoid on T1-weighted and fluid-sensitive sequences, likely reflecting sclerosis, which can be seen in the setting of avascular necrosis. The tibial hallux sesamoid appears within normal limits.

There is no evidence of acute fracture. The joint spaces and alignment are maintained. The articular surfaces are intact. There is no significant joint effusion.

The visualized extensor/flexor tendons and ligaments are intact.

There is no Morton's neuroma. There is mild first webspace intermetatarsal bursitis.

There is no abnormal signal in the musculature to suggest atrophy or denervation.

The subcutaneous tissues are unremarkable.


Findings compatible with avascular necrosis of the fibular hallux sesamoid.

Strengthening the Weak External Hip Rotators

I am very happy I found this video. It is beginning drills for activation of our important external hip rotators. As you strengthen a muscle or muscle group, isometric and active range of motion are important types of strengthening. Excessive internal knee rotation due to weak external hip rotators is so commonly seen, and so commonly a cause or factor in knee, hip and foot conditions. These 3 wonderful exercises are simple, but effective at getting them to work. You can add therabands for progressive resistance strengthening as the patient getting stronger.

One of my early videos on evaluating, and testing, for weak external hip rotators. These are huge muscles that can be very weak in even experienced marathoners. Why? Not sure in many cases, but shows how important these activation drills are. 

Saturday, April 15, 2017

Avascular Necrosis: Article supporting Bone Stim

Some of my patients get avascular necrosis (dead bone) after a sesamoid fracture. I have seen patients heal just fine with prolonged protection with orthotics and dancer's pads, improved bone circulation with contrast bathing daily, creating the 0-2 pain free environment for healing, and the Exogen bone stimulation. Attention should also be made to the overall bone health with healthy diets and Vitamin D deficiencies. Occasionally, it is apparent that a Bone Density screen is needed. Poor bone health overall will definitely slow us down. This review article on avascular necrosis, like all articles on this subject, are all weighted toward surgery, but does have many good points on conservative treatment and appropriate imaging. For the sesamoids in particular, get a CT scan if AVN is noted. The chance of healing is low if the bone has fragmented, which only the CT scan really shows well.

Sesamoid Patient and Performer!!

People of all walks of life get sesamoid issues. This patient is many months from wearing her removable boot, but still has some symptoms. She also is the lead singer in a popular band, so this shoe should work. It is more of a flatform than traditional heel and she combines it with a 1/4 inch felt dancer's pad. This is why I can see 100 patients with the same injury and never be bored. The sesamoid are associated with interesting people!!!

Hi Dr. Blake and hope this email finds you doing well!

Thought you might get a kick out of seeing my latest "sesamoid friendly high heel shoe" for my singing on stage with my band:
*Note:  Only to be worn with 1/4" FELT Sesamoid Pad!    ;-)
    Is it helpful to use Exogen for as long as possible?  I recall reading 9-months treatment but am wondering if longer is helpful??    Thanks again!  

Friday, April 7, 2017

Setting Benchmarks for Recovery: An Important Skill

When patients come in for treatment, they can have a list of what they can not do. I try to get them to focus on what they can do comfortably right now in the 0-2 range. It is important for me to know and it is the first part of our important benchmarks. Therefore, it is important to know that a runner can run 5 minutes every other day, a basketball player can shoot 100 free throws a day, and a ballet dancer can work pain-free at the barre.

And also cross training should be part of this benchmark establishing. If they are a runner, can a bike somewhat and swim and even do elliptical to help with their overall conditioning. Staying in shape biking has proved invaluable for so many sports while we cross train.

And then he comes to the exercises, or the many treatment modalities. What can they do as part of the rehabilitation this month that can be helpful to know. Maybe they can balance on 1 foot for 1 minute. Maybe they can do 2 sets of Level One theraband or resistant cords for their tendinitis, but only 5 reps each. May be they can only go to 10° flexed when trying to fully extend their knee. The amount of total resistance, range of motion limitation, time of an exercise, and sets and reps that can be done can all begin to set our important benchmarks.

The patient comes in at the beginning of April, like today, you can begin to find out what they can and can't do at present. As you set your benchmarks, you can help them measure progress in the future. Some of my programs will take a good year like an Achilles rupture. You can set benchmarks much as attaining goals. It is definitely rewarding as you pass each benchmark.

One example I will use, is a common situation of an athlete coming in with crutches and a removable boot. As a get better, the benchmarks to be used will be first getting rid of the crutches, then weaning off the boot, then wearing normal shoes for 2 weeks, then starting to do sport specific drills (basketball player shooting free throws), then beginning a walk run program, then beginning sprinting or cutting, etc. etc.

I've attach one of my recent videos on posterior tibial strengthening. I was very precise in having the patient progressed through a comprehensive rehabilitation program. I set benchmarks by outlining the different exercises to be progressed through. Please watch the video to get the idea. I hope this is helpful for you. Even if another body part is injured, you should be able to get the right idea of bench marks and goal setting. Rich

Thursday, April 6, 2017

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.
Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.
Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 
Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.
Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.
Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps.

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.
Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.
Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).
Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.
Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"
Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?
Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.
Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)
Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.
Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.


PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.

Sorry these are on their sides!!

Wednesday, April 5, 2017

Ankle Pain and Instability: Patient Email Discussion

This is from a patient I saw several weeks ago. Since the email was so full of great information, I thought I would answer the best in the venue where I could give it the time it desires. She has had chronic ankle sprains with the last one in 2015 causing chronic soreness. She wants to be more active. Has had PRP injections to help tighten the ligaments, which still had some laxity. Her ankle was loose in the normal tests, including what I call translation of the subtalar joint. If I grabbed the heel, it would shift with pressure more than normal side to side. This can easily pinch the capsule (joint lining) when you move. I was not sure if the PRP addressed the ankle joint alone, or the subtalar joint also. I have seen cases of patients having surgery to tighten the ankle ligaments (most obvious) only to have the surgery fail since the problem was in the joint below (the subtalar joint). She walked with lateral instability (outward roll), and the arch of her orthotics (not really designed for supinators) made her worse. She looked slightly better without the orthotics. Her MRI was negative for surprises (no bony problems). I started her on taping to stop supination, contrast bathing for less swelling (this makes the joint more stable since fluid floats the joint surfaces on themselves making them more wobbly), an occasional use of an ankle brace when needed for stress situations (I would wear for basketball), and strengthening (you can always get your ankle 3 times stronger). I told her that each month for 24 months she should increase 3-4 ankle exercises by the amount of reps, sets, time, or level of difficulty guaranteeing that she is doing more and more. At followup, making some new orthotics may be done to control supination. I have placed a video after the email. 

Hi Dr. Blake,

Hope you’re doing well! I wanted to email my follow-up, and I also have some issues about which I would appreciate some advice. 

I’ve stopped using my old orthotics in my running shoes as you suggested. It totally made sense to me that they were causing stress on my ankle. However, I didn’t realize how present my sesamoid problem still is. The sesamoid area on my right foot has started to get a little soar now that I am not wearing insoles - not nearly as bad as it has been in the past, but I can tell if I do not address it the pain in my sesamoid will return in full. In trying to find a solution I went to On the Run, and they suggested a pair of Sauconys (for the wide toe box) and an insole especially for sensitive sesamoids (made by On the Run). After walking in the shoes for 20 min the insoles started to bother other parts of my foot (there was extra padding on the outside of the ball of my foot that squeezed that part of my foot uncomfortably, and the insoles dropped off a little under the toes to take pressure off, but it wasn’t comfortable). I think I need a decent amount of arch support to take the pressure off of my sesamoid, but not as much as my old orthotics provided. Do you think that is correct? Do you suggest I go back to On the Run to see if they have a different insole recommendation? Or do you have a specific recommendation?
Dr Blake's comment: Since the old orthotics protected your sesamoid, I would go back to them in the new shoe. I will adjust them to stop some of the outward roll, and we can talk about another orthotic that both stabilizes the ankle, and protects the sesamoid. If you see my sesamoid videos, at least getting a dancer's pad on to the store's inserts. 

My ankle was pretty irritated the first couple of days after I saw you when I stopped wearing my orthotics in my running shoes and changed my day-to-day shoes (since the street shoes I brought to our appointment were making my ankle roll out). I’ve been trying to find other shoes that work for both my ankle and my sesamoid and have had a bit of a hard time. Do you have any suggestions of brands? Is there any style of shoe you would particularly recommend (for example low top vs high top)?
Dr Blake's comment: The Altra is a soft cushion front with zero heel drop so not adding more pressure on the fore foot while keeping the shoe close to the ground. The Saucony Triumph was always a good shoe for supinators. I love that high tops boots are still in style. But, it is what we are putting in them that is at least half the battle. 

The tape has been noticeably helpful already. Even when my ankle has been a little soar, the tape alleviates at least some of the pain. I have been using it daily. 
Dr Blake's comment: Great!!! I use the opposite taping that is in the video below for pronators. It is a J strap for supinators. 

Contrast Baths
I have been doing contrast baths about every-other day. It is a little soothing. I don’t notice the same kind of relief as the tape provides.
Dr Blake's comment: That is okay. Still important to do. You have a mechanical problem so the tape, orthotics, shoes, brace, strengthening are the most important. Keep doing them for now. 

I haven’t been consistent with the 5-minute icing after exercise (often I forget). When I’ve done it I notice some immediate relief, but it doesn’t seem to last long after I remove the ice.
Dr Blake's comment: Okay, you can stop that for now. 

Physical Therapy
I am going to cut down to every other week with the physical therapist and focus on doing my exercises at home. Over the weekend I pushed my ankle a little too hard doing my exercises (jumping onto a pillow), so I’ve been laying off a little the past few days due to pain, but will go back to my regular routine once I feel up to it (today my ankle is feeling better than the last couple of days, so I think I can pick my regular program back up tomorrow). Also, the therapist said she faxed over a note to your office before our appointment on 3/24 - did you receive it? 
Dr Blake's comment: I will look for it. 

Thank you! I really appreciate having you on my team.
Dr Blake's comment: I am happy to be on your team!!


Monday, April 3, 2017

Achilles Tendon Pain: Where Do I Start?

Achilles Tendon Palpation

So, you begin to hurt in the achilles tendon. A Golden Rule of Foot: If you look at the achilles tendon the wrong way, it will hurt for 9 months. Is it all gloom and doom? Only a few unlucky ones. Are you about to tear it? Usually not, in fact most of my patients that tore their achilles did not have any symptoms beforehand. They are unlucky, probably a small defect in the tendon. Only rarely on both sides. But, this fear we have around the health of our achilles, typically when it begins to get sore, is not justified. However, we do not know if we are beginning to feel just the tip of the iceberg (with a bigger problem brewing). 
     When you first feel your achilles aching, try to play Sherlock Holmes and discover why. I like to always use a rule of three. Therefore, there is probably 3 causes of this injury, and each may have played a big or some role in the injury. Treatment of the possible causes can help in the prevention of its returning. The most common causes of achilles tendon pain are tightness, combined with some common overuse pattern (too much, too fast, too different), combined with some technical issue (switching from normal heeled shoes to zero drop, experimenting with lower heel drops in exercises, going to a shoe far too unstable). I have seen hundreds of combinations.
     The athlete needs to immediately cut their distance in half, as long as they have caught the problem early. If not, and they limp from normal activity, they may need a 2 week or more period in a removable boot. After finding the amount of exercise they can do without flaring up the pain, they need to stretch the achilles (even the plantar fascia), 3-5 times a day. I have included my video on achilles stretches and link for the general principles of stretching. Occasionally, I will find the patient on the opposite end of the spectrum that is overly loose, and stretching is a bad thing. Sorry if that is you. Start thinking about what either over-stretches the tendon, or torques the tendon with pronation or supination (rolling out) forces. Immediately try to remedy that aspect. Could be that you were doing too many negative heel stretches where your heel fell off the edge of a stair? Could be you changed into some lighter, perhaps less stable shoes? 

     So, you have created a pain free environment for healing by controlling the activity, begun to stretch 3-5 times a day, adjusted other possible causes (switched back to more normal shoes), and now you must ice. The achilles is the most powerful tendon in the body. It can lift 8-10 times your body weight under distress. But, it has relatively poor blood supply, and that is a bell shaped curve. The curve means you could be one of the lucky ones to get a lot of blood supply or not. There are so many beliefs in how to get blood supply that it is not the place for that discussion, but it is the place to tell you to control that initial soft tissue swelling from day one or day five, but quickly. Ice pack over the tendon is relatively easy and 10 minutes you are done. But do it 3 times a day. 
     So, smartly use activity modification, stretching, biomechanical awareness, and icing to help change that aching achilles into an achilles you want to bring home to mother. 

Thursday, March 16, 2017

How is frozen shoulder like posterior tibial tendon dysfunction? Why me!!!

Displaying IMG_0300.JPG

I am presently rehabbing a right frozen shoulder that developed following a stroke I had in August. The image above shows the amount of balls I made (6) and missed (many) from 20 feet as I try to get my strength and accuracy back. Possible?  I ignored the pain for some many months and now I am paying for that mistake. I have what would be equivalent to posterior tibial tendon dysfunction. My weakness was caused by my stroke, and then the shoulder joint began to gradually shift out of position with the stronger front muscles to the weaker back of the shoulder muscles. I wish I could make an orthotic for this injury like I do for the foot injury. Oh well. Since this will be a regular game to check my progress I will send updates. Rich

Big Toe Joint Pain: MRI showing Plantar Plate Involvement

This is one of my blog patients (and yes, that is what I call you in my brain as I compartmentalize things). He has been suffering with big toe joint pain, presumably sesamoid, but probably more plantar plate tear. The arrow points to part of the plantar plate in front of the sesamoids by the toes. Some calm down by themselves with sesamoid off weighting, and limited push off for a while. Some remain chronically sore and need surgery to fix the instability created by the tear. Typically, you know what a surgeon will tell you. Read all you can about sesamoid management--off weight the big toe joint, limit the dorsiflexion of the joint, calm the inflammation down (all the white stuff in the image), create a pain free environment. Also, look at my reference on plantar plate testing.

Tuesday, March 14, 2017

Being Part of a Team that Works!!

In my twenties, I was able to be part of a 14 person team that ran 1250 miles as a relay from Oregon to Mexico. There were 10 runners (I am above the T in TO, yes the goofy looking one!!) and 4 alternates. We each ran 125 miles that week. I lost 30 lbs in the training, and another 10 on the trip. Not healthy, but sure what an adventure. It was such a highlight in all of our lives that when we come together randomly at a meeting now, that it want comes into the conversation, something that we are all so proud of. We were a team, divided into 2 groups of 5 runners. When one group ran 70 miles in 10 hours, the other group went ahead and did what they could to rest and eat. Since it was a publicity stunt for California Podiatrists, National Foot Health Week, May 5-12 1981, we also were constantly interviewed by radio, TV, and newspaper. 
     It remains my biggest athletic feat! My wife and I walked 189 miles in 12 days on the Camino de Santiago in Spain 2015, also a tremendous accomplishment. 
     Why bring this up? As life has passed along, I have been part of many teams at work, recreational, and family. I started this blog 7 years ago (almost to the minute). I knew when I started it that my life would be changed by it, and that it has. You have all become by blog family, some of you more vocal, but all important. I hope this TEAM we have formed can grow. Behind the scenes, only 10% of the blog gets posted, most of my answers are to individuals alone. So, please do not be afraid to write me, and I am sorry when life slows this part of my life down. I am just as proud of this blog as anything I have done in podiatry, or as a human being, because I have tried to make it truly a gift and always part of my life, not something to do. Thank you for helping me teach, cry, and try to love you, as I know by your kind words you feel for me. I thank you. 

Monday, March 13, 2017

Flat Feet with Marked Heel Eversion: Inverted Technique

This patient has pronated flat feet with marked eversion of the heels. The Inverted Orthotic Technique will be utilized to attempt to place the heel bisection line close to vertical. You can measure the angle, and use a 5 degree cast correction for 1 degree of foot correction ratio. If the line is over 7 degrees everted, I stop at 35 degrees to get the patient used to this amount of support. A good starting point. 

Saturday, February 25, 2017

Turf Toe Stable or Unstable: Surgery or No Surgery

I just reviewed an MRI and x-rays of a patient with chronic sesamoid injury and there definitely was plantar plate involvement. This is a great article documenting an unstable plantar plate with a 2mm forward position of the non injured sesamoids. The x-rays should be taken in a position where the big toe is bent upwards, called a stress x-ray. 

Arrow under the big toe joint shows a disrupted plantar ligament (plantar plate) with intense inflammation.

Sesamoid Fracture: Email Advice

Hey Dr. Blake,
Thank you for all the hard work you put into your blog. I injured my sesamoid bone three months ago and your blog is the only thing I've come across with any good information. With that said, I have some questions if you have the time and can help me out.

I am a runner, but take very good care of my feet. I have never had any pain or problems anywhere but my right knee (once, after a half marathon last May). In November, I was on a walking break during an easy run and felt a "crunch" in the ball of my right foot. It was followed by immediate pain and I knew I must've broke something. Went in to have it x-rayed that afternoon, nothing looked off. The doctor said this is normal with fractures and to return in 4 weeks if the pain was still present (didn't mention anything about a boot at this time, just told me to try and keep weight off of it). The tricky thing about the timing of this, though, was that this happened the Thursday before I was set to perform in a musical for the weekend. I worked for 3 months rehearsing and wasn't about to quit right before opening night. So, I danced on it for three days (icing it when I could), and started some serious time off right after the weekend was over. My doctor wasn't thrilled that I chose this, but said I should be fine just for a weekend. 4 weeks later, the pain was still there. I went back and they re-did the x ray, this time there was a fracture visible in the sesamoid bone towards the inside of my foot (I believe you call this the medial sesamoid). He put me in a walking boot and scheduled a follow-up for 6 weeks later. He asked me to limit weight bearing activities, but told me I could swim, stationary bike, or do other things that didn't require my body weight. This appointment was mid-December.

I got along okay for 6 weeks, but I really miss running. I swim 3 days a week and do Pilates once or twice a week, too. When I went in for my 6-week follow up last Monday, the x ray didn't show any improvement at all. I'm feeling very discouraged. He mentioned that I'm a candidate for surgery now that it's almost been 3 months since the initial injury, but I'm wary of that option. My questions for you are:

1.) To me, this seems like a very acute injury rather than a chronic stress fracture. My doctor keeps using the words "stress fracture," but should I be treating it differently if it was a sudden, trauma-induced injury?
Dr. Blake' comment: Both are treated the same at this point. Stress fractures you never see the fracture line, and acute fractures yes. A stress fracture never goes  "crunch". So, you have a potentially healing fracture of the tibial or medial sesamoid. The nature of the injury is suspicious of some underlying bone health issue (like Vitamin D Deficiency) so that needs to be checked out. Did you change to a less padded or stiffer shoe just before that could have increase the stress?
2.) What can I be doing to help this darn stubborn little guy heal? I read some of your advice in the sesamoid post "advice when not healing well" and I bought some hapad metatarsal pads and dancers pads for my shoes, but I'm wondering if I need further immobilization?
Dr. Blake's comment: Yes, it is typically get the bone health evaluated and treated if needed. Get the biomechanics secure with off loading in all things, even the removable boot. Spend 3 months in the boot, and if you have attained the 0-2 pain level, begin another 2 to 6 weeks weaning out of the boot with no increase in pain. This usually means experimentation even begins now with orthotic supports, dancer's padding, spica taping, shoe change (possibly Hoka One One). I love of course Exogen bone stim, so see if you can use that for 9 months. It is way too early to consider surgery.

3.) Have you seen runners be able to return to the sport after healing their injury? I'm not finding anything encouraging online and I'm supposed to run my first marathon this November. My training doesn't start until June, but I'm starting to think it's really unrealistic and it's getting me down.
Dr. Blake's comment: Yes, runners get back to running for sure. You should not have any deadlines on your calendar, because that we potentially have you rush through the rehab and take too many risks. Set goals to get better not participate in events right now. Goal #1: Get out of the removable boot in 5-6 weeks into an equally painless environment.
4.) Is it a bad sign to not see any healing in an x ray after 6 weeks? I've been so careful and the only time I haven't been in the boot is when I'm in the pool or the stationary bike at the gym, at home relaxing, or using my Birkenstocks to take my dog for a walk (I don't feel pain when wearing those shoes).
Dr. Blake's comment: X-rays can be 2 months behind showing the actual healing of the bone, so are poor indicators of bone healing at times (and this is one of them). I love MRIs to follow. You need a baseline, and 6 months from now, if you need another one, that comparison baseline can come in handy. Good luck and keep me in the loop. Rich
Again, thank you so much for doing what you do. And if you make it this far, thanks for reading!

Friday, February 24, 2017

YouTube Videos: Summary of 128 for easy access

Dr. Blake’s YouTube Videos      Achilles Tendon Evaluation for Flexibility      Achilles and Plantar Fascia Stretches      Achilles/Calf Stretching for Tough Cases         Achilles/Calf Strengthening     Achilles Tendon Taping Version      Achilles Tendinitis Taping         Achilles Tendon Weak Area        Ankle Sprain: Initial Treatment      Ankle Sprain: Compression Quickly   Ankle Strengthening Range of Motion         Ankle Strengthening with Bands    Arch Strengthening        Arch Taping: KT tape       Arch Taping: Low Dye Classic     Arch Taping: Low Dye Modifications       (Arch Taping: Support the Foot)       (Balancing)      Balancing: Single Leg      Bike Seat Height Changes for Rehab       Big Toe Pain: Spica Taping   Big Toe Pain Treatments    Big Toe Pain: Variation of Spica Taping       Bio-mechanics: Mechanical Causes of Foot and Ankle Pain      Bow Legs: Gait      Bunions: 4 Stages       Bunion Pain: Or is It?         (Bunions: Strengthening)     Bunion Taping        (Bunions: Toe Separators)        Calf Tightness in Achilles Injuries      Crutches: How to Wean Off         Crutches: Progression to 1 Crutch     Cushioning Concepts        (Dancer’s Pads)       Falling Problems Helpful Tips      Foot and Ankle Strength: General Program       Foot Strengthening with Marbles         Foot Strength by Playing the Piano       (Functional Hallux Limitus)       Gait Evaluation Basics       Gait Evaluation Basics 2         Gait Evaluation Basics 3     Gait Evaluation Supination      Hallux Limitus Guidelines of Treatment      Hallux Limitus/Rigidus: Self Mobilization        Hammertoes General Treatment     Hamstring: Upper and Lower Stretches       Hamstring Stretches: For Tough Cases           Hannaford Orthotic Manufacture     Heel Pain Evaluation       Heel Pain Treatment PT        (Hiking Boot Lacing for Stability)    Hip X-rays post Replacement        Ilio-Tibial Band Stretches        Knee Pain: How to Ice        Knee Pain: Foot Wedges Can Help      Knee Strengthening: Short Arc Quad Sets    Knee Strengthening: Home Based       Knee Various Positions Gait     Knee: Weak External Hip Rotators in Gait        Metatarsal Doming Exercise         Metatarsal Soreness    Morton’s Neuroma Evaluation      Muscle Stimulation for Weakness    Nerve Pain: Low Back Cause?       Neural Flossing       Orthotic Check by Heel Change      Orthotic for Supination: Multiple Rx Variables       Orthotic Designs for Supination (custom mold variations)      Orthotic Evaluation for Supination in Gait       Orthotic Evaluation for Supination in Gait after Denton Removal    Orthotic Design Supinators  Orthotics for Forefoot Varus          Orthotic for Supination: Denton Modification  Orthotic: Inverted Technique 60    (Orthotic Mold Corrections for Pronation)      Orthotic Negative Casting to get proper Impressions      Orthotic Rear Foot Posts         Osgood Schlatter’s Knee: Anatomy and Treatment    Phases of Rehabilitation       Plantar Fasciitis: 3 Important Home Treatments      Plantar Fasciitis 5 common treatments          Plantar Fasciitis: 2 Vital Orthotic Components      (Plantar Fascial Stretching)    Plantar Fascial Stretching     Plantar Fascial AM stretching         Plantar Fascial Night Splints       Plantar Fascial Wall Stretch      Posterior Tibial Tendon Anatomy      (Posterior Tibial Strengthening)      Posterior Tibial Strengthening     Posterior Tibial Taping Version       (Posterior Tibial Taping)      PTTD: Gait Evaluation        PTTD: Gait with Inverted Orthosis         PTTD: Muscle Testing       Pronation Walking     Quadriceps Stretches        Quadriceps Stretch: For Tough Cases     Rehab: KISS Principle      (RICE: Initial Injury Treatment)          (Running: Walk/Run Program)      Scar Tissue Breakdown     Second Metatarsal Taping       (Sesamoid Evaluation: Part 2)          (Sesamoid Evaluation: Part 3)    (Sesamoid Fracture Treatment)         Shin Splints: 4 Types     Shoe Flexion and Torsion Tests      Shoe Inserts: Interpreting the Signs            Shoe Power Lacing for Stability           Short Leg Evaluation Standing          Short Leg Heel Lifts   Short Leg Full Length Lifts          Short Leg: Making Sure Lifts Stable         Short Leg: Limb Dominance in Gait        Stretching with Contract/Relax       (Stretches: 5 Most Common)           Stretching: 7 General Principles       Supination: What it Looks Like         Supination: Evaluation in Stance         Supination Running           Swelling Reduction with Contrast     Bathing        Tailor’s Bunions          Toe Injuries Buddy Taping         Toenail Fungus        Walking Aid: Roll A Bout