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Monday, December 15, 2014

Complex Regional Pain Syndrome: Email Advice

Dear Dr.blake
Hope you are doing well .
Just wanted to update you regarding the progress of my algodystrophy (that struke me after my sesamoiditis ) Dr Blake: Algodystrophy is another name for complex regional pain syndrome.
As this might help other people who are in pain or experienced RSD symptoms.

-          I have followed your advice and went looking for calmare therapy – couldn’t find any around since I live In a small country – I found one center who have a PBK “Italian electro machine”
The owner claims that he have amended it’s program to do the effect of calmare/ since I had no choice I tried it /
To my surprise it worked wonderfully. And after only 6 sessions  . my pain was 50 % less . now I have high hopes , I think by Christmas my aldodystrophy will be gone  "6 month after the discovery of the RSD”
So I definitely recommend calmare or alternative calmare ,  since I have tried acupuncture and other  it helped only at first.   Dr Blake: Calmare works permanently on some and some seem to need booster sessions occasionally. Calmare is an electrical current and does not involve anything invasive, like IVs or injections. 

-          My main problem is that after I heal from the main full leg pain I would still have issues with my fingers and sesamoid bones ,  because of the non bearing issue – what shall I do or start doing to improve mineralization in
That area. And as per your  experience how much time it would take to get back to normal in that area after RSD is gone. I am seriously desperate to go back to normal and willing to do anything required.
Dr Blake's comment: This patients has had very bad disuse atrophy of the bones from months of non weight bearing and inactivity. The treatment needs to be directed towards gradual weight bearing. There is no time lines that I know. Set benchmarks on what you can do this month, and reset them in next month. By gradually increasing walking, biking, elliptical, core work, etc. the strength will come back, but never at the pace you want. 

-          I have another issue , with orthotics ,  I have tried a dozen with a collection of shoes . and paid of fortune on these . still I have a problem that when I stand more than 20 minutes in these ,  I feel like I have been standing all day, and
I have to sit for a while before I can walk pain free. Also walking for more than 15 minutes give the same feeling.
I got some weird pain till the point that I thought I have RSD in the second leg . but I don’t /
I know orthotics are not supposed to be 100% comftable and that they changed our gait .   but this is really frustrating and I feel it in both legs , if I have to wear orthotics for a year or so , I really need to find a solution.
An orthopedic doctor told me that my calfs became weak and there’s too much pressure on the feets and heels= he said that  after a year of wearing orthotics my gait changed and my muscles got weaker and that I need to do stationary biking – I cannot do biking now and waiting for a month or so when RSD is fully gone.
Is that kind of pain and discomfort normal when wearing orthotics ,  what can I do to reduce it ???
Dr Blake's comment: All you can expect orthotic devices to do is protect the joint that was injured. Your symptoms seem to be bone fatigue and muscle fatigue and nerve irritability. You seem to be on the right path to restrengthen. Find the most comfortable orthotic you have and experiment with more padding, more arch support, more dancer's pads, etc. See if anything mechanical really improves the tissue threshold you are experiencing now. 
-          Regarding Vitamins .  the doctor told me to reduce smoking and it helped . he gave me raw honey since he said some new researches revealed that RSD is linked to a deficit in the immune system.
And I am taking multivitamins with extra calcium and magnesium.  For how long do you think I should continue taking vitamins ? ? is it ok to take for long months or years or this could be harmful.
Dr Blake's comment: I think that you should sit down with a registered nutritionist and attempt a game plan to reduce inflammation, improve nerve and bone health, and strengthen your immune system. 

Sorry for the long email.

I thank you a lot for your support and wish you happy holidays . Jesus bless for being such a hope for many people around.
Dr Blake's comment: Thank you, I have been so blessed by God that it is hard to ask for anything else. Merry Christmas to you. 

Friday, December 5, 2014

Accessory Navicular: Email Advice

Dr. Blake,

I have been intently searching the Web for some insight on accessory navicular and you seem like a Dr. with a solid understanding of the disorder.  I don't know whether or not you are willing to give me some advice but I thought I might ask???
Dr Blake's comment: The accessory navicular only occurs in 10% or less of the population. If you look at the illustration below, look first at the heel bone. As you move ahead towards the arch, you will see a small bone (accessory navicular) under a bigger bone (navicular). This is where the powerful posterior tibial tendon attaches and helps support the arch.The accessory navicular makes this attachment weak. 

My son is very athletic and loves to play basketball. 

 He was born with nice arched feet.  Last spring he was playing basketball with slip-on sandles and one of his bigger friends stepped on his foot injuring him.  He came home limping but was able to continue playing basketball.  While in a game a few days later something happened to this same foot, it rolled.  We backed off on it but it continued to hurt so we took him to Childrens ER where the Dr. diagnosed my son with accessory navicular.  He explained to some degree what we were dealing with.  The injury occurred in April 2013.  The Dr. gave him some arch supports and along with PT and Dexamethasone, and the Dr. said in 6 weeks he said he could start playing ball again.  We held out letting him play full B-ball until late June 2013.  After a two day tournament he said it was seriously bothering him again.  Needless to say, he started PT again and Dex.  In August we went to a specialist and he gave my son custom orthotics.  We leave the orthotics in his everyday shoes.  We bought him new basketball shoes and put some OTC sports orthotics in them with a high arch.  He is 13 now and playing school ball, he plays alot.
Dr Blake's comment: For playing he should be in the most supportive insert (based on his feel) and be taping. Try one of the taping techniques on my blog, or go to and order small size pack from them. Very supportive and can last a few days. 

His name is Luke and prior to his injury, never complained once about his feet.  He can run two miles right now with zero problems.
Do you think he is going to be fine or do you think this issue is going to keep surfacing? Dr Blake's comment: Unsure, but it is not a predictable sign that surgery is in your future. 
He is very inflexible, he cant come close to touching his toes, he used to be able to.  Do you think this is because of his condition??
Dr Blake's comment: Probably not, one growth spurt can do that to you. But, very important, unless it causes pain, to stretch out the achilles well on a daily basis. See the upper right stretch.

He walks like an old man sometimes, sometimes walking down the steps very slowly, especially after a day of playing hard.  Do you think this is because of his "AN"? Dr Blake's comment: Unsure, may just have played hard.
Other times he looks great on his feet. Dr Blake: When you have a really bad problem, you never look great until it is fixed. Kids are always hard to read. 

Do you think the Kinesiotape will help, if so how should I wrap it??

What type of strengthening should he be doing?

 Dr Blake: Find out which ones he can and can not do without pain. Pain actually shuts down the muscle and makes you weaker. I hope this helps some. Rich

Thanks for any input you may be willing give!!!  I would very much appreciate your input.

He used to run around all the time jumping everywhere now I really dont see him jump around that much, unless hes playing ball.

Biomechanics Medical History

Taking a Good Biomechanics History

    This is where it all begins in the doctor/patient or therapist/patient relationship. The time spent here discussing the historical facts of an injury or pain syndrome, and important contributing factors, can be vital in the success or failure of treatment. Why is it so vital? Follow up visits work off the success or failure of the treatment plan set on that first visit (it is why I am anal with staff to allow that patient ample time, and allow me to see them on time). If the information collected is inadequate, the entire sequence of events following may be subpar. Please review Chapter 3 on History Taking now before we go further.

    The biomechanics history related to injuries is looking for patterns or facts that can cause injuries to occur. Here are some of the many questions that normally get asked, or at least you should add to your thoughts prior to seeing a doctor or therapist. These include:

  1. Do you know if you have a short leg?
  2. Do you believe you have weak or tight muscles in general, or around the injured part?
  3. Do you have loose ligaments in general?
  4. Are you right or left handed?
  5. When you were a child did you have to wear braces or shoe inserts?
  6. Have you ever been prescribed shoe inserts?
  7. Have people told you that you walk or run funny?
  8. What has your history been of overuse injuries (non traumatic)?
  9. Have all or most of your injuries been to one side of your body?
  10. Do you have high arches, flat feet, bow legs, knock knees, bunions, hammertoes, or other abnormalities?
  11. Do you have any arthritis from your hips downward and where?
  12. Do you feel unstable in any joints?

    A skilled practitioner knows the relevancy of the answers to your problem. The answers will help point the course of treatment in the right direction. I sure hope it helps you.


Wednesday, December 3, 2014

Nerve Pain and Gait Changes with Drop Foot: Email Advice

Hello Dr. Blake,

I recently discovered your blog and certainly appreciate the expertise you share.  I see that you are aiming for the Camino de Santiago.  I would like to travel part of the camino but am struggling with my current right foot condition.  Having grown up in Madrid, Spain, I believe that you will enjoy the journey.  I am 65 years old and recently retired!  I am 5'4 and weight 120 lbs.  Other than the spine and leg issues, in good health.

In July 2013, I was diagnosed with L5 radiculopathy with right foot drop (significant).  This was very painful and the pain was mainly below the knee.  MRI did not indicate the L5 radiculopathy, only an EMG. (Dr Blake: 1 problem with low back MRIs is that they are done in spine neutral, most stable position), and not when the spine is stressed so problems with bulging discs can be missed).   After 60 PT sessions, including traction and short term use of an off the shelf AFO (which caused medial pain and per the physiatrist plantar fasciitis), and the passage of time, I have recovered much of the foot control without any surgery.  What remains has caused havoc in my life due to medial foot pain.  I have also had an orthotic with a cork base which was adjusted many times by an Orthotics Center but which I believe contributed to subsequent problems due to a tendency to "roll" the foot due to the weak everters.  I have used KT (kinesiotape) in many ways to support the foot.  More recently an MRI showed a split longitudinal tear of the Peroneal Brevis and tendinosis of the Peroneal Longus (Dr Blake: these tendons can look like this in normal ankles, so difficult to take too serious unless surrounded by major inflammation).  This occurred after initiating additional PT.  The PT indicates that I have a very weak Posterior Tibialis and is also making me a new orthotic that is to support the believed weaknesses better than the prior.  I am awaiting the new one shortly.

I recently had a gait analysis  at a Motion Analysis Center in Michigan, and the report indicates:
*** Dr Blake's notes in red
Mild R forefoot inversion in stance and swing (perhaps anterior tibial spasm)
Mildly decreased R ankle dorsiflexion in early swing (some foot drop)
Minimally decreased ankle dorsiflexion in early midstance bilaterally (antalgic stiff gait)
Mild forefoot adduction in stance bilaterally with R slightly worse than L (perhaps anterior tibial spasm)
Mildly decreased ankle plantarflexion moment in stance bilaterally (stiff not propulsive gait)
Moderately decreased ankle and hip power generation in pre-swing bilaterally
Pelvic rotation pattern reversed versus normal with protraction rather than retraction in midstance.

A fine wire EMG indicated that the TP was active 15-30% of the time when it would normally be active and only during the late mid to terminal stance (so would say 50% loss of Post Tib function)

You would not think that something that is mild/minimal would cause so much pain in the medial foot.  Certainly the lateral foot PL and PB issue causes some discomfort but that is not the main cause of pain.

Recently was referred to another physician that uses ultrasound of the tendons and he said that arthritis of the first metatarsal may be the primary issue and gave me a steroid injection which for a couple of hours helped a bit but then the joint pain was significant.  The orthopedic surgeon that referred me to his colleague for the ultrasound wondered if the problem may be the Anterior tibialis insertion in the Medial Cuneiform.  His colleague did not. (I would have to say Anterior Tibial spasm compensating for weak PT tendon and weak extensors--the ones that causes the drop foot---would be my first choice)

Given the time that has elapsed what might be fixable?  I am willing to have a custom AFO too.  Icing does not usually help.  Ibuprofen minimally helps.  I cannot take Neurontin due to side effects. 

So....the physicians are perplexed about what to do to help me.  I am awaiting the new orthotics which may or may not help.  I am interested in your thoughts/questions to help sort this out more. 


Dr Blake's comment: I am assuming that the MRI did not show a tear in the Anterior Tibial Tendon or Arthritis near the Medial Cuneiform. Have them check if the Anterior Tibial is in spasm. Local anesthetic blocks into the muscle can break the spasm, and biotox is also being used. If it is truly the anterior tibial spasm that is dorsiflexing the ankle and holding up the medial arch, then an AFO should be used until you gradually regain full strength of the ankle, and normal heel to toe motion. Let me know if you have other questions. 

Tips to Avoid Cast/Immobilization Problems

Tips to Avoid Cast/Immobilization Problems

Injuries can bring with them some form of casting to protect the area for a long enough time that the injured part has a great chance to heal. But as healing occurs to one area, other areas can be negatively impacted. The forms of casting available include permanent (plaster or fiberglass-type) and removable. All forms of casting cause a syndrome affectionately called “Cast Rot” or “Cast Disease”. This syndrome includes:

• Muscle/Tendon Atrophy or Weakness
• Muscle/Tendon Stiffness or Loss of Flexibility
• Proprioceptive Nerve Problems with Loss of Position Sense
• Cardiovascular Loss
• Weight Gain due to lessened activity
• Hip/Back Problems when the foot/ankle is immobilized due to height difference from cast side to good side

The permanent cast by far produces the most problems, but even the removable casts can be very destructive. In the rush of reviewing the x rays or MRIs, making the decision to cast, and orchestrating that the proper cast is applied, many simple suggestions are forgotten that can minimize some of the effects of cast disease. If you have a foot/ankle cast, or boot make sure the opposite foot is raised up evenly. A product called EvenUp® can be applied to the shoe on the opposite side to keep the knees, hips, pelvis, and spine level (as demonstrated in the photo above). Find out what cardio you can do to keep the heart/lungs strong (and remember the HDLs) and contain inevitable weight gain. Some walking is normally allowed with weight bearing casts as the soreness resolves, but stationary bikes on a daily basis can keep leg strength and adequate cardio.

Normally you can do pain free isometric strengthening exercises within the cast, but a physical therapist will have to show you how to do these. Normally, push painfree into the cast in all 4 directions, hold for 6 seconds, and repeat 10 times. Do these isometrics 3 times daily. Sometimes, it is appropriate to order a muscle stimulator. This can even be placed inside a permanent cast to begin strengthening as soon as possible. This is normally ordered and applied at the 2 week cast change.
As soon as the cast comes off, you may not be able to increase cardio, but you should be able to increase strength, flexibility, range of motion, and proprioception. Find out what exercise you can do as quickly as possible without risking harm. Keep pushing the doctor and/or therapist to move your rehabilitation along. A prescription for 3 physical therapy sessions (normally once every 2 weeks) can progressively build a home exercise program that you do daily.
Golden Rule of Foot: For every day you are in a cast,it takes 2 days to get back to normal. Your job, if you choose to accept it, is to move the rehabilitation along as quick as possible, without causing increased pain. Pain causes swelling, which causes more pain, which causes more swelling, and the cycle spins out of control. Be your own advocate, ask questions, make sure speedy rehabilitation is part of all those involved mindset for you. Tell them you want to soak to reduce swelling, you want to do exercises for strength, flexibility, range of motion, and proprioception. Tell them you need to get safe but effective cardio as soon as possible. Keep it moving! Another Golden Rule of Foot!!

Monday, December 1, 2014

Giving a Good Sports Medicine History: Come Prepared (type if you can)

Giving Good Historical Information: Helping to Steer the Course of Treatment

I have watched ships and boats sail through the narrow channel between Portovenere and the Island of Palmaria along the Italian Riviera. They perform this task so effortlessly since they have done it so many times. In the medical arena, an important time to steer the ship/treatment plan in the right direction is by giving good historical information. Come prepared with the information typed (unless you have great handwriting typing in the best). Point your doctor or therapist along the right path/channel and it will help you get better faster. Think over each question carefully when answering. The process will clear your head and keep you focused on the most important aspects. While many of these questions can be the most helpful clues, it may also free the doctor/therapist to ask the key specific questions related to your specific injury (for example, does your painful knee lock where you can not bend it?)

I would like to introduce you to a mnemonic that I used in medical school for asking a great history. The basic questions over the years have remained the same and the hallmark of great history taking. I hope you can take these questions and make them paint an accurate picture of your problem for the doctor/therapist you see next. If they are not impressed by your organizational skills, I will be amazed.


The mnemonic goes like this---
F Family History of similar problem? Frequency of pain (how often)?
A What is your Assessment of the problem (what do you think it is)?
What part of your Anatomy is involved?
I How Intense (use Pain Scale) is the pain? What Irritates (makes it
L With one finger, point to the exact Location of the worse pain?
E What Eases the Pain? Does the pain have an Electric sensation with it?
D What has been it’s Duration (how long has it been going on)?
O What were all the events surrounding the Onset of Pain? Are there
any Observable skin changes?
P Pain Scale (0-10) Sleeping? Getting out of Bed? During Activity? End
of the day?
Q What is the Quality of Pain (burning, tingling, dull ache, sharp,
numbness, throbbing, pulsating, etc)?
R Is there Redness? Does the pain Radiate and where to?
S How does Shoe gear or barefoot affect it (or high heels, or various
types of shoes)?
T What have you done to Treat the problem? What Treatment has
helped? What Treatment has made it worse?
U Are there Underlying Health Issues (diabetes, osteoporosis,
arthritis, poor circulation, etc.)?
V Does the pain Vary (better at different times, worse at other times)?
W Can you Work? Were you injured at Work? Does this affect your Work

Sunday, November 30, 2014

Achilles Tendinitis and The Tip of the Iceberg Concept

Are You Looking at the Tip of the Iceberg?


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

1. Straight overuse situation in which the Achilles Tendon is put in major stress (i.e. stair running for the first time, or working out too many days in a row, etc.)

2. Very tight Achilles Tendons.

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


4. Unstable shoes, or excessive wearing of shoe gear with inadequate support (i.e. too much time in the flip flops, etc.)

5. Short leg with compensation of early heel lift.

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

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

8. Very loose Achilles Tendons from over stretching or patients with loose ligaments in general. This produces a weakness in the tendon (see future post on the force/length curve).

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

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

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

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

2. Mild Injury/Moderate Severity of Cause

3. Mild Injury/Complex Severity of Cause

4. Moderate Injury/Mild Severity of Cause

5. Moderate Injury/Moderate Severity of Cause

6. Moderate Injury/Complex Severity of Cause

7. Severe Injury/Mild Severity of Cause

8. Severe Injury/Moderate Severity of Cause

9. Severe Injury/Complex Severity of Cause

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

1. Mild Injury/Moderate Severity of Cause

2. Mild Injury/Complex Severity of Cause

3. Moderate Injury/Moderate Severity of Cause

4. Moderate Injury/Complex Severity of Cause

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


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

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

Saturday, November 29, 2014

Knee Pain from a Podiatrist's Perspective

As a podiatrist dealing with foot mechanics, I am called to treat knee pain all the time. I have learned that there are many ways to help knees and understanding some basic principles can be greatly helpful. When I first joined the practice that I have enjoyed these 33 plus years, it was primarily an orthopedic practice. Most of my patients the first few years were there for knee pain treatment. I was fortunate to have Dr James Garrick, orthopedic surgeon, and Jack Rockwell, physical therapist, to help me develop my skills in treating knee pain. Of course, the patient's feedback on our treatments greatly helped me fine tune the process.
The schema below is meant to just begin to orientate you on knee anatomy. When talking about the knee, you talk about the quadriceps and patella (or kneecap) in front, the hamstrings in back, the "medial" side is closest to the other leg, and the "lateral" side on the outside of the knee. Podiatrists are not called to treat acute knee injuries initially, but need to know the mechanics when called to initiate treatment during the post surgical Restrengthening or Return to Activity phases, or when the surgeon is attempting to avoid surgery in the first place. Shifting weight, stabilizing the knee joint, strengthening the knee, etc, are all in the realm of a podiatrist during visits to help knee mechanics. Podiatrists are called routinely to treat knee injuries that are overuse in nature. This is 98% of knee pain that presents to an orthopedic practice. They are typically non-surgical problems and respond well to many general treatment principles that will be presented here.

    Podiatrists mainly deal with foot and ankle problems, but the knee is not far behind. This is because the knee is so influenced by changes in foot position from the changes in shoe gear to the design of orthotic devices to the activities they participate in doing. You really can not treat the foot in isolation since “the foot bone is connected to the ankle bone, the ankle bone connected to the leg bone, etc etc”. The knee is influenced by the foot/ankle complex biomechanics, but also by its own independent joint motions, and also influenced from the hip and spine above. Some patients have a one to one relationship between their foot and knee mechanics, and some have a reverse relationship where the foot moves in one direction and the knee another direction. It is crucial to watch your patients walk and run and see what the influence of changes in biomechanics of the foot mean to how the knee moves (you can place the patient in different shoes, different wedges, even different speeds of running). The knee is like the big toe joint in that it is actually two joints in one (“double the pleasure, double the fun”). There is the joint between the femur (above) and the tibia (below), and the joint between the femur and kneecap (aka patella). Problems can occur from one or both joints at the same time. There are so many issues on how the knee cap moves that I can not keep up with all the names for the same problem (patello-femoral dysfunction, runner’s knee, dancer’s knee, biker’s knee, chondromalacia patella, quadriceps insufficiency, etc).

In general, the knee moves with the foot. As someone walks and runs, you want internal rotation at the knee following heel contact (as the foot pronates). This motion is crucial for shock absorption at the foot, ankle, and knee. Then, you want external rotation at the knee from midstance to push off as the foot supinates. These motions, when in sync, produce little or no stress on the knee. But, when the motions are excessive or limited in one area or in opposite directions, trouble occurs. Orthopedists have been studying knee motion for years, along with physical therapists, so they can sense when the motions (or lack of) are problematic. I believe it is really having someone take the time to assess these simple issues to suggest if changing the abnormal stress can help the symptoms. I find gait evaluation to be crucial in this area, not only in the discovery phase, but then in changing the motion to reverse the abnormal stress. I think here lies the problem with knee pain. The physicians and PTs see the abnormal motion, but do not know how to reverse it (sometimes impossible), so surgery is too often gone to. 

What are these abnormal stresses that are easily observable in gait?

     When we watch someone with knee pain walk and/or run, you look at various aspects of that motion that can produce problems and has cures. Unfortunately, since we are always looking for clues on what we know, sometimes we miss the real problem because we simply do not understand it. All of the following observations can cause problems and can be broken down to various treatment modalities.  These gait observations include:  

What is the foot doing? 
What is the knee doing?
Is there abnormal pronation that is effecting knee motion that can be treated?
 Is there abnormal supination effecting knee motion that can be treated? 
Is the foot pronation linked with internal femoral rotation, or does the knee externally rotate at that time? (indicating opposite motions)
Is there varus thrust at the knee with excessive foot supination, or with excessive foot pronation? (causing wear of the medial knee compartment)
Does the foot pronate while the knee remains straight? (where torque stress can build up in the knee joint)
Is there limb dominance to the side of the worse knee pain? (Possible sign of short leg syndrome)
 Is there excessive internal femoral rotation more than foot pronation? (Possible sign of weak external hip rotators)
Is the knee functioning too flexed, instead of straightening during midstance? (Possible sign of tight hamstrings)
 Is the knee functioning too straight, instead of flexing during the heel contact phase? (Possible sign of weak quadriceps)

Let us take for example the patient who functions with the knees too flexed. It is typically caused be tight hamstrings (I am in that club!!) Here is a discussion on developing a good hamstring stretching program. 

Hamstrings tightness is very common to athletes. Stretching of the hamstrings is one of the 3 most important lower extremity stretches that should be done both before (to prevent injury) and after (to gain flexibility and relax muscles) exercise. The other 2 muscle/tendon groups crucial to stretch are achilles and quadriceps. I feel most stretching articles are too overwhelming with 5 plus exercises. I would rather you understand one well, before proceeding further. For this discussion, I am only going to talk about Lower Hamstring (not Upper) Stretching.

The photo above shows the basic lower hamstring stretch getting the muscle/tendon loose around the back of the knee. The patients are told to place their heel on an elevated surface, like a chair or bench, where they feel no tension placing it there (the ballerina is showing off as usual). The knee should be held straight and the toes straight upwards. The patient should not attempt to touch their toes which places too much stress on the back. It is emphasized to the patient to lean forward over the leg being stretched feeling the bend at the hip joint, not the back. Imagine the back as completely straight. Lean forward over the leg until you feel tension behind the knee. It is very important since you are standing on one leg to feel very stable. Be near a wall or table that you can hold on with your arms if needed to gain stability. Do not make this into a balancing exercise.

       Once you feel a great stretch, hold the stretch for 30 to 60 seconds (I love 5 to 8 deep breathes to get oxygen into the stretch. With every exhale, go slightly deeper  into the stretch). There should never be pain with stretching either during or after. Pain during stretching will always mean 2 hours later you are tighter than when you started. Pain after stretching means you stretched too hard and next time stretch easier.

When stretching both legs, I like to alternate sides. The three stretch variations for the lower hamstring is all based on the big toe position. Let us discuss the right side, and I will leave it up to you to do the opposite for the left side. With the big toe at 12 o'clock, lean forward over the leg until you feel the pull of the hamstring behind the knee. Hold this painfree stretch for 30 to 60 seconds, or 8 deep breathes. Then do the left side. The second stretch for the right side is with the big toe at/near 9 o'clock. This gets a greater stretch on the medial hamstrings (semi-tendinosis and semi-membranosis). Then do the left side. The third stretch for the right side is with the big toe near 3 o'clock. This gets a greater stretch on the lateral hamstrings (biceps femoris, long and short heads).

You may be very surprised that one of the three stretches gets the sore muscle/tendon better than the other two. If so, do one more stretch to this variation for 8 more deep breathes, or go back it that stretch alone several times a day.

The photo illustration above shows the upper hamstring stretch. It is so important to stretch both the upper and lower hamstrings. This athlete is quite limber, so most of my patients will put their foot up on a wall to hold it for 30 to 60 seconds. It is okay to have your knee slightly bent. You should feel it high up on your thigh. 

Probably the most common knee complaint that a podiatrist 

will be called into treatment involves the kneecap.

  • Also called Runner's Knee, Biker's Knee, Dancer's Knee

  • Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc...
  • Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation illustrated by the young women with her right knee below

  • All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO with short arc single leg press and quad sets, and
  • Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.   

Bauerfiend GenuTrain Knee Brace for Patellar Tracking Issues

Here is some advice I emailed a patient inquiring about knee pain and flat feet:
Dear Dr Blake:

I am in a conundrum.  Spend out of pocket to see a podiatrist or spend out of pocket to see a PT.I am Flat footed.

In 1990, my right knee hyper-bent with 150 lbs of backpack weighing me down with my right foot stuck in snow as the left foot slipped downward.
Current symptoms:
- Clicking knee cap
 - Kneeling on carpet, great pain until the knee cap pops into place from pressure upwards
 - Grinding knee upon flexing
 - Pain on the inside of the rt knee and lower left quandrant of patella
 - Pain and tightness from right side of knee up to the hip
 - Pain behind my knee at the back (anterior)
 - Extreme pain in knee and hip when rising up from a kneeling position
 - Pain and tightness on the inside of my thigh at the knee
 - Feeling of being swollen in the knee itself
 - Walking in running shoes with support is OK at best
 - Walking in dress type shoes with no support results in pain after 25 yards or so
 - When I use to take spin classes, the instructor noted an outward or inward? movement of my leg/knee and asked me to keep it straight, which I could not. 

I have sat at a desk for 8hr/day for the last two years ~ the first desk job in my life and this may be part of the problem.
I am self pay ~ no health insurance.
What would the cost range be for a diagnosis by you, treatment and possibly orthotics?
How long would it take, should we work together, to know if your regiment for me is working?
At what point would it be wise to pony up for an MRI?  Do I need one?
I am 53, and until recently, in good shape if not great shape.  I need help!
Best always and Happy New Year!
Robert, Thank you for the email. This is definitely a question about timing of treatments when both can be very helpful.
   With that much knee pain, you are really in the immobilization/anti-inflammatory phase. Orthotics would be part of a restrengthening/return to activity phase. The immobilization is any thing that creates a pain free environment, from braces, to shoes, to activity changes, and yes, to orthotics if that is what it takes.
    I would tend to have a PT cool  your knee down first, and then add orthotics when you are ready to increase your activity again. Orthotics can play a role when you are throwing everything into the treatment arena but the kitchen sink (an approach used with unlimited funding).Definitely, cool the knee down with PT and Icing. The icing for the knee must be 30 minutes 3 times a day. Yes, 30 minutes is normally needed to get deep into the knee.   Try to stay away from anti-inflam meds since they can slow bone healing. Get an MRI, around $500 self pay, if your symptoms plateau (look at it one month at a time).   Try to create a pain free environment over the next month, which may mean staying in your most stable shoes. You can also try Sole over the counter Arch Supports (get one of the soft athletic versions). These are easy to adjust.You have already established a relationship between your feet and knees, but see if you can get them calmed down, less fragile, over the next several months.

Wedging of Medial and Lateral Compartments

The knee joint has 3 compartments.The anterior compartment is the patello-femoral  

joint, and then you have the medial and lateral compartments. All 3 of these compartments 

can get degenerative changes where possible surgeries with joint replacements are 

common place. Podiatrists are typically called into this arena to wedge the foot/shoes to off 

weight the knee compartment that is initially compromised. In the US, it is typically the 

medial compartment, and in Asia, the lateral compartment with more knee flexion as part of 

that culture. It is amazing how difficult it is to predict how effective foot wedging is on these

compartments, especially the medial side. 

Podiatrists are taught to invert the wedge when the foot pronates excessively for medial 

compartment disease, orthopods do the opposite. If the foot is supinated or neutral, then 

both specialities valgus wedge the foot to help the knee. Both specialities do the same 

varus wedging for the less common lateral compartment disease.

dreamstime_s_25432096.jpgAs a podiatrist, I team up with orthopedists to treat many knee conditions. One of the most gratifying is the treatment of lateral knee compartment disease. In attempt to avoid complete or partial knee replacements, I am asked to varus or medial wedge them to open up the lateral joint line. I can not tell you how successful it is, but I have many very happy patients. The treatments are always teamed with a variety of other treatments including synthetic cartilage injections, knee braces, knee strengthening, shoes selection, icing, and some cortisone shots.

Ilio-Tibial Band Syndrome:

  • Runs from the lateral pelvis, across the lateral side of the hip and knee, and attaches into Gerdy's Tubercle on the proximal lateral aspect of the tibia (in front of the head of the fibula).

  • Women tend to get pain at the hip due to their wider pelvis, men at the knee.
  • Ilio-tibial Band Syndrome is almost exclusively a repetitive stress syndrome caused by running.
  • Excessive Pronation causes the ilio-tibial band to rub across the lateral femoral epicondyle at the knee, or greater trochanter at the hip.
  • Excessive Supination strains the band as it attempts to stabilize the lateral aspect of the hip and knee from the varus stress.
  • A short leg syndrome can commonly cause iliotibial band syndrome as the band attempts with every step to straighten the legs (to no avail).
  • Treatment includes correcting the biomechanics, icing several times a day, strengthening the hip abductors (core in general), and stretching the IT Band alot. I especially love the lateral wall stretch and the use of the ethafoam roller on the IT Band.
A patient with classic limb dominance to the left suggestive of short leg syndrome. It could also be excessive supination on the left only throwing the hip laterally. The IT Band can get very unhappy as it attempts to constantly stabilize the lateral hip and knee. 

Pes Anserinus Strain is another running related injury.

The illustration above shows this very unique structure on the front and inside of the knee (anterior and medial) that is designed to stabilize the knee at heel contact. I see this as a secondary help to the knee joint in high stress like running down hills when the quadriceps have to stabilize a force up to 10 times body weight. The Pes Anserinus is made up of 3 tendons conjointly attaching in the front of the knee. The 3 tendons are the Sartorius (hip flexor), Gracilis (adductor), and Semi-Tendinosis (hamstring). So the quadriceps are helped medially by the pes anserinus and laterally by the ilio-tibial band.

When Do We Begin To Save Our Joints?

    Just saw Lynne several days ago. Lynne brought up the age old question at her young age of 59 "do I stop running now to save my knees for the future?" Her knees have some X-ray and MRI findings of wear and tear. Lynne has never had any pain. She did have an episode of knee swelling and sought medical advice. Age old probably sage advice is to stop running since it is the most stressful of her activities on her knees.Lynne is high level triathlete. Yet is it the best advice for Lynne? Does running chew up your knees and hips and ankles silently until you wake up one day and can not walk? What do we know about the Nutritional Theory of cartilage health? What protects joints? What breaks them down? So many questions to be individualized for each of us.

    My bias for recommending to Lynne to keep running comes from 5 factors. #1 Joint Cartilage is feed from pressure created in the joint from activity (nutritional theory of cartilage health). #2 Pain is our friend and will normally tell us way before severe damage is created that we must start limiting certain activities. #3 Sports Medicine for podiatrists evolved from being able to get injured knee patients to run pain free when the medical establishment was telling them to stop running forever, and I come from that time period of the mid 1970s.. #4 I personally want to keep exercising until I am 100 and I will continue to find ways to exercise (my last 3 orthopedic injuries found me at odds with surgeons wanting to cut, and I was able to successfully rehab each one, and am back playing full court basketball painfree). #5 When you break away from generalizations like stopping running to avoid knee wear and tear, you must own your knee more directly and do positive things daily for it.

    So, Lynne had been running for 40 years, never had knee pain, did get swelling and her images showed classic wear and tear of a 59 year old. She did not have the knee joints of a 90 year old, so all the running she has done has not been bad for her knees. There was a famous study from Sweden or Norway (way up there) in the 1970s. Twelve 90 year olds who had died had there hip joints examined. All 12 never had hip pain. 6 of the 12 were very active their whole lives. 6 of the 12 were very inactive their whole lives. Guess who had the hip joint cartilage of 20 year olds--yes, the active group. The 6 individuals who had been inactive had hip joints of 90 years old (and not a day older). This study helped secure the global recognition that the cartilage in our joints needed pressure to drive the synovial fluid into the cartilage (a form of forced feeding).

    Lynne stopped running to save her knees, but may be actually speeding their demise. Lynne can sure be smarter and try not to run down hill frequently where the force that your knee must absorb is up to 10 times body weight. And Lynne can get her knees strong with daily quad sets, straight leg raises, and short arc quad leg presses. Since most of her problem with wear and tear is behind the knee cap, and the load on the knee cap increases dramatically over a 45 degree knee bend, Lynne should do her activities and exercises in a 0 to 45 degree flexion range. Running is perfect for that, some parts of biking may not be. Let pain be your guide.  Lynne should ice her knees with swelling or pain after activities, she should wear a knee brace (I love the Bauerfiend GenuTrain for this problem) when she runs to see if it helps. She could also learn the many ways of taping her knee like McConnell Taping. She should take glucosamine daily. And lastly, Lynne should listen to her body and get back out there, and not listen to general rules that may not apply to her. And as Sue Sylvester on Glee says: And that is how I C it!

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