Treating Nerve Pain at the Foot: Algorithm

     I treat many patients with nerve pain, some as the primary injury like Morton's Neuroma, and some as secondary nerve hypersensitivity develops following an injury. This algorithm can help the patient with nerve pain review their treatment and discuss other options here with their doctor. 

Plantar Fasciitis: Treatment Algorithm

     The treatments are typically non-painful stretching as outlined in this video. 

https://youtu.be/0eAqJ4-oKTM

Weight transfer concerned getting the weight into the arch with an orthotic device. This is successful when most of the pain is in the heel or ball of the foot areas. 

Podiatrists always love to recommend the Rolling Ice Massage technique 5 minutes twice a day to get the inflammation under control. 

The 1 Day and 2 Day Pain Level Increase Rules of Rehabilitation

     When I am rehabilitating a patient, we always talk about good and bad pain. It is so important for the patient to know the difference. And, it is very important for me to know where their pain is in my rehabilitative process. 

https://www.drblakeshealingsole.com/2020/12/good-vs-bad-pain-how-can-any-pain-be.html

     When you are rehabilitating a sore area, and you are progressing the patient through the 3 Phases of Rehabilitation, increased stress to the area is applied routinely every other day in activity progressions. This is typically Monday, Wednesday, Friday or Tuesday, Thursday, Saturday. You have kept the pain between 0-2 successfully, but this increased stress (important for healing and return to activities) will elevate the pain for a period of time following. The goal during rehabilitation to keep the increased tissue soreness within 2 days or the 2 Day Pain Level Increase Rule. Therefore, if I am starting a more strenuous activity, like progressing to the Walk Run Program, or allowing small jumps in ballet, the increased pain needs to be contained within 2 days and not linger more. If you exercise on Monday, by Wednesday's start you should be back to square one even if Tuesday showed increased pain. 

     The One Day Pain Level Increase Rule is for the maintenance program. You are back at your normal level. You are exercising at a good level 3-4 times per week. Any increased pain after an activity is normal as long it is not during activity, not increasing in severity week to week, and contained with one day. 

   It takes alot of understanding to excellently rehab a patient, or yourself, of these 2 rules to avoid serious setbacks. Good luck 

Big Toe Area Pain: Years after Healing Sesamoid Injury

Hi Richard,

I wanted to write to you because of pain in my big toe that has been bothering me for the past few weeks (about 5 weeks). Unfortunately, this pain is fickle and elusive, and very hard to describe.

My history:

- turf toe and sesamoid AVN in 2019-2020, which I recovered from thanks to your wonderful blog

- I was walking perfectly fine for a ~6 months

- played tennis one day and had pain the next day in my big toe, but a different one than I'd had before - it hasn't gone away unfortunately

The pain:

The pain is sometimes very sharp when I put weight on my foot right after getting up, but then immediately subsides. At first it felt like "pins and needles", but now it hurts more "traditionally". I can't tell where exactly my toe is hurting, but it definitely hurts when I press in the webbing between the first and second toe. My joint clicks a bit (though when it does, it is painless), and to be honest I can't remember whether it did that before feeling the pain or not. Moving my big toe doesn't hurt, I have full range of motion, my sesamoids seem fine. It occasionally hurts when I compress my first phalanx with my hand, I think it's called the "proximal phalanx of the big toe". Overall the pain tends to be better in the morning, and worse after a whole day of walking.

Please let me know if you have any leads, because I admit I'm quite perplexed by my current condition!

May God preserve you and your family in this difficult time. 

With all my consideration

Dr Blake’s Comment: Thanks for your email and glad the sesamoid AVN finally healed and you were back to good activity. Some of the symptoms are definitely nerve, like the pins and needles and pain that comes on and disappears quickly. In your case, it could have just be the body trying to tell you that something is amiss that needs protection. Your original injury was to the big toe joint. Previous joint injuries tend to pop up from time to time. Like you are doing now, you have to take them seriously, but they represent that the joint is not perfect. Imperfect joints (for me they are the left ankle, right knee, low back, and right shoulder) from old injuries are generally alittle stiffer (so they can get jerked easier) and the body’s reaction is quicker (from nerve memory). 

     So, what does this all mean? Typically, we are not dealing with anything serious if the range of motion is normal and there is no swelling, black and blue, or redness. Also, it is a great sign that there are times of the day that it does not hurt at all. These aggravations of old injury areas need to be treated seriously since this joint is a weak spot for you. The 3 areas to address are mechanics, probably spica taping or bunion toe separators to start, inflammation (so icing and contrast bathing once or twice daily), and nerve hyper-sensitivity (neural flossing with non painful joint motions, and non painful massage for 2 minutes twice daily. This should be done for 2 weeks, and then based on the response, either lessen your treatments or increase them in some way. 

     I hope this makes sense. Rich 

Resolved Calcaneal Stress Fracture: Email Advice

Hi Dr. Blake,

Good news - my foot is back in action!  I’ve put it to the test over the summer and all systems are a go.  I’ve been running 100%, gone backpacking, and hiked dozens of miles (including a 17 mile day) without pain!  Thanks for all of your help getting me back in action!

I don’t see a need to meet up again, but am curious about how I should proceed over the long term.  My recovery program was focused on 1) protecting my damaged heel (now recovered), and 2) supporting my high (collapsing?) arches - presumably until they can hold their own.  I’ve got orthotics in all of my athletic shoes, am using cushy HOKA’s or Oofos 90% of the time (in everyday life), and am doing 15 minutes of stretches after all of my runs.  Since I’ve been babying my heel and arches for 2+ years, I’m wondering if I should be conditioning them over time to "toughen them up" and/or get them more used to “unassisted”  or “less-assisted” walking/running.  Questions:

• At what point (if any) should I stop wearing orthotics?  I’ve been rotating shoes and orthotics, sometimes going without (eg. Just walking around) with the thinking that they shouldn’t get too comfortable with one set system.  My hope is that at some point my high arches will be able to “hold their own” without the aid of my heavily-built up supports, but I don’t want to rush it.  Just wondering if I should be taking some sort of gradual approach to ween them off of the super-duper high arch supports that I’m currently using.  

• Are HOKA’s a good choice from here on out?  I have several pairs of different levels of cushiness that I use for all athletic activities.  Is there value in moving back to (or rotating in) non-rocker footwear or shoes that aren’t so cushy?  

Many thanks!

Dr Blake’s Response: Thanks for your feedback and great questions. I reviewed your chart today before answering so everything was clear. You developed a heel stress fracture from pounding at heel strike while running. The goal of each of your mechanical treatments are: cushy shoes for impact shock attenuation, arch supports for weight transfer into the arch and off the heel, and rocker bottom to decrease the pull of plantar fascia that push off on the heel bone. 

     So, theoretically you could now just go “cold turkey” back into traditional shoes with no rocker and no orthotic devices. I love to gradually change stresses since you are doing so well. You may find that you love either the orthotic devices or rocker bottom cushy shoes so running forever, or the orthotic devices while you have the added weight in backpacking. So, as you gradually change the mechanics, each level should be evaluated for any symptoms. 

     If would emphasize, especially for the reader, that orthotic wearers should do single leg balancing for 2 minutes each evening and metatarsal doming once a day (10 repetitions). You can use the search box on this blog to find these videos. This keeps the feet very strong if any weakness is occurring with the orthoses. 

     So, for now I would start and do half of your runs in Hokas and half in traditional shoes. Listen for any symptoms. You could very easily keep this pattern for years to expertly vary stresses. Initially, start with longer runs with Hokas and shorter runs with traditional shoes, but over the next month you will not have to be particular about the distance any more. 

If there are no increase in symptoms, in 2 months start not wearing your orthotic devices on short runs only, and short walks. I would stay this way until 4 months from now (therefore all the highest stress activities have the extra protection of the orthotic devices). If all is going well, the next 2 month interval you could either go without Hokas completely, or without orthotics in all activities but running. In two more months, you could then go with no orthotic devices at all. 

     So, this outlines a gradual 8 month progression into both traditional shoes and away from orthotic devices if that is your goal. If you have some symptoms as you change, we would have to address that if it comes up. Right now you are doing so well with all this protection, but like a cast, we eventually have to cut it off! 

I sure hope this makes sense. Rich 

Why I love Sports Medicine, and if you are injured, Why You Should Too?

The following is an excerpt from my book "Secrets to Keep Moving".

TEAM Approach Vital to Sports Medicine

What is Sports Medicine?

 

 

The sports medicine approach to injuries, athletic or not, can be very different from general podiatric or orthopedic approaches. Sports Medicine evolved from the professional and college teams needing to get their players safely, but as quickly as possible, back onto the playing fields. It evolved away from the surgical treatment of injuries as the mainstay of treatment. Was there another way to treat an injury, besides surgery, that led to the same results without the surgical scar and without the time off required for surgery? Was there another way to treat an injury without prolonged casting/immobilization of the body part? And in those early days of sports medicine (1960 and 70s), there were no removable boots available!!

 

The sports medicine approach is a paradigm switch from “Doctor please heal me!” to “What can I do to help myself get better?” The sports medicine approach is a switch from pills and shots and casts to ice, soaking, alternative exercise, home exercise programs, braces, etc. Sports medicine doctors will use surgery when needed, shots when needed, casts when needed, and medicine when needed. The doctor’s orientation to an injury is less doctor focused, and more physical therapy focused, and more patient involvement. Treating a patient with a sports medicine approach is truly an attitude difference. Hopefully, this book will infuse the reader with this attitude.

 

A sports medicine approach is in its purest sense a team approach---patient, therapist, doctor, other specialists (acupuncture, trainers, dietician, coaches, etc.) Everyone’s input is vital, looking at the same injury from different perspectives. The patient’s subjective view, experiencing the problem first-hand, is balanced by other sometimes more objective views. Having treated many athletes and non-athletes, I realize patients can be very objective about their injuries, or not at all. Most importantly, no one should advise anything that potentially harms the patient (patients have a way of doing that to themselves too much already).

 

From 1975 to 2000,  the sports medicine explosion happened. Prior to 1975, there were sporadic sports medicine centers across the country, now they dominate the healthcare world. Everyone wants to use the word sports medicine in their practices, but how do they practice sports medicine?

 

The consumer needs to find the sports medicine doctors and therapists in their areas by talking to fellow athletes, the running shoe shops, the cycling stores, the athletic clubs, and online services like Yelp.com. In podiatry you go to www.aapsm.org and go to their membership list. They need to shop around if their initial treatment plan is lacking in patient home programs, physical therapy programs, alternative exercise programs, and other signs that this doctor does not really practice sports medicine principles.

 

I personally do not think the doctor or therapist needs to play sports to be good at sports medicine, but it helps immensely. Does the doctor/therapist understand your need to get back to exercise quickly? A typical proactive program contains a minimum to 4 and sometimes 7-8 activities for the patient to do between office visits to get better. Some sports medicine physicians do leave this to the therapist, but I prefer some individualization from the doctor.

 

1. What stretching can be done?

2. What strengthening can be done?

3. How often do I ice the area, or should I soak it?

4. What does physical therapy have to offer?

5. Would alternative activities (for example, biking if it is an injured runner) help and what kinds?

6. Should I take medicine? And when?

7. Should I wear a brace, splint, or do some form of taping?

8. Should I change something about my shoe gear, equipment (for example, have my bike pedals adjusted), lacing, shoe inserts?

9. Should my training be different?

10. Will I need any tests, and how it that decided?

 

These are such basic questions that must be answered within the first 2 visits of a typical sports medicine practice. Since 99% of all sports medicine injuries are non-surgical, the sports medicine specialist, or his/her team, should be the expert in rehabilitation. It is so important for our bodies to get the best and safest treatments. We need these bodies to be fully functional for hopefully a long time.

Every health care profession has a sports medicine division. That can be a good place to look for a specialist in your area. For podiatry, the American Academy of Podiatric Sports Medicine (www.aapsm.org) is the appropriate starting place. But, I have found that no matter how you label yourself, the patient must evaluate whether or not you really have the sports medicine attitude.

Treatment for Acute Injuries: Remember P.R.I.C.E.

PRICE therapy

 

Here I will use an Ankle Sprain as an example of Acute Injury needing PRICE.

Following an Ankle Sprain, it is important to create a pain free environment. The keys components have been taught in High School and College Health Classes forever.

 

P----Protection

R----Rest

I-----Ice

C----Compression

E----Elevation

 

    Protection is always a start so that the injury does not re-occur in the days, weeks, and months following the acute episode. The rule of thumb is that the second sprain is always worse than the first. Braces, like those worn after an ankle sprain, are needed until the surrounding muscles get strong again. However, a type of shoe, an orthotic, a pad, some tape, a splint, can also be part of the protection to give crucial “protected weight bearing”. Here an orthotic to stabilize the arch is used to protect the injured posterior tibial tendon which supports the arch. With the orthotic device in place, the injured tendon does not have to work as hard and can mend faster.

Orthotic device used to center the heel in a pronated foot.

 

    Rest is a four lettered word to most athletes, but crucial in minimizing the re-aggravation of the ankle. Rest is created by whatever it takes to make the ankle pain free. This may be crutches, removable cast, ankle brace, limited activity, and/or completely getting off the foot involved. I tell the patients that we must use Activity Modification principles, but never use the R word!! The first 4 days after a sprain is the most crucial time to chill out. Yet, since no one can really be sure 100% of the time what is wrong, the first 2 to 3 weeks following a sprain should be relatively pain free.

 

    Ice for 96 hours following a sprain is crucial. Other Anti-Inflammatory Measures are also helpful. Yet, ice is used for months and months in a typical sprain, it is just knowing when to use it that is important. You use it constantly after activity, or for 4 straight days after any flare-up.

 

Compression is also crucial to move swelling out of the swollen area. The product seen below is of Tubigrip, but a common substitute is an Ace Wrap.

The secret to compression is to put more compression below and less compression above the ankle. This may require some tape of some type to hold on the wrap above the ankle. Make sure this tape is not wrapped all the way around and possibly cut off the circulation.

 

Elevation of the foot and ankle even 1 inch off the floor is very beneficial. As long as it is comfortable, and as long as there is swelling, try to elevate the foot and ankle as much as possible. Super Elevation once a day for 30 minutes is very important. Super Elevation is where you lie on the floor and elevate your foot on the wall or couch 3 feet above your heart. Combine this with compression and gentle non painful range of motion of the ankle and the swelling will improve  greatly.

The above is from my book "Secrets to Keep Moving". I hope you will read it to learn how I practice podiatry.

My wife, Patty, and I just got back from a great week in South Lake Tahoe. We had some excitement with an experience with a nearby bear. The sunset was glorious, but the orange/red glow is from the Wildfire nearby! Sad!

Healing Plantar Fascial Tear Images: Dark, Intact, but Irregular

This is my grandson, and one of my best friends, Henry. Henry is shown here starting Kindergarten about 3 weeks ago. He says his favorite is "Math" because he loves looking for "Patterns". Just an Angel. 

Here is an MRI image for a plantar fascial tear healing well. The plantar fascia is this dense band of fibrous tissue that runs from the heel to the front of your foot. This image is at the 6 month point, therefore a second MRI. The fibrous bands look mainly dark, but very irregular, as this process of healing is a bit different from patient to patient. If you look first at the heel bone, and then 2 inches in front, you can see normal looking dense regular plantar fascia that we hope will happen over the next 6 months. 

Tip for Orthotic Devices in Side to Side Sports: Keep Them Low to the Ground

High level soccer player presented today for his orthotic devices solely for these cleats. The custom orthotic must be low to the ground, so when you flip this over, the heel does not have its typical post or lift. I always joke with the patient when they bring in such bright shoes, that they better be good to wear these!!

Here you can see after flipping over the orthotic device that there is no additional lift that could potentially lift them out of their shoes. This is ideal for any side to side cutting sports where the risk of ankle sprains is higher than running or walking. 

An even closer look at the orthotic bottom (plantar) area. The orthotic device really supports the foot well and distributes weight very evenly around the foot, so stress points are harder to develop which can lead to injury. 

5th Metatarsal Fracture: 10 Weeks into the Healing Process

10 weeks ago this military vet rolled her ankle avoiding her dog and that abrupt twist fractured her 5th metatarsal base. She was 6 weeks in a removable boot with crutches when I saw her. To protect the bone, and allow her to get out of her boot and back to activity, I made a rush of some custom orthotic devices and taught her how to use KT tape to circumferentially wrap the area. She took 10 days to painlessly wean from the boot, and has been walking for 3 weeks in athletic shoes, tape, and orthotics. Since she walks without a limp, and is controlling her pain within the 0-2 pain level parameters, I started her on an every other day walk run program. She is to email me when she gets to level 5 and then level 10. If you are uncertain about this program, you can type it into the search bar. 

     She had no pain on examination today. I felt no need to xray since the fracture line never looks great on xray for the first 3-4 months. I find I can rehab the patient based on their symptoms. 

Foot Pain: Can I Off Weight? Great for the Bottom of the Foot Problems

Today I want to discuss a product I use daily, and many times each day. It is called "Adhesive Felt" with 1/8 inch the preferred thickness for the bottom of the foot. In the photo below, I am protecting a sore 2nd metatarsal with an off weighting horseshoe shaped pad. When the bottom of your foot hurts, consider this remedy. Rich 

https://www.amazon.com/Felt-Adhesive-Orthopedic-Aetna-Corporation/dp/B0053D30TC/ref=pd_sbs_2/137-5657958-3764962?pd_rd_w=NArKX&pf_rd_p=0f56f70f-21e6-4d11-bb4a-bcdb928a3c5a&pf_rd_r=6XJA9FEW5NJ0K863RMX1&pd_rd_r=707526a4-402c-4860-8d21-fd0d0634bb19&pd_rd_wg=XZAPp&pd_rd_i=B0053D30TC&psc=1

Ankle Sprain: How to Present the Injury to a Health Care Provider

I just got back from a 6 day trip to see my son and daughter in law and grandson William in San Diego. My wife and I had a marvelous time, but it is time to get to work tomorrow. Perhaps I care share one little photo of William for my readers. 

William is 6 months old and of course I am much older

     This post is about having an ankle sprain and trying to write down all the important things to tell the health care provider when you go in for the visit. However, it could apply to any injury, and it is both for the health provider and you. After the initial pain, and maybe you are still lying there on the ground, you have to start asking why? Why me? Why now? What lead up to this injury? The answers to these and other questions can help prevent other injuries in the future.

#1  What exactly happen? Fall down stairs, land on someone's foot, etc

#2  Has this happened before? Are you prone to sprain your ankles? 

#3  Did you feel that your ankle was weak before your sprain occurred?

#4  Were you doing too much prior to the injury?

#5  Do you have good stable shoes for your ankle?

#6  Do you wear ankle braces during the activity you sprained your ankle?

#7  In what direction did your ankle move during the sprain?

#8  In what direction did your body move during the sprain?

#9  Did the sprain cause you to fall?

#10 Was a pure accident like a slip on slippery surface?

I hope these questions will help you focus on the injury to get at the cause and mechanics of the injury. Rich 

Thickened Nails: Sometimes There Is One Growing Underneath!!

Hello, this is my last post for a few days as I visit my grandson William in San Diego. I will be back on Wednesday 9/8. At the end of the post, I will show you a picture of William, so very cute. 

     A patient on Monday presents with a thickened and possibly ingrown toenail. There was no pain, but it did not feel right at all. After doing both some electrical thinning of the nail, and then some manual debridement with clippers, this is what we ended up with. I surmise that this is the normal nail beginning to grow under. I will see her in 3 months and we will see how it grows back. 

     Okay, here is William. So sweet. Definitely like his mom and dad (my son). 

Calcaneal Stress Fracture: A Cause of Acute Heel Pain

https://youtu.be/8xxbQwogdb8

I love Dr. Nabil Eberheim. He runs a simple straight forward You Tube channel with great medical education. Please review some of my other posts on calcaneal stress fractures, a common cause of acute heel pain. 

https://www.drblakeshealingsole.com/2012/11/calcaneal-heel-bone-stress-fractures.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-plantar.html

https://www.drblakeshealingsole.com/2020/07/how-i-approach-problems-heel-pain.html

https://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-11.html

Academy of Neurologic Physical Therapists

https://www.neuropt.org/

     I am always sending my patients with some sort of nerve pain to seek the advice of a physical therapist specially trained in nerve pain. It took years to find out that these physical therapists had a national organization. Even though I find the website a bit confusing, any physical therapy office in your town may have an associate member. Ask the office if any of their providers are members of ANPT, or at least have a sub speciality in nerves. 

     When dealing with acute or chronic problems, I find that some many patients have a primary or secondary nerve problem. A chronic problem can develop nerve hypersensitivity needing nerve treatments, or an acute injury may be to the nerve primarily. There are easy problems like tarsal tunnel and Morton's neuroma which need nerve attention in treatment, but there are more subtle problems like chronic achilles pain or heel pain that are produced by the local nerve. 

     I always teach that there are 3 sources of any pain issue: mechanical, inflammation, or neuropathic. It is the neuropathic pain that does not respond to as well to mechanical and anti-inflammatory treatments and may need some nerve TLC. 

Use of Sleeping Splints for Plantar Fasciitis

Good morning Readers, 

     It is a beautiful Sunday morning in San Francisco, although the Fires in the West of USA are frightful!

I pray for all those that have lost their homes to these fires. 

     The question today concerns the efficacy of the posterior sleeping splints for plantar fasciitis. I have attached a link to a video I did long ago still applicable.

https://youtu.be/lyd9HAv9e9o

<iframe width="560" height="315" src="https://www.youtube.com/embed/lyd9HAv9e9o" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

I use it for the patients with morning soreness when they wake up. It is important to find out how long they have symptoms when they arise. A simple case of plantar fasciitis normally hurts for 5 minutes or so. I am surprised when I ask when the patients say that it can take an hour or so. I have even had patients tell me the pain either never feels better, or they never have morning soreness. In both these cases, if your diagnosis is plantar fasciitis, you may be wrong. There are so many other causes of foot pain incorrectly diagnosed as Plantar Fasciitis. 

So, plantar fasciitis is normally diagnosed by historical review, but a good examination is also important. I have left the link from my video on Heel Pain Examination. 

https://youtu.be/plbBvPASXwM

<iframe width="560" height="315" src="https://www.youtube.com/embed/plbBvPASXwM" title="YouTube video player" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Can Plantar Fasciitis occur in other areas of the foot? For sure!! But, a non-heel diagnosis of plantar fasciitis is always suspect. 

What is this Quick Tape? More Diagnostic for Plantar Fasciitis than an MRI for most cases!

Good Morning my wonderful readers! Yesterday I put in a plug for Quick Tape from a company near Seattle, Washington called Support The Foot. For my treatment of any heel and arch problem that I believe may be plantar fasciitis, or sometimes it is the patient who believes the most in that diagnosis, I will use Quick Tape as a treatment and as diagnostic tool. If the pain goes away while you are taping, or at least feels a-lot better, you most likely have Plantar Fasciitis. The taping is worn for about 2-3 months on average, each piece lasting a week. If the tape does not help, I begin to look for another cause of pain like nerve issues, stress fractures, and torn something. Even though not 100% accurate, it is pretty close. It is very easy to get by ordering from the website. Good luck!

Here are my students at the California School of Podiatric Medicine showing off their Quick Tape after learning the technique

I love to teach, and being in private practice, my teaching is primarily with my patients. However, I have had the great luck or fortune, to have some involvement with the school since I was a student, each and every year for the last 45 years (one year longer than I have been married). I will try to keep those 2 streaks going!!

Can I Start this Blog Over Again and a Plug for Quick Tape?

      Those of you who read each one of my posts I deeply thank you. This is my 12th year writing, and I do want to feel what is was like when I started in March 2010. I have definitely had an overall collapse in blog enthusiasm since Covid hit my reality last year. I could no longer work at the hectic pace of my youth. I am now a part time (50%) practicing podiatrist as of July 1st 2021. I am 67 years old. I have worked for 40 years trying to help people doing something I love. I wish I could thank all my teachers for helping me become a Podiatrist. The job is 24/7 365 days a year, and I am both exhausted by it and honored by serving my patients as well as I could. I will retire completely from private practice on 1/9/24 my 70th birthday. I love my little community hospital. We are one!

     In each blog post from here on, there will be something of me personally. I make no apologies. I am a deeply spiritual being, and practice podiatry from my heart. Podiatry is a profession of health. I wish all my students at the California College of Podiatric Medicine could fully understand their impact. 

     So today, I am starting again. I hope to go 12 more years, and perhaps start again. Most of my practice life is in the words of this blog, so how can I talk one day longer. We will see.

My wife Patty in blue and I just visited a friend in Sun Valley Idaho. We walk and walk where ever we go. My wife was wearing Quick Tape from www.supportthefoot.com for her chronic plantar fasciitis. I converted from the more difficult Low Dye Taping to Quick Tape for this problem now 7 years ago. 

Please help me with this change of direction. Comment below when you can. Rich 

     

     

Customizing OTC inserts: Quick Way to Begin to Change Mechanics

Podiatrists are always designing custom inserts to change a patients mechanics in some way to help their problems. Sometimes that correction is direct (like off loading a sore area seen with the horse shoe shape blue pad), and sometimes that correction is indirect (like the white metatarsal pad to help center the foot). Here I have added 3 adjustments to this Dr Scholl's inserts. The patient initially had the gray appearing heel wedge to help with pronation forces. When the patient returned, both his knee and low back had felt better with pronation control, but he was having new problems with the front 2nd metatarsal. The blue padding was then to help that. Once the inserts wear out, because I take photos of all of these inserts, I am able to re-make them if the patient sends into the office a new pair. Ah, biomechanics!!

Sesamoid Injuries: What To Do Right Away

If you hurt your sesamoids, here are tools that can help right away!

https://youtu.be/lFc5gjZDo2A

Fifth Metatarsal Fractures: Excellent Summary of Treatment by Dr Lindsey Klassen

     The above slide is from a 4 day conference I just attended in Los Angeles, California, of course virtually. Dr. Lindsey Klassen gave a wonderful presentation on fifth metatarsal fractures summarized by this last slide. 

Finding Neutral during Weight Bearing Exercises: A Wonderful Video by Dr Emily Splichal

Finding Neutral is incredibly important for properly lining up your feet and legs for bipedal (both feel on the ground) activities like gym workouts. The video below by Dr. Emily Splichal focuses mainly on the barefoot pronated position. However, this is just as important for those of you who supinate too much. Being able to center your weight with fairly equal weight on your heel, first metatarsal and fifth metatarsal can be incredibly important to a well grounded position. We called it being well stacked up, where in the ideal world the foot is properly under the ankle, the ankle under the knee, and the knee under the hip. 

https://youtu.be/Y_7Ch1uv3X4

Swollen Legs: Tip on Compression Hose

     Just sat in on a great lecture by Kevin Kupka, PT. The tip he had is that he prefers to have his patients with swollen ankles to get a light weight compression, lighter than recommended, and definitely easier to put on, and then use two of them at a time. Last about 6 months. 

Peroneal Tendon and Lateral Ankle Taping: Video Presentation

https://youtu.be/ouGN5pSwUk4

This is a new video on peroneal taping, with my last one in 2017. I go over the application of peroneal tendon and lateral ankle taping with the powerful Leukotape. So many of my patients have been able to wean out of their removable boots, or get off their crutches, faster with this taping. On the blog, I have a similar video on posterior tibial or medial ankle taping. The end result should really stabilize the lateral ankle and most patients can master the technique themselves or with the help of a partner. 

Negative Cast Pouring Position: 3 Typical Scenarios

This evening I am pouring plaster of Paris liquid into the negative cast to make a positive cast. Tomorrow I will begin the process of correcting that positive to a shape I desire to help with the patient’s pronation pattern. I have 5 pairs of casts to deal with this weekend, and this left foot, shown in 3 possible positions, is my most pronated foot of the 10. The RCSP, or resting heel position, in the patient is 12 degrees everted to the ground. The forefoot to rear foot measurement during my examination was over 10 degrees fore foot varus. The first method of cast correction is an ASIS correction. Therefore, you pour the cast at this 12 degree everted position. Although this is a very pronated subluxed position, it is assumed the foot pronates even further when standing. You are pouring, or correcting, this foot in a position of severely pronated, but you are not attempting to create a new arch (sometimes a great challenge), and you are stabilizing this foot with arch re-enforcement, deep heel cups, posts to add motion and stability, etc. This is a viable method especially with shoe fit issues, or previous arch intolerance. More in later posts. 

This same foot can be poured vertical, the classic Root technique, attempting a 12 degree change (12 degree everted to vertical). Of course this does not happen, but the orthotic made off this Root Balanced device, will be be changing and stabilizing the foot. I typically found a great need for orthotic adjustments with dispensed these for this foot, as the force of correction was too much in the soft tissue of the arch and forefoot. I began expert in making them comfortable with compromise, thus needing a new orthotic within the year as the forefoot varus (supinatus) begun less. Again, more in a later post. 

Here, this same left foot, which stands 12 degrees everted in resting position, is being poured at 20 degrees inverted to make the Inverted Orthotic Technique. With this technique, the arch is filled in to not block first ray plantar flexion vital for propulsion (per Dr Dananberg). 20 degree correction will typically change the heel valgus position from 12 everted to 8 everted. All the other good orthotic device stability measures: plastic thickness, deep heel cups, full shoe width, zero post motion, all help in making this a very stable device. Again, more in a later post. 

     Here I summarize 3 orthotic negative cast pouring positions that I have used to help with pronatory symptoms and stability. 3 different pouring positions from the lab are used for this severely pronated left foot where the fore foot varus equals the RCSP (not an uncommon issue). I propose that good/great stability to the foot will be accomplished by all techniques. I recommend re-casting a foot like this 6 months to a year after dispensing the orthotic devices (you should get a reduction in fore foot varus angulation). I firmly believe that if I can produce angular change (say 12 degrees everted resting position towards a vertical heel), overall the patient will be better off unless they have rearfoot valgus (like genu valgum). 

Common Advice for Plantar Fasciitis

Hey Dr. Blake, 

A couple of days after seeing you last week, my left foot started hurting.  The pain is on the inside of the foot right where the heel meets the arch (and is confined to a very small area).  From my amateur research it appears to be plantar fasciitis, but you are the expert.  It is not very painful -- more sore than sharp in terms of pain.  I have researched some stretches and have been icing it.  It seems fine when I exercise on my stationary bike.  I am wondering if I should avoid walking (and the bike) or whether non-strenuous walking would be fine.  Also, whether there is anything more I should do.  I could not get an appointment with you until September (between my schedule and yours) and the pain is really not bad (more bothersome than anything else).  Except for sharp pain in my left heel a couple of months ago that lasted only 2 days, I have not had any plantar fasciitis-like symptoms before.

Hope you are well.  Any advice you can give would be appreciated.  Thanks.

Dr. Blake’s comment: 

  Here is my office handout of general rules. I think your exercising is fine, but do not push through pain. Ice after workouts, and several times a day. Do the plantar fascial wall stretch on my blog. Let me know in a month how you are doing. Rich 

Plantar Fasciitis 

The top 10 common treatments for plantar fasciitis are:

1. Plantar fascial wall stretches for 30 seconds 5-10 times/day.

2. Rolling ice massage for five minutes 2-3 times/day.

3. No negative heel stretches.

4. Avoid barefoot walking (something like Dansko sandals at home).

5. OTC or custom orthotic devices to transfer weight into the arch (you must feel that the heel is protected and weight is in the arch).

 

6. Physical therapy or acupuncture (two times/week for four weeks and then re-evaluate).

7. Posterior sleeping splints when morning soreness lasts over five minutes (these can be used at any time as rest splints when you are going to sit for 30 minutes or more).

8. Low dye/arch taping daily initially and then with strenuous activity.

9. Activity modification to avoid “bad pain.”

10. Calf stretches (straight and bent knee) two times/day.