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Friday, December 6, 2019

Movement: One of the Secrets of Life

Movement: One of the Secrets of Life

For over 35 years I have watched a wonderful group of patients dedicate themselves to motion of some sort or other. They are not the athletes you read about in the papers; some would not consider themselves athletes at all. But they deeply understand that movement is crucial to their lives. I have helped them occasionally through life’s ups and downs, but mainly observed them and been inspired by them. This motion may start physically with some activity, but it is part of a larger pattern of involvement in life. They are engaged in life, inspired by some passion, or just very, very grateful for their time here on this planet. Daily they open the package called “the present” and celebrate in their own unique ways. 
I have come to appreciate the movement or rhythms of their lives. I can only weakly imitate some, as I try myself to find my rhythm of having a successful life. It is a type of success in life that is taught through movement, respect of the body and of others. It includes a respect of the soul, that inner force that calls each of us. That movement is away from the couch, away from self-pity, away from inertia. It is one of the deepest secrets in life that I know. Most 80-year-olds know that if you stop moving, you might as well cash it in. They understand. I hope I understand at 65. Can most 20-year olds-understand? It probably depends on how reflective they are.
The struggles to keep going are sometimes the food of the soul. In injuries, or disabilities, great lessons are learned. But in appreciating movement, deep truths are experienced and learned. An athlete that is self-centered has not learned the truth. A true athlete will learn many truths (humility, patience, kindness, etc.) when the secret of movement is realized.
One example of a person in motion is from my early days at Saint Francis Hospital in San Francisco. There was this funny old doctor when I first started—Dr. Waldo Newberg. Funny because he ran everywhere; between the office to the hospital, his car to the office, the elevator to the lunch room. When I first met him, I didn’t know what to think. I hadn’t learned the secret lessons of motion, even though I was an athlete. Dr. Newberg had seven children, donated time and money to the missionaries in Africa, ran the San Francisco Marathon when he was 80, and he was never rushed to say hello, or to answer any question.
My mother-in-law, Marilyn, was another wonderful example of a person in motion, even though she would say she is allergic to exercise. Her day is one of beautiful movement. A mother of five, with all her children and grandchildren in her daily conversations and concerns, she was always helping out. Always driving where she was needed, always bringing the family closer, always a beacon of love for those fortunate enough to know her. You never knew what city Marilyn will spend her day in, but everyone always felt her loving force, moving the conversation along, moving the grand kids to another event, moving the inertia personally from this world in a fully centered way.
So this movement is with the body, but it must come from the heart. It must come from deep within us. When it comes from this depth, a force is noted by all those around. It becomes an inspiration for how to live our lives. I felt that with my basketball, and my recent training and walking the Camino de Santiago in Spain. I feel a deep connection to my well being in my struggles and successes to move my body as I did as a 20-year-old. My job would tie me to a desk, dragging me into stillness, dragging me into 40 more pounds. I need movement to pull me out of my inertia and awaken my soul. I am a better person because of it. Now that I have finished my 500 mile journey across Spain, I pray I can find another way to keep moving, keep being engaged, keep caring, keep loving today for the present it is.

The preceding is from my book: Secrets to Keep Moving

Sesamoid Fracture Email Advice

Hi Dr. Blake,

I wanted to thank you so much for recommending hiking shoes to me a while back in August of this year. I was able to do some light hikes and felt comfortable for the most part.

However, I’d like your opinion on my sesamoid and if you think I have a fighting chance of it ever healing. I’d be happy to pay you for this opinion, so please let me know how I can. I’m worried that I may need surgery and I’d love to send you my xrays and mri if possible. Let me know if you accept them via drop box or if you want me to send to you.
Dr. Blake's comment: Yes, please send. You can give a donation on the blog, but none is required. They are sent to Dr. Richard Blake, 900 Hyde Street, San Francisco, Ca, 94109. Email at when you put in the mail to be on the lookout for. 

Here’s my story: Late September 2018, I was experiencing severe foot pain and decided to wait a week until I would visit a doctor. On October 2nd, I went to a podiatrist and he diagnosed my right foot with a medial sesamoid stress fracture. I was in the air cast for about 8 weeks and then he recommended I use a u shaped pad for offloading in my tennis shoe for two months. After walking about a week in the tennis shoe I experienced a horrible relapse in pain and was unable to walk comfortable. Any weight placed on my foot was painful. I visited them again and they recommended a cortisone steroid injection. He injected it right into my fat pad on the ball of my foot and it did absolutely nothing except cause my foot to swell and increase in pain. After 2 weeks of feeling worse pain, post injection, I decided to get a second option and visited and orthopedic surgeon.
Dr. Blake's comment: Yes, no cortisone injections around bones you are trying to heal. Hopefully they gave you short acting cortisone which is safe for the bones, but really not that effective. 

The orthopedic surgeon said I had lots of edema and that my fracture was still not healed. He recommended me to be completely non-weight bearing for 2 months. I used either a knee roller and crutches for that time. Once the 2 months was up, my pain decreased from a 9 to about a 4 and it has remained a 3-4 since early February this year.
Dr. Blake's comment: Even though non weight bearing is almost never necessary, your case it is was justified since you have to get the pain down to within 0-2 for healing to occur. 

I’ve visited this orthopedic surgeon and another one and received the same recommendation. Use a carbon foot plate and get custom orthotics with a cut out for my sesamoid. I’ve work these since March and though I am able to walk it has not improved. Walking for a long period of time or bending back the ball of my foot (for example, when trying to do a push-up or calf raise) still causes a sharp pain or dull ache in the bottom of my foot to the point I cannot do these activities.
Dr. Blake's comment: When you get an MRI, and I like them early in sesamoid injuries, it is a baseline. 6 months later you typically get the next one to compare. I like going to the same place for both if the quality is great. I like 3.0 Tesla if you can get that, but Saint Francis has 1.5 which is very good. You can ask the doctor reading if it is good quality. Doctors know. So many times at the 6 month interval MRI the sesamoid is clearly only 25-50% healed. At least I can help the patient with their expectations then. 

I’ve told my doctors this and they say to wait it out or proceed forward without recommending any further treatment. I just would like to know if my sesamoid has a chance or if I need to proceed with surgery. Based on my mri please let me know if you think a bone stimulator, contrast bath or if you have any other recommendation would help me to avoid surgery! 
Dr. Blake's comment: Will do!! Rich

Thanks again for your help. Your help is greatly appreciated. 


Wednesday, December 4, 2019

Standard Sesamoid Fracture Treatment Orthopedic Viewpoint

     This is the standard sesamoid treatment in the podiatry/orthopedic world. It is standard of care, but there are so many other options available. Unfortunately, surgery is the norm for many treating physicians, and I know this is only a superficial article by a brilliant doctor. I read any and all articles on sesamoid injuries, because I am always trying to have one more trick in my ability to heal sesamoid fractures. This week I have had 3 patients come in that I successfully treated for sesamoid fractures over the last 20 years, going back to full activity, and without the need for surgery. They were not in the office for the sesamoids but for another problem. If you have a sesamoid fracture, please read through this blog for the 30 common aspects of treating sesamoids. Perhaps you can send me a tip that you have found vital to your healing or the healing of your patients. The basic message with ball of the foot pain is to get to a diagnosis early, create a 0-2 pain level quickly, and do not settle for providers telling you that if you are not better in a specific period, then surgery should be done. It definitely has taken me over one year in most cases to decide on surgery in the less than 5% of all sesamoid fractures I see.

Monday, December 2, 2019

Biomechanics Lecture at the New York College of Podiatric Medicine

To Ice or Not to Ice: That is the Question?

     Here is a nice article that proposes, and quite well, that health care providers ice their patients too much, and to the patient's detriment. I believe that there is a role for ice, but solid sports medicine principles are 1) non painful motion (movement) is always better than rest, and 2) ice is to control swelling, contrast bathing is to remove that swelling. Contrast bathing (going from hot to cold submersion) is the most powerful method of reducing swelling. I can always tell when a patient is not contrast bathing when they have more swelling at a followup visit. When this good article did not even mention contrast bathing, which should replace icing at day 4 or 5 of an injury, I realize that they have too much at state condemning icing.
     Each individual is so different and each body part is so different. For one patient, ice needs to be deep so 20-30 minutes is needed. For another patient, 5 minutes of icing will do the trick since the injury is very superficial. This is also why the article is correct since patients are told to ice, but sometimes left alone on how long, how many times per day, and for how many days. If it is a month between office visits, you can see how ice can get a bad name.
     Yes, we need inflammation to heal, but icing if done correctly will just control the inflammation and not let it get out of hand. I love my patients to ice right after they aggravated something, but do contrast bathing when the injury just needs swelling reduction. And yes, I could go on and on. One of our PTs never used ice, and his patients were the ones that had bad flareups after PT. All of our other PTs used ice when appropriate and the patients had more comfort.

Tuesday, November 26, 2019

Part of Proper Shoe Fitting with Orthotic Devices

When I am fitting a wide orthotic device like an Inverted, I must place my fingers along the distal medial edge and make sure it is sitting on the base of the shoe. I do not want it to hang up on the edge, as that will tilt the whole orthotic device and jam up the first ray. 

If that is the case, you have two choices. You can narrow the entire orthotic plate from medially, and lose some of your correction. Or, you can take off the distal medial corner only, like in a first ray cut-out, which maintains the original support. 

Sunday, November 24, 2019

Shoe Wedging for Pronatory or Supinatory Problems

This post is a photo coverage of the common steps I use in shoe wedging for severe supination or pronation issues, that custom foot orthotics are not adequate enough.

This is a patient that had a complication in ankle fusion which left her right foot in varus foot (leaned to the outside) with terrible ramifications for her foot and the rest of her body.

First the midsole of the shoe is split with a 10 or 11 blade scalpel about 2 inches deep and within an inch of the toes.
Here the shoe is being stretched apart to make sure I got adequate cuts
I will then be using 1/4 inch Korex or grinding rubber that I purchase from JMS plastics in New Jersey to form my wedge.
The photo on the left shows the opening is separated as the glue dries. The photo on the right shoes both the shoe and wedge are glued and allowed 20 minutes to dry. The image below this is a closeup of the beveled wedge. 

There the wedge has been placed into the shoe and the excess removed

Superglue will used to seal any gaps 

Final product showed

Friday, November 22, 2019

Sesamoid Injury: Cortisone Shot or Not?

Hi Doctor Blake,

I stumbled upon your blog after lots of sesamoid research! And now I am asking for your help with my recovery... 

Long story short I’ve been off from dancing (just wearing special sneakers with dancer’s pads) for 7 weeks now for a micro fracture of my sesamoid. I just received an MRI with these results below (apologies if the translation from another language is weird):

Presence of bone edema of the entire medial sesamoid, with low T1 hypersignal T2 signal.  No fracture-separation of the bone, no sign of necrosis, and in particular no deformation of the bone surface.  Reactive joint effusion of the MTP 1. Light hallux valgus (confirm on radiography under load).  No sign of sesamoido-metatarsal osteoarthritis.  A little edema of hyperfunction of the plantar tissue in contact with the medial sesamoide.  No anomaly of the stabilizer of the sesamoid.  No abnormality of the hallux tendons.  Moreover no anomaly of other MTP and inter-capito-metatarsal spaces.  CONCLUSION: Appearance confirming medial sesamoiditis, without fracture or underlying necrosis.  Light hallux valgus (confirm on x-ray in charge)

I am seeing two different specialists in my country but now I have run into the problem of opposing medical solutions and I am not sure which to go with. 

One doctor recommends a cortisone injection and the other recommends oral anti-inflammatory medication. The doctor who recommended the oral medication told me that the cortisone injection is very dangerous for a sesamoid as it damages the foot’s natural padding, therefore exposing the sesamoid to further damage... 

The doctor who recommended the injection told me that the oral medication will not do anything to help the sesamoid and that all stories about sesamoid’s being made worse by injections are mainly myths and cannot be proven.

I am emailing to ask your advice on this debate? I am hesitant to get the injection because of all the mixed reviews online but it is a more “immediate” and localized option which is tempting. Do you have any feedback or success stories of oral medication? Or any thoughts on cortisone’s long term risks?

Any feedback you could offer would be greatly appreciated! 

My apologies for such a dense email, but your knowledge would be so helpful for me!

I thank you in advance for taking the time to read this email and I hope to hear from you soon.


Here on this MRI image healthy bone is dark. The light tibial sesamoid indicates a healing response from the body. Hard to tell stress fracture (can not see) from bone bruise in these cases

Dr. Blake's comment: 

 I must side with the oral medications, which can not be taken before you dance (only after). Your MRI shows that the sesamoid has been slightly injured. Cortisone will mask pain for up to 3 days (short acting cortisone and not dangerous) to 9 months (long acting cortisone). Your dance career can not risk masking pain where the sesamoid injury worsens. You can ice twice daily and do contrast bathing every evening. You must float the sesamoid with Dr. Jill's dancer's pads of either one eighth or one fourth inch (3 to 6 millimeters). These can be bought on line and worn even walking around barefoot to protect the sesamoid. I have my patients get 2 lefts (both sizes) and 2 rights (both sizes) since the adhesive is on one side and at times you are wearing it on your foot, and at times you are putting it over or under inserts in shoes. Whatever you put on your injured foot, should be on the other foot for balance. I hope this helps. Rich 

Saturday, November 16, 2019

Thursday, November 7, 2019

Ankle Sprain with Significant Ankle Problems: Email Advice

Hello Dr. Blake,

You had helped me immensely through a long sesamoid recovery 7 years ago. In the end, I made it through to fully healed with no pain! For anyone with bad sesamoid injury, you can and will make it through the nightmare!  It can be done. 

Unfortunately I return with a new issue. 2 weeks ago I twisted my ankle stepping off a curb. I had some pain, though the majority of that pain went away in a few days. Then a few days later i was pushing my kids in the stroller up a steep hill (I’m new to the Bay Area) which put my ankles into intense dorsiflexion. I started getting pain the day after and was not able to dorsiflex, but Especially plantar flex without pain in my ankle (in the back). I was able to walk on it for the next week,  but had to limit dorsiflexion to avoid pain. After seeing a podiatrist, I was recommended to wear a boot (talk about PTSD from my sesmoid injury). The majority of my pain is on the lateral side, right behind and under the boney bump of the ankle (fibula). 

Nothing showed on x-ray, which I’m starting to realizing doesn’t mean all that much.  Today I got MRI results back and was hoping you could help to interpret and provide your thoughts? Photos attached.  I clearly have a talar dome issue (cartilage), though my Dr. seems to think that’s been there for a long time. For a long time I’ve always had some minor stiffness and pain in this ankle, but it always went away after a few minutes of getting ready in the morning. I’m assuming that what that is. But since that issue is more on the medial side (whereas my pain is lateral), is it possible that’s not the driver of most of my current pain? Or could a lot of this be due to that and I will need surgery?

My Dr believes the majority of the pain is from the sprains (ligaments) that need to heal. Though I see some remarks in my MRI about “stress reaction” which makes me think that there is possibly a stress fracture, but for some reason that didn’t make it into the MRI’s concluding remarks. What are your thoughts?

The Drs plan is to stay in the boot and revaluate after 4 weeks? I also know better and will do contrast bath.  

Does all these seem reasonable?  I “feel” like there is enough pain to possibly be a fracture, but can’t tell if it’s ligaments and soft tissue issue we’re dealing with here. How long of a healing process do you think I’m really facing?  I just want to set the expectation for myself, my work, and my family correctly. 

Thank you,

Dr. Blake’s comment: thanks for the update on your sesamoid. You have a fragile ankle, and someday you may have to have it cleaned out, possibly bone graphed or replaced. Someday! I see people all the time that sprain their ankles and wake up a sleeping giant, which you could have done. You have to treat the worse possible scenario to protect you, so you place it in a boot for awhile, gradually wean out into a brace, gradually increase all activities and follow how the ankle behaves. With the goal of walking around with 0-2 pain as our guide, you go one month at a time. Have you achieved 0-2 in the boot? Do not let anyone put cortisone into your joint as it can weaken it further. If you get a bone scan, and it lights up, you can call this a stress fracture and qualify for the bone stimulator. That may just strengthen the bone enough to have you dodge the surgical bullet. Separate from your injury, I would get surgical consult from several orthopedist or podiatrists on what they would do if this does not improve. Hope this helps. Rich

Wednesday, November 6, 2019

Great Article on Running: Forefoot Strike more Prone for Plantar Fasciiits

Here is the link to "Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis":

Posterior Tendon Tendon Taping: Leukotape

Leukotape with Coverall to protect the skin is the best tape for pronation control and posterior tibial tendon injuries. It starts just below the lateral ankle bone, goes under the heel and up the inside of the ankle 2/3 up the leg

Tuesday, November 5, 2019

Anti-Pronation Shoes Work, but only until the athlete fatigues

 2019 May 14;14(5):e0216818. doi: 10.1371/journal.pone.0216818. eCollection 2019.

Effects of anti-pronation shoes on lower limb kinematics and kinetics in female runners with pronated feet: The role of physical fatigue.

This is a great study showing how stability and motion control shoes work in controlling pronation only to the point the athlete fatigues. Shoes and proper training and strength work are all key ingredients to athletic success.

Plantar Fasciitis: Support the Foot Taping

My patients know I love Quick Tape from for my plantar fasciitis treatment. It is meant to stay on up to 7 days. My wife just wore it every day in our 500 mile trek across Northern Spain to prevent her right plantar fasciitis from ruining the trip. I feel it is diagnostic also, since other problems that are not plantar fasciitis can mimic the symptoms. If you use Quick tape, and your symptoms improve, you definitely have some plantar fasciitis. 

Sunday, November 3, 2019

Plantar Fasciitis: Success Email

Dr Blake,
Your patient with the left foot plantar fasciitis that is virtually gone with your 4 pronged approach.  😊
Dr. Blake’s comment: Simple first visit plantar fasciitis treatment is rolling ice massage for 5 minutes twice daily, plantar fascial wall stretches 3 times a day, Sole OTC inserts, and Quick Tape by Works most of the time if it is pure plantar fasciitis. 

Got up the next day after tennis with oven baked Sole inserts and 0 pain. Just feeling a tiny 0.5/10 “this might return” sensation now that doesn’t limit my activities at all.

Found Quick TapeTM 3 pack on Amazon for $30 but only up to size 11, not my size 12.  I want to have them ready for use on day 1 of a flair.  Was I using regular size up to men’s size 11 from your office or is there a better source?
Dr. Blake’s comment: Use Quick Tape regular size on every one men’s 14 and smaller.

I’m stunned at how effective this has been. Thank you for this great combo treatment that isn’t on UpToDate or other reputable sources.

Look forward to celebrating over coffee, tea, meal and checking out the Sole fit at your convenience


Good Success Post Sesamoid Surgery

Wednesday, October 30, 2019

Lifts for Short Leg help Hamstring and Low Back Pain

Here are two 1/8 inch lifts under the patient’s left foot. The reason I highlight this is that the patient presented for biomechanical assessment with chronic low back, hamstring, right jumper’s knee and foot pain. In my evaluation, he had mild pronation but significant limb dominance associated with short leg syndrome. Standing evaluation noted 3/8 inch short left. Our follow up today after 2 months reveal complete resolution of hamstring and low back symptoms, and no change in knee symptoms. 

Soccer and Sesamoids: Cleat Adjustment

It is soccer season, or for some schools coming in a month, and I get alot of sesamoid pain coming into the clinic. Typically, one of the cleats  is right under the sore sesamoid. I tried to shave down the exact spike at least in half, of course the athletes are terrified I am ruining the cleats. I usually works like a charm. 

Tuesday, October 29, 2019

Heel Pain: When the Plantar Fascia is Not Involved

Swollen Left Heel on MRI showing Good Robust Plantar Fascia that I thought may be torn

The cause of the pain is an infra calcaneal bursae or bursitis. See the Black lump under the plantar fascia and pushing the normal fat out of the way.

Treatment of this Subcalcaneal Bursitis with be ice massage, off weighting the heel for awhile, very soft cushioning around the heel while cooking and prolonged standing, soft Hannaford based orthotic devices, and PT to try to drive out the inflammation with ultrasound, soft tissue mob, and electric stim and ice.

Monday, October 28, 2019

Over The Counter Insert Recommendation

Greetings Dr. Blake,

I’ve recently come across your blog, thankfully, and have been attempting to utilize techniques you’ve already suggested. I’ve had nagging type injuries most of my adult life, which have apparently caught up with me this year, as I’ve been to the doctor more than I can ever remember. Most of my issues are back pain, knee pain and toe pain, and I am sure they are all connected in some way. I recently began seeing an Orthopedic doctor after having major swelling in my right knee, which he has diagnosed as Patellofemoral arthritis, trochlear dysplasia and patella maltracking. I have similar symptoms in both knees, so although my right knee is the one that underwent the MRI, I believe I also have similar ailments in my left knee. 

While dealing with my knee issues, my left big toe became very swollen and painful. Initially my primary healthcare doctor believed it was Gout, which he began treatment for, but my blood work returned normal, leading him to say he believed I had turf toe. I spoke with the orthopedic doctor during a follow-up on my knee, and he believes I have hallux rigidus, although the testing was not very thorough, in my opinion, and there were no x-rays or MRIs completed. 

Regardless, I’ve been dealing with pain in my toe, which has lead to other pains in my foot, due to being unable to walk normally. The toe issues began about three weeks ago, and have thankfully begun to improve. I still feel pain, but it is not constant (weighted or unweighted on foot), and while my walk is still not normal, it is better than it was. I believe part of it is due to being prescribed a steroid dosepak early on, then continuing with ibuprofen, ice, heat baths, self massaging and stretching, and most recently, spica taping has helped a lot! 

I know one of your articles mentioned having correct shoes to eliminate pronating, but I am required to wear boots throughout my work day. I am in law enforcement and I have to wear black boots, thankfully, due to my role as a dog handler, they don’t have to be polished, so I’ve mainly utilized hiking boots. I recently bought a new pair, which are supposed to have a more rigid sole, but I was wondering if there were any OTC orthotic inserts you could recommend that would help improve my biomechanics when walking, and hopefully get me to the point of run easier at work. I’ve seen some claim to provide support and correct alignment within your body, but am hesitant to spend as much money some are asking for their products, without solid reviews from others with my issues. Thankfully, I’ve been fortunate to not be tested very much while attempting to deal with these newfound issues, but the day will surely come, and I’d like to be as close to my prior form as I can be. Any additional advice you may have would be greatly appreciate. 

I, and I’m sure many others, am grateful you are running your blog and giving out such great advice. The way my own doctors read these issues off made it seem similar to a sprained ankle, where just a brace and time would fix the issues, and not much in-depth information was given. 

Thank you for your time and generosity,

Dr. Blake’s comment:
Thank you for your email. And thank you for the kind words. I really like the Red Sole inserts with the black bottom. These are very stable. If the arch is alittle high you can fill it down some or a shoe repair store can take some out of the arch. Let me know how they help. Rich

Saturday, October 26, 2019

Sesamoid Pain that is Possibly Nerve Pain

     I had a wonderful chat today with a young lady from the East Coast. She has been treated for sesamoiditis for a long while, with many opinions, and recently a very smart PT said that it may be her nerves. The sesamoiditis is on both sides, and produced by going from orthotics to no orthotics over night. There has been no swelling, MRIs are negative except some swelling in the tissue around the sesamoiditis. She wore a pair of wedges that put more weight on the sesamoids but actually felt better than flats. She has an intolerance to shoes. She has a documented L4/L5 stenosis at 49 years old with minimal back issues, and disabling foot issues. She had a negative Nerve Conduction Test.
     All these findings point to nerve pain as a problem and I told her to seek a peripheral nerve doctor that understands the concept of Double Crush. I told her Nerve Conduction Tests were document nerve damage but not nerve hypersensitivity. She may need an epidural or something that is invasive, but she can start with topical nerve creams like Neuro Eze or Neuro One, neural flossing, warm soaks or contrasts, B complex supplements, TENS units, loose shoes (sorry for winter coming), and no prolonged stretches and learning how not to irritate the sciatic nerve. PTs can teach that.
     One of the golden rules I have learned about nerves is that all of the treatments to help can irritate when you first learn them. I have shown each of the above, and most of the time the patients feel great and that they help, and then another patient will say it irritated them immensely. I apologize, and try to modify with less intensity in general. If you treat pain, and what you commonly do irritates a patient, it probably documents you are dealing with nerve pain. 

Sesamoid Fracture: First 3 Months of Treatment

I forget how much I like my own video. Here is a discussion of the vital first 3 months of treating a sesamoid fracture. Of course, the first 3 months of treatment may not be the first 3 months you have  had the problem. It starts when the diagnosis is made.

Treating Heel Pain: What Type of Orthotic To Start With

In the article below from my friends at La Trobe University in Australia, they discuss the use of custom or over the counter inserts for acute heel pain. I could not agree more, that if there is no other reason but heel pain to use the orthotic devices, it is best to start with over the counter inserts. I like over the counter inserts, like Sole and Powerstep (and there are others), that I can customize if needed. The typical modifications include softening the heel area, and adjusting the arch higher or lower based on patient tolerance.

Thursday, October 24, 2019

Metatarsal Pain: Consider Bike Shoes with Embedded Cleat

     Had a patient today with chronic bilateral metatarsal pain. As we work through the diagnosis, I suggested to get bike shoes with embedded cleats to wear at least 4 hours per day to decrease the motion across the sore areas. I find thinking about making changes in the biomechanics of the patient can usually make significant improvements. This is even true when you have the patient use those changes for parts of each day. 

Wednesday, October 23, 2019

Pain Level 8 in the Heel without Swelling

     I had a patient recently with left heel pain normally around 8 on a scale to 10 for several months. The examination showed no swelling. She was unsuccessful in PT treatment, so referred by her PT to see me for an opinion. She was diagnosed as plantar fasciitis, with morning pain, but was not responding to plantar fascial treatment. 
     My first thought, which became my tentative diagnosis, was nerve pain. She had morning pain, at 8 level, but it never loosened up better than 5-6. She had orthotic devices, and felt some much better when I removed the heel posts that can focus the pressure on the heel area.
     She had some sciatica on the same side, although negative straight leg test today. What I did find is very tight hamstrings which can be from neural tension. She felt better with support the foot taping for plantar fasciitis and did hurt only at the plantar fascia. 
     So, I was getting mixed signals from her. But over the next month, she will
  1. Wear the orthotic devices with no post
  2. Wear support the foot taping if it continues to work for her
  3. Use warm not ice
  4. Use neural flossing three times a day
  5. Do no prolonged calf or plantar fascial stretches
  6. Avoid positions of maximal ankle flex ion (most stretch on nerves)
  7. Buy Neuro Eze or Neuro One from Amazon and apply three times a day
  8. Refer to Dr. Irene or Robert Minkowsky for peripheral nerve evaluation 

Tuesday, October 22, 2019

Plantar Fascial Ruptures: A Video and A Comment

Please watch this video about plantar fascial ruptures. This is a good anatomical lesson, but there is so much more to treatment for the majority of patients. I find some patients do not respond well after their initial period of removable cast or bike shoes with embedded cleats and Quick tape from At this time, you have to customize the arch support with functional orthotic devices, and probably add PT, shockwave therapy, and/or PRP injections. Different doctors in your area may be more skilled at any of these treatment components and you need to search them out. Surgery I believe is in the 1% of patients who tear the plantar fascia from partial to complete. 

Where do I go from Here?

     Thank you for reading this blog. I am in my 10th year, and I find writer’s block is my daily friend. 
My wife and I just got back from walking over 500 miles in Spain along an old, but very relevant in today’s world, pilgrimage trail called the Camino de Santiago. I helped many pilgrims along the way with my Podiatry knowledge. I experienced incredible peace and joy. I was blessed to do it with my wife Patty, the love of my life for 42 years.
     I just finished my second book “The Inverted Orthotic Technique” for Podiatrists, and I am working on my third. I hope those who read “Secrets to Keep Moving” were helped. I plan on teaching and writing more next year as I move into semi-retirement. I hope you will continue to bless me with your friendship. Rich

Thursday, October 17, 2019

Can Patients Fly After Foot and Ankle Surgery? Part 1: What’s the General Risk?

The following is a great discussion on flying risks after foot or ankle surgery. Rich

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Issue 108
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Oct 15, 2019

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Can Patients Fly After Foot and Ankle Surgery? Part 1: What's the General Risk?

  Jarrod Shapiro, DPM

PRACTICE PERFECT   October 15, 2019

Recently, I travelled to a conference via airplane, and while sitting in the airport lounge, I noted a person across from me wearing a CAM boot. It caused me to think back to a recent patient in my office who had sustained a fracture and decided not to fly to her vacation due to concerns of getting a deep venous thrombosis (DVT). I'd also had a similar patient who wanted to travel a few weeks after a surgery. I prescribed the patient enoxaparin as a prophylactic, which she accepted but didn't use when she was traveling.
This confluence of patient situations highlights how common this situation is. I also realized that I really didn't know the evidence, and therefore, didn't know whether there is significant risk for patients to do long plane flights after their foot and ankle injuries that required immobilization. The advice I've given over the years was based on wisdom that I received from my teachers and attendings and wasn't based on the evidence. As such, let's explore long air travel after foot and ankle surgery and immobilization. What is the actual risk of DVT when traveling by air? Should we allow our patients to travel by plane?
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The Basic Science
There is, of course, a logical scientific basis for the clot concern: Virchow's triangle. You'll recall this physiologic mechanism leading to increased coagulation risk is made up of blood vessel intimal injury, venous stasis, and hypercoagulability. Surgery of the lower extremity leads to all of these components, and one must wonder why we don't have more clotting episodes than we do? There are clearly balancing mechanisms to offset the clotting cascade, and it is for this reason that it's not a black and white "no, you can't fly after surgery" answer.
What's the DVT Travel Risk in General?
To gain some perspective on our question let's take a look at blood clot risks in general.
Arya and colleagues reviewed 568 passengers who went on long haul flights (defined as greater than three-hour trips in the preceding four weeks) who had suspected DVT1. They found an odds ratio (OR) of 1.3 when comparing DVT versus airline travel alone (no relationship of airline travel with DVT). However, when other factors were considered (surgery and previous DVT), the odds ratio increased to an average of 3.0.
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Similarly, Cannegeiter et al performed a subgroup analysis of a larger study, the MEGA study, that examined risk factors for venous thrombotic events (VTE) in a large cohort2 . This was a case control cohort study that compared patients with a DVT episode with their spouses (the control group). Two hundred-thirty-three patients from the original study were identified to have travelled greater than four hours in the eight weeks preceding the DVT event. They found the risk of a VTE due to any kind of travel to have an odds ratio of 2.1 (a two-fold increased risk), and travel by plane, car, train, or bus had the same overall risk. Other factors significantly increased the risk: Factor V Leiden (OR 8.1), BMI kg/m2 > 30 (OR 9.1), height > 6'2" (OR 4.7), and use of oral contraceptives (OR > 20).
Ferrari, et al, by the same token, found an odds ratio of 3.98 for VTE in people who had undergone recent travel by train, airplane, or car when compared to a control cohort3. The trips were on average 5.4 hours. The authors stated that travel alone was a risk factor for VTE.
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These research studies and others looked at the relationship between travel and DVT in groups more likely to have DVT in the first place (a higher prevalence), so we are more likely to see DVT in these groups - something to keep in mind.
Based on these and other studies the following factors are believed to increase the risk of VTE after travel4:
  1. Prolonged travel times > 4-6 hours (2x risk)
  2. Age over 40 years
  3. Use of oral contraceptives (up to 20x risk)
  4. BMI > 30 kg/m2 (up to 9x risk)
  5. History of thrombophilia
  6. Tall or short stature (up to 5x risk)
  7. Recent surgery (up to 3x risk)
Prolonged travel times of 4-6 hours doubles the risk of DVT.
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We can make two primary conclusions:
  1. There is an increased risk of venous thromboembolic events during any prolonged type of travel (somewhere in the range of 2-4 fold increased risk).
  2. Patient-specific factors significantly increase the risk of a VTE above the baseline risk.
FOR comparison, while LONG trips double the risk of DVT, Oral Contraceptives raise the risk 20x, BMI>30kg/m2 raises it by 9x, recent surgery by 3x, and strangely enough, tall or short stature by 5x.
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At this point, we can tell our patients with confidence that their clotting risk is elevated when they travel. What we haven't figured out yet is if recent foot and ankle surgery is one of those patient-specific factors that increase the risk of VTE while traveling. And that, my intrepid travel-concerned caregivers, is where I will leave you - a little cliffhanger to find out next week, when we'll discuss the clotting risks specifically associated with foot and ankle surgery and if there are suggestions we can make to patients to mitigate these possible risks. Until then...
Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor

  1. Arya R, Barnes JA, Hossain U, Patel RK, Cohen AT. Long‐haul flights and deep vein thrombosis: a significant risk only when additional factors are also present. Br J Haematol. 2002 Mar;116(3):653-654.
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  2. Cannegieter SC, Doggen CJ, van Houwelingen HC, Rosendaal FR. Travel-related venous thrombosis: results from a large population-based case control study (MEGA study). PLoS Med. 2006 Aug;3(8):e307.
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  3. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease: a case-control study. Chest. 1999 Feb;115(2):440-444.
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  4. Gavish I, Brenner B. Air travel and the risk of thromboembolism. Intern Emerg Med. 2011 Apr;6(2):113-116
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