Video discussing Sesamoid Fractures and use of Xrays

https://www.youtube.com/watch?v=I-SQjmo-hIc

Book 4 is now on Sale of Practical Biomechanics for the Podiatrist

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist3

This book is the end of my series on Practical Biomechanics for the Podiatrist. The information in these books took me 40 years to understand, practice, and see patient responses. This book reviews the topics of:

• Custom Made Functional Foot Orthotic Devices
• Computer Assisted Gait Analysis
• Common Shoe Changes Made
• 23 Patient Cases showing how to thoroughly look at a patient at each visit and make recommendations

My overall goal is for the student, resident, or those beginning to treat patients from a biomechanical lens. 

Biomechanics: Mentoring the New Generation of Podiatrists

    I just received this by email today. I lecture, write, correspond, and mentor the young generation of new podiatrists. It is very rewarding as any of you know who is involved in mentoring. Today I will spend all morning with a 3rd year Podiatry student for more of the same. It is a small but powerful act. 

Article on Sesamoid Surgery and Return to Athletics

https://journals.sagepub.com/doi/10.1177/0363546520962518

Sesamoid Injuries: Thoughts on Chronic Inflammation

Patients with sesamoid injuries deal with three types of pain: mechanical, inflammatory, and neuropathic (nerve-related). I thought this discussion with a patient would be helpful. They are trying to progress from non-weight bearing (NWB) to a weight bearing (WB) removable boot. 

Hi dr Blake, I seem to be finally making some progress as pain has significantly decreased. Starting the day of thanksgiving I have been on a knee scooter 95 percent of the time not stressing my foot at all. When I do need to walk it’s not more than a few hundred steps a day in my walking boot. I’m getting ESWT done weekly and have had a few sessions of dry needling with my PT. My custom orthotics have come in and they have been helping with the sclerotic sesamoid pain on my left foot.  I also have gone back to the gym to try and fight some of the atrophy I have faced all this time by doing NWB leg strengthening exercises. Though the pain has decreased, the inflammation is still present, and especially at the end of the day is it worse. I’m not sure when it is time to transition out of the scooter and into the boot or if I ditch the boot. Because even when I use the boot the inflammation is present. I don’t understand why inflammation is still there if it’s starting to heal, I would imagine if it’s healing the inflammation would subside. So it’s really hard to not get discouraged that maybe I’m not healing after all even though the pain has lessened. I tried to read the blog and find more out about inflammation but was hitting a dead end. Does it sound like I’m on the right track? Thank you

You are definitely on the right track, putting good pieces of this complex puzzle together. Dallas, there are two types of inflammation, acute (right after an injury), and chronic (related to the body's attempt at healing). Since inflammation causes symptoms, it is one of the hurdles you have to understand more. Swelling, which I assume you are doing contrast bathing in some regularity, will limit you, but you can still progress. Everything has to be done gradually. If you have been in a good place (0-2) for the last month, begin to transition from knee scooter to boot with your orthotics within the boot. The transition should be 2-3 days at one hour and then progress in 30-60 minute intervals every 3rd day as long as the pain remains low, and your expected increased pain is back to normal the next day. Hope this helps. Rich 

Tiem Bike Shoes with Embedded Cleats

For times when I want to immobilize the bend of the big toe joint for a while, but do not want the unevenness of a removable boot, I use bike shoes with embedded cleat. A patient came in with one the other day that I am using for a plantar fascial partial tear. I also use for sesamoid fractures, plantar plate tears, and hallux rigidus. 

Plantar View with Embedded Cleat

Top View of Tiem Bike Shoe

Cross Section Heel 
Area showing Partial Tear Plantar Fascia

Good article about the Positive Effects of Daily Walking

https://www.runnersworld.com/runners-stories/a62696452/30-day-walking-challenge/?fbclid=IwY2xjawGQbW5leHRuA2FlbQIxMQABHW29s2RxeMd0VQo3ghdUvW-ioWTrLQRmY9OvGDj5T8_eJAIZYzQRQ8kJ8w_aem_-1wG9vqnua-UH4t2-AiJ4Q

Great Biomechanics Seminar in November: Please read by Facebook Post

So happy to be invited to give 2 talks in New York this Fall. The seminar will be both in-person and on zoom. It is the best United States Foot Biomechanics Seminar. Hope you can make it if you treat patients. 

https://www.facebook.com/RichBlake72/posts/pfbid07irVmsh715HdTPgft1ZU6UAiyNQugjkf8sSTpnBYbGjDowHRihNVMbcrgTPuW2d8l

Recurring Bunions: Great Article on some Predisposing Factors

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7322783/

Chronic Sesamoid Pain: Possible Relationship to the Presence of Bunions

This is a great review of something I think about, but probably do not consul patients regarding. The blog patient commented to me how their chronic sesamoid pain could be related to a developing bunion. This is true since bunions are produced by a malalignment of the big toe joint and that malalignment can be a cause of chronic inflammation in the joint. Where does inflammation in the big toe joint tend to settle? Well, gravity pulls the swelling down around the sesamoids. So, one or both sesamoids can hurt on examination even if they are not injured themselves. This can lead to inappropriate sesamoid removal. You can get some idea of the role of the bunion has on the sesamoids by treating both the malignment and inflammation for a good two weeks. This would include toe separators or bunion taping (both can be found in this blog), and contrast baths each evening as a deep flush. You have go two full weeks to check, and not wear tight shoes that shove the bunion in the wrong direction. Hope this helps some of you guys. Thanks to the person who sent me the article!! I will answer them privately. 

https://www.sciencedirect.com/science/article/abs/pii/S1268773111000154

8 Fitness Myths to Reconsider: Definitely a Worthwhile article

    The 8 Fitness Myths presented are true myths, but I will still keep my 10,000 step rule for myself (as I do long distance walks on a yearly basis). 

https://www.nytimes.com/2024/01/04/well/move/fitness-myths.html

Ice Submersion for Acute Injuries

Great video on Diagnosing Plantar Plate Tears on MRI

https://youtu.be/JQxweI_KJzY

Excellent Article about Rotating Different Types of Shoes: Great Common Sense

https://run.outsideonline.com/gear/the-three-different-shoes-every-runner-needs/

Sesamoid Fracture presenting as a BiPartite Sesamoid

Only the abstract is linked here. It shows the dilemma patients are left with when they have bi- or tri-partite sesamoids. Fractures are missed and a needless year of suffering is documented here. We fracture at weak spots in bone. The junction between two fragments of bone like a bipartite sesamoid is such a weak spot. In so many cases, the injury is called a normal variant, and the possibility that there is a possible fracture is dismissed. If you have pain in your big toe joint, and the x-ray shows a bipartite or tripartite sesamoid, discuss the probability that this can be a fracture with your physician. 

https://www.jfas.org/article/S1067-2516(18)30550-7/fulltext

NSAIDS (like advil and aleve) can Affect Bone Healing

A well known fact is NSAIDs (non steroid anti-inflammatory drugs) can slow down bone healing. And like anything, one person will be greatly affected and another almost not at all. If you need to decrease inflammation, ice and contrast bathing remain the non drug of choice for home treatments. And of course, Physical Therapy is wonderful with their machines to reduce inflammation. There are also homeopathic remedies, acupuncture, etc. 

https://pubmed.ncbi.nlm.nih.gov/30260913/

Sesamoid Fractures: Typical Orthopedic Approach with Comments

     I have just retired. My time now can be more involved in this blog I started almost 14 years ago. One of the injuries I write about, and treated extensively, was sesamoid fractures. I just received emails from two readers about sesamoid injuries. All doctors will treat injuries slightly differently. When I read the article below, I would emphasize the importance of some treatments more. But, overall the article is well written. Exogen bone stimulators are a must to me. 3 months of cast or bike shoe immobilization is very important. Daily contrast bathing. Evaluation of Vit D and overall bone density is crucial. Orthotic devices with off weighting the sesamoid needed. Spica taping to limit big toe bend can get patients back into activity. Avoiding NSAIDS since they can retard bone healing. Ice activity aggravation. Hope this helps. Rich

https://orthoinfo.aaos.org/en/diseases--conditions/sesamoiditis

Stretching Achilles and Plantar Fascia for Plantar Fasciitis: You Have to Stretch Both

https://journals.sagepub.com/doi/10.1177/1071100717732762

Here is a helpful video!!

https://youtu.be/0eAqJ4-oKTM?si=t0NBhcIL1OsY_Oe_

Slowing Pace Down can Improve Knee Pain

https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0295645

If Your Child Has Very Flat Feet, here is a Checklist for the Doctor to Evaluate

https://pubmed.ncbi.nlm.nih.gov/10943496/

Plantar Fasciitis: Stretching May Be Your Best Treatment

Stretching of the achilles for plantar fasciitis may be the best treatment overall per this article. I have attached a video on Plantar Fascia Stretching for your information. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6134886/

https://youtu.be/0eAqJ4-oKTM?si=bXkfMjxZBGzE4Qqx

One of the Most Predictable Reasons for an Injury: You had the same one less than 12 months ago

Why is this important? Because healing the injury is one thing, getting at the cause and reversing it is another thing totally!!!

https://link.springer.com/article/10.1007/s40279-014-0194-6

Comparison on 15 and 25 Degree Inverted Orthotic Devices on Lower Extremity

The following paper is a good look at the dynamics of 2 Inverted Orthotic Devices (15 degrees and 25 degrees) and the Shoe alone. There are questions around the loss of ankle plantar flexion motion with the 2 inserts vs shoe only which has possible explanations on the positive and negative side. At foot loading, a loss of ankle plantar flexion probably only implies that the orthosis is supporting the arch and less ankle plantar flexion range is needed. But, does a loss in ankle plantar flexion at toe off imply a more inefficient push off or a more stable foot with less plantar flexion needed for push off? The summary of angles in the paper show these findings are less than 1 degree in amount in any direction, but of the the 31 subjects the variation could have been more or less. 

     If you are looking for a good paper on Inverted Orthoses, this one is very good with 60 plus references to sink your teeth into. Rich Blake

J Multidiscip Healthc. 2023; 16: 2613–2623.

Published online 2023 Sep 5. doi: 10.2147/JMDH.S420003

Effect of Different Foot Orthosis Inverted Angles on Walking Kinematics in Females with Flexible Flatfeet

Nour Alsaafin, 1 , 2 Nabil Saad, 1 Shima A Mohammad Zadeh, 1 , 2 and Fatma A Hegazy 1 , 2           

       

Chronic Pain: Ketamine May Help

https://www.cnn.com/2023/12/26/health/chronic-pain-ketamine/index.html

Secrets to Keep Moving: A Holiday 50% Off Offer from Dr Rich Blake

I am pleased to add a 50% off offer on my book Secrets to Keep Moving. This will be for the first 25 using the code GD5YR4 from today to midnight 12/31/23. 

https://store.bookbaby.com/book/secrets-to-keep-moving-a-guide-from-a-podiatrist1

Sesamoid Injuries

I have a lot of information to help you manage your sesamoid injury within the pages of this blog. Please go through the Labels/Index to find information. Here is a wonderful comment I just received. Rich

You’re a true gem of a human and doctor. My sesamoid pain began two months ago and it’s stopped me from doing my favorite activities like drumming and climbing. In only a few days of following your advice, I can already feel my foot healing. It’s motivating and giving me the confidence needed to overcome this. I’m surprised and grateful to find a doctor sharing so much knowledge freely and consistently for as long as you have. Thank you Dr. Blake and happy holidays.

Secrets to Keep Moving: Page 1 upcoming 2nd Edition

Secrets to Keep Moving: 

A Guide from a Podiatrist

by

Richard L Blake DPM MS

2nd Edition: Proposed 2025

Introduction

     I am happy to embark on a daily adventure to write the 2nd Edition of Secrets to Keep Moving, first published in 2016. As I finish each page of this 200 plus book, I will publish that page on my blog www.drblakehealingsole.com, including this page. The goal of the book is to update, shorten to make it less expensive, and make it center around self help (within reason). I hope to publish it in 2025. I am excited about getting your feedback on pages (comments to each blog post) so I can make multiple revisions before going to publication. I want this book something that you would want to give to a friend with knee pain, or understand all the self treatments for bunions. I am so excited that since this aspect is electronic, I can include videos of techniques or further explanations. Let’s get started.

General Book Organization

      I will have to break the book down into easy to digest injury chapters. These are:

1. Foot Pain

2. Leg Pain

3. Knee Pain

4. Thigh and Hip Pain 

5. Low Back Pain

Of course, as a Podiatrist, I can only discuss problems above the leg that I treat conservatively.

The Effect of Foot Orthotic Treatment in Posterior Tibial Tendon Injuries

https://pubmed.ncbi.nlm.nih.gov/33040609/

Foot orthoses, together with exercise programs, seemed to improve the effect of orthotic treatment. Foot orthoses with personalized internal longitudinal arch support were more effective than flat insoles or standard treatments in reducing pain.

Good vs Bad Pain

What are First Line Agents to Help Nerve Pain when Diagnosed?

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544553/

     Here is a good article summarizing the progression of medicines used to treat nerve pain in patients. We will focus on the first line therapies to help calm down the pain. Here is a summary from the abstract:

"Multidisciplinary conservative care and non-opioid medications (tricyclic antidepressants, serotonin norepinephrine reuptake inhibitors, gabapentanoids, topicals, and transdermal substances) are recommended as first-line therapy."

The TCAs most commonly prescribed today include: Anafranil (clomipramine), Asendin (amoxapine), Elavil (amitriptyline), Norpramin (desipramine), and Pamelor (nortriptyline).Two of the most common SNRIs are duloxetine and venlafaxine. Clinically used gabapentinoids include gabapentin, pregabalin, and mirogabalin, as well as a gabapentin prodrug, gabapentin enacarbil. Additionally, phenibut has been found to act as a gabapentinoid in addition to its action of functioning as a GABA_B receptor agonist. There has recently been a warning not to use gabapentinoids in patients with respiratory problems. Common topicals are a myriad of compounding formulations with or without Ketamine. OTC topicals I use most are Neuro Eze and Neuro One both with L-Arginine in concentrated form. The transdermal product I use is 5% Lidoderm patches. 

Many patients try other nerve desensitizing treatments first, before drugs, with neural flossing or gliding, Acupuncture, TENS, and Quell units. 

Heel Pain: Treating Plantar Fasciitis; American Physical Therapy Association Guidelines

https://www.jospt.org/doi/10.2519/jospt.2014.0303

Response Regarding Possible Contact

Congratulations Dr.Blake on your new Biomechanics Book. Coming across your website has given me hope of figuring out a chronic sesamoid(I think) issue. I have Charcot-Marie-Tooth Type1a which I believe is making matters worse for recovering from this. Absolutely no one has been able to help me. Is there any way I could get in touch with you directly? Look forward to hearing back. Thanks!

Response from Dr Blake:

     I am presently working a little with Dr Ajitha Nair in Oakland, California due to my recovery from Open Heart Surgery. She can be reached by email at anair@propelfootandankle.com. Her and I discuss cases once or twice a month also. I hope this avenue can help you. Rich 

PS. Chapter 6 in Book 2 has a detailed description of possible treatments for Big Toe Joint Pain. Some may apply to you. 

https://www.amazon.com/Practical-Biomechanics-Podiatrist-Richard-Blake/dp/1667863401/ref=sr_1_1?crid=1EUGRXNFQO1AT&keywords=Practical+Biomechanics+for+the+Podiatrist+Book+2&qid=1701491505&sprefix=practical+biomechanics+for+the+podiatrist+book+2%2Caps%2C128&sr=8-1

Great Article on Choosing Cleats by Dr Spitalny

https://www.hmpgloballearningnetwork.com/site/podiatry/sports-medicine/advising-parents-choosing-right-cleat-young-athletes

Link to my Kevin Root Medical blog posts

https://www.kevinrootmedical.com/community/xenforum/general-discussion

     I have been taking a break this year for 4 things. One is to write a blog post each week for one of the best orthotic laboratories in America. It has been my honor, and has taken a lot of my time. I have attached a link to that medical forum above. The second reason for my break was I needed to have open heart surgery on Oct 11th, 2023. I had my first of 36 cardiac rehab sessions today, so the next 3 months will help build back my strength. I am so happy to be alive. My aortic valve was failing and I literally had 3-4 months left before I would have died. I have known about this for 16 years, but I finally went into heart failure at the beginning of this year. To those who knew about this, thank you for all your prayers and good thoughts. The 3rd reason for my break was I published Book 2 and Book 3 of my Practical Biomechanics for the Podiatrist. Book 1 also came out this year in Spanish. So, I have been busy with things I love. The 4th and best reason for my break was for trips and other celebrations (one in England's Sussex County) with my family. Today is December 1st, 2023. It is the day I vowed to start my blog again. If you will join me, I am grateful. Rich Blake

Impressive Foot Problem Website

https://www.foothealthfacts.org/foot-ankle-conditions/browse-foot-ankle-conditions

Book 3 Practical Biomechanics for the Podiatrist

https://store.bookbaby.com/book/practical-biomechanics-for-the-podiatrist-book-3

     I am so excited about published my third book on Practical Biomechanics. These books, with one more to be completed next year, are an accumulation of my 44 years as a Podiatrist. This book covers injuries from the ankle to low back as treated by a conservative Podiatrist. It also covers the injuries produced by pronation and supination. There are chapters limb length difference, shock absorption problems, weak and tight muscles, and current concepts being used to treat these issues. 

Make Sure Shoe Lacing is Tight!

https://scholar.google.com/scholar?hl=en&as_sdt=0,14&q=foot+sliding+in+shoes&btnG=#d=gs_qabs&t=1682140474682&u=%23p%3DQuHvU32VEDEJ

Use this Website to learn Foot Anatomy

https://radiopaedia.org/cases/foot-x-ray-labelling-questions

This is very cool, especially if you are trying to read a radiology report to understand your injury. Rich

Tibial Nerve Test Video

https://youtu.be/qwbDfG71dgU

     So many patients with foot and leg pain may have the tibial nerve as a component. They may think they just have plantar fasciitis, achilles tendonitis, or metatarsalgia. This test can point to nerve involvement, which of course, has certain specific treatments different than standard. 

Big Toe Joint Pain: Could there be Nerve Pain?

https://onlinelibrary.wiley.com/doi/10.1002/acr.25125

Excellent Article on Conservative Care of Achilles Ruptures vs Surgical

https://www.tandfonline.com/doi/full/10.2147/TCRM.S116385

Great Video with 3 easy Internal Hip Rotator Strengthening Exercises

https://youtube.com/watch?v=JlxndP60w8E&feature=shares

The Importance of Extrinsic Rear Foot Posts in Pronated Patients

Very Everted Heels with initial Orthoses and no Rear Foot Posts

Subtalar Neutral Almost Obtained with Extrinsic Rear Foot Posts Applied

     These photos were sent by my friend, Dr Jinwook Song, from Seoul Korea. He was treating a patient with the Inverted Orthotic Technique and captured the heel correction without and then with the Extrinsic Rear Foot Posts. 

Metatarsal Doming (aka Short Arch exercises) shown to reduce pain of Pronation

https://pubmed.ncbi.nlm.nih.gov/30860412/

https://youtu.be/GY-mJjXmeIc

Balance and Flexibility for Movement

Human movement is often taken for granted, but it is crucial tour existence. Movement for various activities is complex and learned. What Michael Jordan can do to a basketball or Tiger Woods to a golf ball, is complicated, but learned (with the help of genetics). "Muscle memory" is a term coined for the adaptation of muscle to perform a task. Want to learn to do something? Break the task down to each of its component motions. Practice each motion 10,000 times (100 times a day for 100 days). Muscle memory will take over. 

But what are the attributes that are key to completing complex tasks - attributes that you and I need to be graceful, and less injury-prone, when learning or performing a task? These attributes include strength, balance, coordination, flexibility, agility, etc. This article will focus on balance and flexibility. As a practicing sports medicine podiatrist, I spend most of each day attempting to make my patients/athletes more balanced and more flexible. I will attempt to keep this discussion as practical as possible. 

Flexibility is a good place to start since most athletes are familiar with this topic. Flexibility of muscles and tendons allows for overall less strain on the muscles as they move us around. The tighter we are (I like to use the term "muscle bound"), the greater our chance for injury. A muscle pull or strain is created taking weeks or months to heal. Doing simple stretching exercises on a daily basis can help prevent these injuries

But, what if you know the stretch and do not know how to stretch? There are some generalizations I use successfully when teaching patients to stretch: 

1. The best time to stretch is after your activity. This is when your muscles are warm and easily stretched. You will make the most progress when you stretch after activity (i.e. after running, after basketball, after aerobics). 

2. Before activity, warm up your muscles. This is a time for a walk before you run, or a slow run before a more intense run. If there is time to stretch gently after you have warmed up the muscles, even better. However, this is usually not crucial. Many patients have actually hurt themselves by aggressively before an activity. 

3. Stretch 3 times a day to gain flexibility, and 1-2 times a day to maintain flexibility. This seems to be a tried and true rule, especially as we age. This means even on your days off from running, the flexibility exercises should continue. Remember NO REST FROM STRETCH. 

4. Forget counting, and BREATHE. Breathing gets oxygen into the muscles to help with flexibility. When you count, you normally stop breathing (hold your breath). Most stretches require 5-10 deep breathes to get adequate elongation. Slowly breathe in and as you exhale, gently lean into the stretch, getting deeper into the position. Hold that position while you inhale again, then relax into the stretch deeper as you exhale again, 

5. Know your tight muscles and stretch these more (50% more than other muscles). As you begin to stretch consistently, you will begin to know your body better. Some muscle groups will be harder to stretch than others. For me, it is my hamstrings, always much tighter than other muscle groups. Even more complicated, my left hamstring is always tighter than my right hamstring. I do more hamstring (back of thigh) stretches than any other group, and I hold the left stretch 5 more deep breaths than the right stretch. Just try each day to even them out, and slowly you should be able to. 

6. NO BOUNCING while stretching (Don't be a jerk!). Stretch slowly, gradually, evenly. 

7. Stretch muscle groups in various positions to optimize the stretch. For example, a great way of stretching the hamstring is to put your foot out in front of you, and onto an elevated platform (i.e. car bumper, a chair, a table), as long as you can comfortably stretch the muscle and not lose your balance. Now, your foot position dictates the line of pull of the stretch. First, while doing this stretch, hold your foot straight with your big toe on the right foot pointing towards the ceiling. After 5-10 deep breaths, now point your right big toe to the left. This will stretch your inside hamstrings more. When you point your big toe to the right, you will stretch your outside hamstrings more. Most muscle groups have 3 or more fairly easy variations like this to get better stretching of any particular group.

8. During some times of injury, it is important to heat up a muscle/tendon before stretching, and especially before activity. Reusable hot packs, deep heat liniments, massage, and hot soaks are all commonly utilized. And this practice can be especially beneficial in cold environments and after long waits. One athlete I was treating who went to the 1988 Olympics in Seoul, South Korea, said the long waiting from the warm-up area, through 5 or more security checkpoints, until you were into the event area, was so bad that her muscles all tightened up. A gentle massage can excellently heat up a muscle, and relax it, and mobilize swelling when needed. When athlete has tendonitis, I recommend heat before and ice after activity, 

Therefore, tight muscles/tendons can limit range of motion of joints, interfere with optimal performance and lead to injury as the muscle strains, pulls, or tears. The tears can be microscopic, but require lengthy rehabilitation. A sidelined athlete is an unhappy athlete, so preventative exercises can play a major role in your quality of life. 

Balance and coordination define the athlete. Watching the moves of John Stockton, Scottie Pippen, Michael Jordan, or the recent British Golf Open, reminds me of the complexity and beauty of fluid, graceful motion. In any activity, success occurs when the athlete conquers the components that throw off the balance of the movement. In a golf swing, it can be hand placement on the club, too fast a back swing, and on and on. In running, there are many factors which I look at daily that make up that balance or fluidity of movement. Some of the factors are: show selection, terrain, joint stability, limb-length difference, foot motion, muscle coordination/strength, and running style. When I watch an athlete walk and/or run in the office, I can observe all of the above factors, except terrain. I ask myself "How balanced or coordinated is their running?", and "Are there easy ways to help smooth out their gait?" Gait refers to style of ambulation (still a funny word). Our office has several shoe recommendation handouts that can be requested. One of the handouts is the current list of stable athletic shoes, and another handout is "Tips on Buying the Proper Running Shoe" (i.e. time of day, etc.). There are many ways that shoes alone can severely affect gait. It is important for runners to find good shoe stores in their area that are aware of running and proper shoe selection.

 Limb length difference can greatly affect the balance of a runner, even a difference as small as 1/8′′, or 3 mm. With a short leg, the body must try to even itself with every step. The energy expenditure is great, with loss of stability, proficiency, and an overload to various muscles/tendons and joints. With a runner, there are few exceptions to treatment of all or most of those with a shore-leg difference. Simple inserts to elevate the short leg can have miraculous results. A sports-minded physician, podiatrist, therapist, or chiropractor can help you evaluate your limb-length inequality. Some experts have the opposite opinion than I, that is, that most leg-length differences should be left alone. I have seen too many injuries get remarkably better with lift therapy to agree with that approach. 

It is relatively easy to improve your balance. On a daily basis, do 3 to 4 of the 8 positional balancing exercises. Do each position for 1-2 minutes. See if you can follow these instructions for better balance. Stand in a doorway. Stand up one leg time, with the other leg bent at the knee, off the ground. Put both hands at your side. Do each exercise first with the knee straight, then with the knee bent. 

After 30 seconds of balancing with your eyes open, close your eyes. Feel your foot roll side to side. Hold on to the side of the doorway as much or as little as you need. Try to stay on that one foot for 1 minute without opening your eyes, First, knee straight, then bent 20-30 degrees, transferring your weight to another area of your foot, making balance more difficult. Then slide a 1⁄2" thick book under your heel. Repeat the balance exercises, 30 seconds eyes open, 1 minute eyes closed, knee straight; 1 minute eyes closed, knee bent 20-30 degrees. Then turn the book so that the whole side of your foot facing your other foot is elevated off the ground (i.e. under the inside of the heel and big toe). Again, 30 seconds eyes open, 1 minute eyes closed, knee straight, 1 minute eyes closed, knee bent. Lastly, place the book under the outside rim of your foot (from heel to little/baby toe). Then repeat the exercise pattern. Every day do 4 of these positions for each foot. Do with shoes on or off. Do with orthotics in or out. In all perceivable patterns, let muscle memory begin the 10,000 times needed. Athletes who perform these simple exercises which affect the foot, ankle, knee, and hip in a functional weightbearing way, have testified to its effectiveness in strengthening and coordinating their legs. 

In summary, some simple but, I believe, powerful advice for improving flexibility and balance or coordination has been given. These two often neglected areas of daily athletic endeavor can help lengthen your time of athletic pursuit and also improve the quality of your performance greatly. 

Thank you.