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Saturday, February 21, 2015

Dancer's Pads from Dr Jill Company for sesamoid protection

Dr Jill's Dancers Pad

    One of my sesamoid suffering patients brought Dr Jill's Dancers Pad to my attention. She loves it since it sticks comfortably to the foot and so she can wear in shoes/situations that may not work well with orthotic devices.

Friday, February 20, 2015

Sesamoid Injuries: Questions

This is my answers to a student studying the treatment of sesamoid fractures with my comments in red. 

Thank you so much! Below are some questions:
1. Which method would you recommend for the rehabilitation of the sesamoid bone in the foot? 
     I prefer to treatment conservatively with a removable boot for awhile, then orthotics that can off weight the area. The only other method would be surgery, which may be unnecessary, and I think the last resort. Lack of response to treatment, coupled with MRIs showing bone fragmentation will sway me towards surgery. Any treatment done, if surgery is eventually needed, will help greatly in the rehabilitation (like designing a good off weighting orthotic device). 
2. Why this method? 
     My personality which is conservative, and seeing patients still having bothers after surgery sometimes, knowing that surgery is not always the perfect fix. Any treatment should get the patient to no disability, and conservative treatment can do that the majority of time. 
3. Which method would you say is the worst? Why?
     Neither, because both have their pros and cons. The surgical treatment for a broken sesamoid is technically easy, and gets patients back on the road quicker than stubborn cases of conservative treatment. The con of surgery is that you are potentially removing a vital bone, and surgical complications can lead to some permanent problem. Conservative treatment avoids bone removal (leaving your anatomy intact) and avoids surgical complications. However, conservative therapy may take up to 2 years to complete (generally 6-9 months is normal), which would be difficult in a highly functional athlete, with no complete guarantee that it will not, in the end, require surgery. 
4. What is the most common way of injuring the sesamoid bone in the foot? 
     From the impact of sports
5. Have you ever heard of someone getting arthritis in their big toe from a certain treatment?
     The sesamoid is bottom part of the big toe joint. If the bone is fractured and irregular is can start arthritis forming on the under surface of the first metatarsal. When I x-ray and MRI or CT, I am always checking for signs of that. 
6. If you had to put your patient in orthotic devices, would it be a Morton's extension or a Dancer's pad (apologies if my terminology is off, while researching I realized some doctor's use different names)?
      The six basic designs for sesamoid injuries, which can be used in some combination, or with all of them are:
  1.  Enough arch support or varus wedging to shift the weight back into the arch and over to the 2nd and 3rd metatarsals as you move through your foot.
  2. Metatarsal arch support to shift weight laterally (towards the outside of the foot).
  3. Dancer's pads (aka Reverse Mortons) to shift the weight laterally as the weight goes onto the metatarsals at pushoff.
  4. Cushioning under the first metatarsal head
  5. Minimal heel lift not to shift too much weight forward
  6. Stiff forefoot area to minimize bend if needed (at least a design that does not encourage excessive big toe joint motion).  
7. What sort of side-effects could occur if one was to perform surgery to remove the bone(s)?
     I find that the crucial question is why did the patient get this in the first place. If the surgery does not correct that, and most of the time it can not, then removing the sesamoid puts the other at more risk. Losing one sesamoid is not the perfect scenario, but you are still highly functional. If you lost both sesamoids, you have not protection for the first metatarsal head. Removing the medial sesamoid does make you more at risk for bunions, but if you start wearing toe separators and yoga toes, and start doing abductor hallucis strengthening, you can minimize that. Typically when you injure something, there is an obvious cause, and several still important less obvious causes. After surgery, you have to know what the causes were and prevent them in the future. I find this area is addressed the best while the doctors are trying to avoid surgery in the first place, learning why it happened helps with designing treatments. Only some of the causes are: poor running or walking styles, poor shoe selection, inadequate fat pad, high arches, plantar prominent first metatarsals, training techniques, improper cleat placements, poor bone health, transient Vit D or Calcium inadequate intake, over pronation, stiff foot that does not adapt to ground, etc. I am sure I have left out quite a few. 
8. It was brought to my attention that some people are born with their sesamoid already in two pieces, do they experience the same problems of someone who has broken their sesamoid experiences?
     Yes, even when the sesamoids are congenitally in two or more pieces, they can still fracture or bruise these small bones. I feel having the bone in multiple pieces greatly confuses the diagnosis. It is too easy to say they are congenitally that way, so they must not be injured. These separated pieces can develop fractures, but they are even more prone to sprains between the bones. These sprains are impossible to fully diagnose, and seem to cause lingering pain more than from a fracture. So, when I see the bone in more than one piece, and the pain matches a stress fracture level, I am more worried that they are going to have a difficult time healing (at least quickly). I sure hope all these answers help you and other reading. Dr Rich Blake

Thursday, February 19, 2015

Sesamoid Fracture: Email Advice

Hi Dr. Blake,

My name is Martha (name changed), I am a Southern California/NYC resident. I am a professional actor performing in a show until a stress fracture of the inner sesamoid on my left foot caused me to have to take a break from the show. 

I injured the foot back in November of last year, and have now been off of the foot and not bearing any weight for 2 weeks, prior to that I was pretty active doing the show 9 times a week. I am currently in an air boot and crutches, as well as using a magnet for healing several times a day, calcium supplements and am waiting for a bone stimulator to be approved. 

I wanted your advice on how to best heal and about how long I will be out of the show. In the show we mostly do pedestrian dancing, walking, running, etc. I want to heal as fast as possible as this show means a lot to me, and I desperately want to go back soon. I have several questions for you, if you have the time to answer them! 

1. How can I best heal, besides what I am doing? 
Dr Blake's comment: Basically creating a pain free environment (0-2 pain level) with protected weight bearing (removable boot, orthotics, dancer's pads, stiff sole shoes, etc), anti-inflammatory measures of icing and contrast bathing, bone healing measures (like Vit D3, Calcium, zinc, bone stimulator), lower extremity strengthening including cardio (typically orchestrated with a PT), and gradually increasing weight bearing. 
2. What is the likelihood of healing vs. surgery? 
Dr Blake's comment: I would need to see MRI imaging. With sesamoid injuries, you typically get a baseline MRI and then 3-6 months get another to see how much healing is occurring. If you have a disc, you can mail to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109 and I will try to let you know what it says. Without that information, it is hard to tell. Only 10% of my sesamoid fractures require surgery, but as you read in the various blog posts, there are so many variables. If you have had sesamoid pain for 3-4 months, and you are not responding, you are considered a surgical candidate. I know many of the professional athletes (and you fit that category) get surgery much earlier in the game to get them back onto the playing field faster. It is really a judgement call case by case. What makes sense for you. And what are your risks.
3. What is the timeline for going back to the show (assuming I have custom orthotics?  
Dr Blake's comment: Too many ifs, ands, and buts!!! As you go from Immobilization to Restrengthening to Return to Activity, you have to keep pain free (0-2). You have to be 2 weeks in the removable boot with no crutches walking fine, before you can start to wean out of the boot. The weaning process can take 2-6 weeks, so you have to have the boot with you at all times, and you have to keep the pain between 0-2. What helps you wean out of the boot the fastest----anti-inflammation measures of icing and contrast bathing, keeping your core strength, spica taping, dancer's pads, cloughy wedges, orthotics, shoes that protect and cushion.  
4. Even after my foot has healed will it feel "normal" again? Or should I expect some pain? (I read the article on good vs bad pain, is it safe to assume the good type of pain will be typical? 
Dr Blake's comment: Patients who heal from sesamoid fractures have no pain and are fully functional. That process from you to no pain can take up to 2 years, hopefully shorter. The healed sesamoid can remain strong, but sensitive due to bone swelling and nerve hypersensitivity. The patients who remain sensitive can not ignore the symptoms, so have to tape, ice, avoid barefoot, etc for longer periods, even if they are back to full activity. Read the post on the Magic 80% Rule. When you are 80% better, you can be fully functional, but you still have 20% of the symptoms to deal with. Good luck. Rich

Thank you so very much. It is difficult finding a doctor who specializes in this injury that accept workers comp. Your blog gave me much relief. I look forward to hearing from you. Again, thank you so much. 

Fondly, Martha

Sunday, February 15, 2015

HOKA ONE ONE: Maximalistic Running Shoes probably here to stay

I have recommended Hoka One One Running Shoes for great shock absorption for walking and running. They are stable, take a little time to get used to, but can minimize the impact shock that can destroy knees. For those long distance runners with Hoka One One and Hannaford Orthotics (previously prescribed) their impact shock is almost nada, nilch, zero, zip!! Yes, we are talking about another version of runner's high. 

Saturday, February 7, 2015

Iliotibial Band Syndrome: General Thoughts

The top 10 treatments of IT Band Syndrome are:

  1. Develop an appropriate stretch that you can do to reduce the pain, then do that stretch 5 times daily. Go to Youtube and type drblakeshealingsole iliotibial band stretches.dreamstime_m_48700943.jpg
This is a yoga version of Iliotibial band stretching to stretch the lateral side of the hip and knee. It can be done also standing upright and also leaning against a wall.

This version of iliotibial band stretching can be done laying all the way done and then draping your leg over the other with a gentle pull from your opposite hand.

  1. Gradually strengthen the hip abductors with limited range of motion. I prefer theraband progressive resistive exercises. Keep your knee straight as you do them.  dreamstime_m_120661.jpg
Whether you are doing these standing or side lying, and especially if you add resistance, please you limited motion (max 3 inches away from other heel, starting 1-2 inches in front of and across the other foot). Too far away from mid line irritates the hip and is not in the functional range we need.

Here with the resistance bands you walk slowly sideways in one direction, then the other, building up time. I would use a longer theraband so you did not have to have your knees so bent.

3. Ice pack for 10-15 minutes or ice massage 5 minutes 3 times daily.

4. Use activity modification, typically you can run until you get initial symptoms, stop stretch walk several minutes, and begin running again. Repeat as needed with 20 minute ice pack afterwards.

5. Physical therapy to stretch, decrease inflammation, strengthen, and look for biomechanical faults.

6. Correct any biomechanical faults that may be causing like over pronation, over supination, or short leg syndrome.

7. If symptoms are mainly at the tibial attachment at Gerdy’s Tubercle, get a baseline x ray.

8. If symptoms do not respond at the hip greater trochanter, consider a cortisone injection for trochanteric bursitis.

9. Massage, either professionally or self, should be limited to the area above the knee and below the hip to avoid the bony prominences. This includes when you stretch/massage with the ethafoam roller.dreamstime_m_8846383.jpg
10. Taping of the leg has begun to prove helpful at times.
Not this type of taping!!
More like this type (there are many versions)

11. Like any tendinitis, BRISS is initiated. But, if symptoms linger, you have to think deeper, and consider xrays, nerve testing, MRIs, etc.

Music to Relax when dealing with Chronic Pain

Cognitive Behavioral Therapy and Nerve Pain

Calming down the nervous system is a great chore. This article discusses the possible benefits of Cognitive Behavioral Therapy.

Friday, February 6, 2015

Patella (kneecap) Problems: General Thoughts

  1. Patellar Tracking Problems (kneecap)

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
Wonder what he did??

- 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 anything 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).
This is why the kitchen sink is not included
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.

    The top 10 initial treatments of Patella problems are:
  1. Create a pain free environment.
  2. Ice 30 minutes 3 times daily
  3. Start Quadriceps strengthening painlessly on day one
  4. Stretch the quadriceps and hamstrings 3 times daily, although avoid knee flexion over 45 degrees.dreamstime_m_15225478.jpgToo much knee flexion for kneecap pain
  5. Knee Brace for Patellar stabilization like Bauerfiend Genutrain Knee Brace
  6. McConnell knee taping with Leukotape and underwrap or KT taping.dreamstime_m_36278072.jpg
  7. Core Strengthening for external hip rotators, including gluts, iliopsoas and piriformis muscles.dreamstime_m_17645150.jpg
  8. OTC or Custom inserts to stabilize any overpronation tendencies, or just varus cant. Goal is to get the knee to function in the center and not internally rotated.
  9. Use activity modification to get cardio without irritating the knee. Consider raising the seat in cycling to prevent too much flexion (over 45 degrees the patella starts pushing hard on the femur). dreamstime_m_18879601.jpg
  10.  If it is a running injury, shoes are crucial for stability. Have a good running shoe store help you pick out a great stability or motion control shoe for you.
Your shoe selection should help avoid the heel valgus seen here where the heel rotates outward driving the knee inward too far.

Anatomy of the Foot and Ankle Video

Thank you!!

Tuesday, February 3, 2015

Power Lacing Question

Hi Dr. Blake,

I just watched your YouTube video on power lacing and I was wondering why you need to skip the 3rd hole?  Is that necessary?  It looks really strange on my shoes because the 3rd hole is actually an extra strip of material, so the strip sticks out when not laced.

Anyways - thanks for your time!  I appreciate it!  


Dr Blake's response:

     No, you only need to skip the 3rd lace if you do not have enough length to the laces. If you have adequate length, by all means, use all the eyelets. Rich

Sunday, February 1, 2015

Knee Mechanics: General Podiatry Concerns

  1. 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 knee cap (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. Or, they never really watch the walking and running motions, so they assume it can not be caused by abnormal mechanics.

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)

Functional Hallux Limitus: Meaning and Email Response

What is the difference between Functional Hallux Limitus and Hallux Limitus/Rigidus?

     There is Functional Hallux Limitus (described well in Dr Jenny Sanders video below), Hallux Limitus (described in my video below), and combinations of both. For functional Hallux Limitus, custom orthotics along with self mobilization (seen in another video below) and dancer's padding (aka reverse Morton's extensions) are crucial. In its purist sense, functional hallux limitus is a jamming of the big toe joint due to pronation or some other structural issue that orthotic devices typically reverse. 

     As Dr Sander's video says try to place a form of dancer's pad in shoes that the orthotics do not fit in or crowd too much.
Dancer's Pad to off weight the big toe joint

Tibial Stress Fracture: General Treatment Thoughts

Tibial Stress Fracture: General Treatment Thoughts

    Stress Fractures are areas on a bone that fatigue with either chronic overuse or an acute load that is more than the bone are tolerate. Stress fractures can develop into complete fractures as demonstrated by the photo above, so diagnosis is important if the demands of the activity allowed in rehabilitation could make the injury worse. So often the athlete is diagnosed with shin splints, and allowed to continue running. In this case, that was a mistake. So when is a shin splint really a stress fracture? Compression of the bone from side to side typically is sore with stress fractures not shin splints. A tuning fork, x rays, bone scan, and MRI are all used to help with the diagnosis. If the pain came on suddenly in an impact sport, the Golden Rule of Foot is that it is a stress fracture until proven otherwise. I am surprised on how many runners say the pain of their stress fracture was never more than a 3 or 4, so a low pain level may not be a good diagnostic tool with this injury. In runners, the tibial stress fractures are typically behind (posterior) the bone, and in ballet dancers the front or anterior aspects.
    The top 10 initial treatments with tibial stress fractures are:
  1. Create a pain free environment emphasizing biking and swimming and weights.
  2. Take x rays if the pain is above 4 at any time
  3. Take x rays if the pain is 4 or below after 3 weeks, if the symptoms are not improving.
  4. If there is a possibility of a stress fracture, do not have the patient run.
  5. As running is allowed, avoid running hard downhills with a passion (up to 5-7 times body weight needs to be handled running down hills).dreamstime_m_10687224.jpg
  6. Ice pack the shin area for 30 minutes 3 times per day to get deep cooling of the tissues.
  7. Make sure you are taking 1500 mg of calcium and 1000 units of Vit D3 (most can be gotten in a healthy diet).
  8. I love emphasizing 1-2 hours per day of cycling if a runner can not run, but you have to build up to this. dreamstime_m_31349919.jpg
  9. If you need to know immediately, like when you are on a sports team, I love bone scans which are hot within 24 hours.
  10. Many patients love calf sleeves to take pressure away from the bone.dreamstime_m_25630091.jpg
Yes, even race horses can get shin pain.

Monday, January 26, 2015

Metatarsal Pain (including Morton's Neuroma) Taping with Pad

This is a simple, but often effective, wrap for various forms of metatarsal pain including Morton's Neuroma. Readily available 2 inch Kinesiotape or Rocktape, and small Hapad metatarsal pads can be used. Purchase Kinesiotape from Amazon and go to Hope it helps you. Rich

Sunday, January 25, 2015

Calf Strain: General Treatment Thoughts

Lower Calf Strain
by Richard Blake, DPM

The lower calf above the achilles tendon is comprised of the big calf muscle fibers (gastrocnemius) and the lower smaller soleus fibers seen more to the side in the photo above but going into the tendon

The lower calf is the beginning of the merging of the calf muscles (gastrocnemius and soleus) before the start of the achilles tendon

The top 10 treatments for lower calf strains are:

1.   Ice pack or massage for 10-15 minutes three times daily initially, and then following activity that may aggravate.
2.  Avoid non supported heel positions/activities until the pain resolves and the strength returns (like getting off your seat in cycling, etc, except perhaps the downward dog in Yoga).
3.  Begin re-strengthening the calf muscles as soon as injured, but avoid negative heel positions. Use theraband resistant bands knee straight and bent first, and after building to 2 sets of 25 reps, begin 2 sided calf raises.

Theraband for soleus strengthening ankle plantarflexed knee bent

I love starting with 2 sided toe raises (calf raises) but do not drop your heel below the plane of the front of your foot.

4.  Stretch the calf by doing the 3 achilles stretches 3 times daily. Go to YouTube and type drblakeshealingsole achilles stretches and you will find them demonstrated.
Here the heel is on the ground perfectly for the initial knee straight stretch for the gastrocnemius.

5.  Various forms of taping can help take tension off the muscle
6.  Deep calf massage is crucial for many calf injuries and 6-8 sessions is typically enough. You can begin this process with massage sticks and rolling pins for self massage. You need to find those trigger points and work them out.

7.  Avoid barefoot as much as possible initially, and consider heel lifts (¼”) and clogs or stable heels to relax the calf.

8.   Have your achilles flexibility tested when/if you go to PT since many patients actually have too flexible tendons and should not be stretching.
9.   Create a pain free environment even if a removable boot is necessary. For calf problems, the boot must go to just below the knee and use an EvenUp for the other side.

10.   If the initial injury had some black and blue (ecchymosis), you should try to get to physical therapy sooner than later to help lessen the overall scarring that can settle in and be stubborn to remove.

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