- Dr Richard Blake
- San Francisco, CA, United States
- I have been a podiatrist for 34 years now and I am excited about sharing what I have learned on this blog. I love to exercise, especially basketball and hiking. I love to travel. I am very happily married to Patty, and have 2 wonderful sons Steve and Chris, a great daughter in law Clare, my new grandson Henry, and a grand dog Felix.
• Cortisone shots can be divided into short-acting or long-acting. • Short-acting shots normally are beneficial for 3 days and are used t...
I have both observed and been asked the question: Why do toenails become more curved as we age? The answer mainly lies in these 3 photos. It...
Subject: question about fibular sesamoid non-union fracture in dancer from Milwaukee, WI (photo above pointing to the tibial sesamoid, the ...
How to Conservatively Treat Bunions Dr Rich Blake Bunions are no...
This video presents the use of 2 inch Kinesiotape to help support the arch relaxing the pull of the posterior tibial tendon. The various i...
Thursday, January 14, 2016
Wednesday, January 13, 2016
Saturday, January 2, 2016
This email was Happy New Years to me. I have been working with this patient for many years. I recommended Calmare Pain Therapy several years ago. She had to drive to the doctor's office, stay 2 weeks at a hotel, and get the 10 required treatments to help her very severe left foot nerve pain. She may require some booster treatments in the future. Right now she is very gradually testing out her new left foot!!
I’m emailing you with fabulous news about the effects of the Calmare pain scrambling treatments that I received in December.
After 10 sessions, the intensely debilitating nerve pain has drastically dissipated! Words can’t even touch the depth of gratitude I feel and the degree of excitement I have with this increased mobility in my life. Since Dec. 22nd, I’ve danced for 10 minutes at least 3x, have walked with a friend for 50 min, have gone window shopping with another friend, and even baked muffins!
I’m taking things s l o w l y and steadily to ensure that I remain on this healing path. Wow, there’s nothing like an absence of nerve pain to bring out the giddy “kid in a candy store” and the “where do I want to travel to first” parts of me. I’m embracing this moment fully with glee and at the same time, am humbly moving forward to stay within the zone of diminished nerve pain. I am sooooo thrilled!!!! I still have joint, tendon, and ligament pain in the ball of my big toe joint and throughout the tendons and ligaments that connect to it. However, now that the nerve pain has diminished, I trust I’ll be able to tend to these mechanical issues with greater and more rapid success. Aho!
Thank you from the bottom of my heart for your prayers. I deeply appreciate you holding my healing journey within your heart and for your prayers during these treatments. I connected to the web of support many times while receiving these treatments and want you to know how palpable and significant your prayers were … and are. Thank you. Truly, thank you.
(And, if there is anyone who didn't receive my prior email, please forgive me as I’m sorting through my 800+ contacts and I very possibly missed you.)
For those of you from the Bay Area dance community, I hope to see you soon - even if for 10 minutes at first - on the dance floor. I look forward to being with you within the non-verbal depth of our meditation practice and welcome connecting with you there. And for all of you from the Bay Area, I’m now available for walks in nature - as long as you’re open to sitting together at the midway point to rest and commune with the elements.
I wish you a year of rich and heartful connection with all that brings joy to your world. And, I wish for this planet and for all sentient beings who live upon it, that this is a year when the human race acts on greater behalf of this generous, amazing, abundant, stunning, and interdependent orb of life.
Love to you,
Contrast bathing is one of the best ways of reducing swelling. This is even true for deep swelling in the bone/soft tissue which is not visible to the eye. The normal routine involves:
- Obtain two containers large enough to accommodate the body part involved.
- Place the two containers side by side, one is filled with ice and cold tap water (approx. 55 degrees F), and the other filled with warm/hot water typical for a hot tub (approx. 100 degrees F). Use your fingers first to test that the warm water is not too hot.
- Place the body part in the warm water first for 4 minutes, and then immediately into the cold water for 1 minute. This is a perfect technique for feet, ankles, and hands.
- Repeat this cycle for a total of 4 times totaling 20 minutes.
- You should also feel that you are looser and less swollen.
- Attempt to do this once a day on work days, and twice daily on your days off.
- Move the body part through a pain free range of motion while immersed in the warm water.
- Continue contrast bathing for 1 week longer than you think you would need based on your symptoms.
As long as you are using ice in the cold bath, it is not necessary to try to keep the warm container near 100 degrees F during the full 20 minute cycle. As long as there is a good difference in temperature, you will obtain the desired result. The warm water causes vasodilation increasing blood flow, while the cold water causes vasoconstriction decreasing blood flow. By going back and forth between the two water baths, you can create a mechanical pump for the swollen area. While immersed in the warm water for foot or ankle injuries, pretend your big toe is a paint brush. Gently move through the letters of the alphabet, using both big and small letters, then on to hieroglyphics, or Chinese lettering. While immersed in the cold water, keep the body part still.
This is an 80% heat to cold ratio with the goal of reducing swelling. Following the typical 3 days (72 hours) of ice after an acute injury, I find it helpful to slowly build up to this amount of heat/cold ratio. For 3 days, I will use a 1 minute heat alternating with 1 minute cold cycle (1hot/1cold ratio), repeating 10 times, for the same 20 minutes. If the body part is less swollen and the patient feels less stiff, I will advance the patient to 3 days of 2 hot 1 cold ratio repeating 6 times for 18 minutes. Again, if the swelling is reducing and the range of motion feels better, I will advance the patient to 3 minutes heat and 1 minute cold repeating 5 times for 20 minutes. After 3 days of further improvement, then on to 4 hot and 1 cold as described above. Normally, if the swelling has been around for 2 weeks or more following an injury, it is okay to start at the 4 to 1 ratio. If you aggravate your injury during the contrast bathing phase, just return to ice for 3 days or more until the symptoms have stabilized. Following the aggravation, normally the 4 to 1 ratio is fine to restart. Never use heat, only ice, immediately after an injury or with re-aggravation of an injury. To summarize the above:
Days 1 to 3 Ice Alone
Days 4 to 6 Alternating 1min warm/1min cold cycles repeat 10 times
Day 7 to 9 Alternating 2min warm/1min cold cycles repeat 6 times
Day 10 to 12 Alternating 3min warm/1min cold cycles repeat 5 times
Day 13 and on Alternating 4min warm/1min cold cycles repeat 4 times
Contrast bathing should never make a patient feel more swollen and stiff. If so, you are using too much heat and must begin to experiment with less heat as mentioned above. However, it is worth the effort. Contrast bathing can produce incredible gains in range of motion, pain reduction, and lead to quicker returns to activity. A wonderful addition to contrast bathing is elevation. With the increased blood flow due to contrast bathing, immediately dry off, wrap the area with some form of compression, lie on the floor, and elevate the injury as high as possible for 20 minutes. You can gently move the ankle up and down to help the drainage process. For most foot and ankle injuries, lie on the floor and get the foot up on the wall or couch way above your heart level. I call this Super Elevation!!!
Since the typical ankle sprain leads to swelling for 3 to 4 months, and a bad ankle sprain can be swollen for over 1 year, you may be contrast bathing for awhile. Be a good multi-tasker, but never do contrast baths near a power surge. As the soreness goes away, you may experiment with just 20 to 30 minutes of warm water soaking alone. See if you get the same results. Good luck.
Rehabilitation of any injury is a logical game if you know the rules. Inflammation can get much worse with heat, so ice initially, and then as you aggravate or irritate the injury as you move through the rehabilitation process, ice some more. Ice is for initial injury for 4 days, and for months and months with repeated irritations. So, there will be many days where you ice and contrast bath both at different times of the day. You have to distinguish between the chronic pain with swelling (time for contrast bathing) and the acute pain of aggravation (back to ice). At times the aggravation can be for 2 days to 2 weeks, so the icing alone will feel like you are back at square one. The rehabilitation process for patient, therapist, and healthcare provider is one of learning to minimize these aggravations/irritations while allowing as much function as possible.
And more Adele....
As I am beginning my seventh year of this blog, I will begin updating previous posts to improve on my teachings. Plantar Fasciitis is one of the most common problems facing podiatrists.
Several Golden Rules of Foot are common.
Golden Rule of Foot: Plantar Fasciitis begins gradually over weeks and months before effecting athletic performance. It does not come on suddenly.
Golden Rule of Foot: Even bad cases of plantar fasciitis have no swelling. Heel swelling typically is a sign of something worse.
This can be such a stubborn problem that it is easy to get very frustrated. Very few people need surgery for this since there are so many options for treatment. 30 years ago 1 in 10 patients required surgery, now surgery is less than 1%. The treatment options are so numerous that we are normally limited only by our time and imaginations to develop a successful treatment plan. Each week there should be improvement once active treatment begins. If improvement plateaus, a change in treatment protocols should be made. Analyzing what is working and what is not working should be part of the process.
The patient and health care provider deal constantly with the 3 areas of treatment---anti-inflammatory, stretching or flexibility, and mechanics (one being the transference of pressure from the painful areas to non-painful areas). Most cases of plantar fasciitis need simple solutions like daily icing (anti-inflammatory), plantar fascial and achilles stretching 3 times daily (flexibility), and arch support (either custom orthotics or store-bought arch supports). Some more stubborn cases of plantar fasciitis need the above along with physical therapy to improve flexibility and anti-inflammatory measures, custom-made orthotics if not already manufactured, night splints to gentle stretch out the plantar fascia, cortisone shots if a bursitis under the heel bone is found, and many other options.
In resistant cases, 3 months in a removable cast can help calm down the inflammation. The moral of the story with plantar fasciitis is never give up. Keep trying to find the right combination of anti-inflammatory, flexibility, and mechanical changes. Good luck. Also remember that 25 to 30% of all cases I see for plantar fasciitis for a second opinion, have something else. Neuritis, bursitis, stress fractures, and plantar fascial tears all head the list in the differential diagnosis. I hope this helps and gives you encouragement. Dr Rich Blake
Here is a video on the stretches to do and not do when you have plantar fasciitis.
When I talk about mechanical changes that effect plantar fasciitis, there are many Golden Rules of Foot and come into play.
Golden Rule of Foot: When designing an orthotic device, or using an OTC arch support, the patient must feel that the weight is being transferred into the arch (even borderline obnoxiously) and the heel is feeling protected.
Golden Rule of Foot: The most stress on the plantar fascia and achilles is when the heel just comes off the ground. Treatment of plantar fasciitis therefore typically involves staying in elevated shoes, orthotic devices, clogs, and remaining flat footed in some exercises like the elliptical, and not getting off the seat in cycling.
Golden Rule of Foot: A negative heel stretch (where the heel drops below the ball of the foot) can irritate the plantar fascia with all of the body weight suspended at its attachment. This is in stark contrast with the same position of the Downward Dog in Yoga which never seems to bother the plantar fascia with body weight well in front of the plantar fascial attachment.
Golden Rule of Foot: Plantar Fasciitis patient hurt less walking on their heels than flat footed. If you think you have plantar fasciitis, try to walk barefoot normally, on the balls of your feet, and then on your heels. If you hurt the most on your heels, you probably do not have primary plantar fasciitis, and more bursitis, plantar fascial tears, or heel stress fractures. All three of these are diagnosed by MRI.
The video below discusses heel evaluation.
My initial visit for plantar fasciitis typically includes:
- Teaching the patient Support the Foot taping (www.supportthefoot.com) and giving them a few extra strips.
- Rolling ice massage with frozen sport bottle 5 minutes 3 times per day
- Plantar fascial and achilles stretches (see video above) 3-5 times a day. Typically, gastroc and soleus stretches 1-2 times per day, and plantar fascial stretch 5 times.
- Mechanical changes based on their activities, like no barefoot around the house, and staying flat footed on the elliptical.
- Consideration of physical therapy, night splints, removable boot, all based on their symptoms, speed on healing needed, etc.
Please enjoy Adele and her beautiful song entitled "Million Years Ago"
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