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Monday, September 1, 2014

Slomo: A Soul check for us all

     I have been asked why I write my blog for hours and hours on sunny days or late into the night. Part of the answer lies in this very well done video on a doctor that simplified his life to save his soul. This blog is more from my heart and soul than anything else I do in medicine, because it is pure. A pure gift without expectations of rewards. It allows me to get off my treadmill of chaos and deadlines, and just be with the act of giving.
     The video explains that this doctor had to save his soul or materialism and bitterness and depression would have got him. He had to do something big, but individual, and right for him. He had to do something "soulful" which always brings you peace, joy, and happiness. In the video, you can see the true joy he receives. Contrary to majority opinion, it is not escaping life, but living life robustly.
     I work hard, and have some materialistic tendencies I fight, but I try to find what brings me peace, joy, and happiness to stay centered. When I am not centered, I am unhappy. I have been centered enough in life, that I feel terrible when I am not.
     Some of you know I love basketball. It is a game I have played in 7 decades, so it is the only remaining activity of my long ago youth. Playing basketball, as I did this morning, makes my heart sing for joy, even when I am not wearing my iPod. I do not have to visualize my childhood, one or two dribbles and I am transported back 50 plus years ago.
     My best friend is my wife. Being in medicine, and working long long hours has not afforded me many long term friends. Alot is my fault, but in reality, it is really my choice. I have willingly chosen to dedicate my life to my best friend for the last 42 years. She is my soul mate, my companion, my heart and soul. I would rather be with her, or my children, than anywhere else.
     So, I will not start the San Francisco version of Slomo. But, I will take his incredible insights, and continue to find my soul, and keep my soul healthy. I will continue to ask when confronted by opportunities, is this something that will help my soul and bring more love and health and peace into this world? If the answer is yes, I may be adding a new skill.

Sesamoidits: Email Advice

Good morning Dr. Blake
Hope you are doing well . I wish I can travel to meet  with you as I know you re the most expert in these fields.
I have emailed you few month ago regarding my chronic ( 9month) sesamoiditis , maybe was a result of my hallux limitus.
That was later developed to algodystrophy (aka reflex sympathetic dystrophy).
I have waited for the MRi results so I can send you a better picture , I hope the pic below is fine. Sorry for the long email

Displaying photo.PNG

The Mri results mentions only two anormalities :
·         A small kyste synovial of 4 mm in second articulation metarso-phalagienne( sorry it’s in french I am trying to translate)
·         A small ostheophytose in the first arcticulation metarso-phalangienne.
·         The report mentions nothing regarding the sesamoid bones although I am in pain. ( can you please check the picture attacehd if they are fine coz one seems not that healthy for my eyes)
Dr Blake's comment: I agree that the sesamoids do not look perfect, but that would be accepted if you are getting some bone remoldeling with healing. It is the 2nd joint with the cyst plantarly and some soft tissue reaction that looks the most involved at present. Does it hurt on range of motion of the 2nd joint, or palpation of the 2nd metatarsal head? The sesamoid injury which started, developing the algodystrophy, may be healed by now. See if you can send the T2 image of the same view where the bone is dark and swelling shows up bright white. 

Here are my symptoms :  I have nothing of the usual algodystrophie symptoms you usually read online , such as changing in skin colors , nails droping or hair loss…ect
My bad foot even looks 98% as my good foot , don’t have any swelling or feeling of heat..
but I have sharp pain in my sesamoid after walking 10 min max without orthotics.
When I wear orthotics pain increase in my heel.  When I don’t pain incresae in the sesamoid area ( so basically I am lost here)
Dr Blake's comment: Why do you think the orthotics give heel pain? Can that be remedied? Maybe the orthotics need more padding in the heel or a slightly different design. This seems crucial to getting you well. Try if some Hannaford version can be made for you. I would have 5 different pairs with different qualities if needed to experiment since this is so crucial to you. It is not unreasonable to be in the orthotics full time for the next 2-3 years as the bone continues to heal the sesamoid. 
For the last two month or so I have been swimming or biking on daily basis ( biking with orthotics to avoid pressure on the sesamoid , I don’t know if you recommend)
Dr Blake's comment: Definitely, biking, swimming, elliptical, typically are great if you can avoid bend of the toe and excessive weight on the sesamoid. 

I appreciate your recommendation regarding my case , since I so down lately with this hard case.
Note that I cannot affoard a bone stimulator since it’s not covered by insurance here “ I don’t know if it’s needed”
Dr Blake's comment: If the sesamoid on the T2 image is still very white then a bone stimulator would be wonderful. Once you send me that image I will place on this post. 
I was considering buying used ones on Ebay but I am not sure which ones to pick and if they are good or have high counters.
Dr Blake's comment: I love Exogen from Bioventus!!

Saturday, August 30, 2014

Hallux Limitus/Rigidus: Email Advice

I have hallux limitus/rigidus but would really like to keep running/walking.  Is there a shoe or insert you would recommend to allow me to continue.  I am able to practice yoga but with some pain.  I have constant pain even at rest but don't want to do anything invasive at this point.  I can tell I'm getting more and more depressed without the natural stress release of running or vigorous walking.  Any suggestions?


Dr Blake's comment: 
     First of all, with hallux limitus/rigidus the pain is primarily with bending the big toe joint. You definitely should attempt sports that limit that motion like biking, swimming, and elliptical. Secondly, you should work on the 4 areas that affect the big toe (that is covered throughout my blog): shoes that do not bend, carbon graphite inserts that restrict bend, spica taping that restricts bend, and orthotic devices that off weight. Thirdly, you can treat the arthritis daily with a steady dose of anti-inflammatory like icing, traumeel, zyflamend, voltaren gel or flector patches. And fourth of all, get some form of imaging or some way or checking it's progress:xrays, MRIs, CT scans, range of motion examinations, etc. 
     So, what are simple generic responses to your questions:
  1. Consider an MRI that you can get every few years if needed?
  2. Try cross training with sports that do not need so much toe bend.
  3. Experiment with New Balance 928 or Mizuno Wave Nirvana to limit motion.
  4. Experiment with Carbon Graphite plates (like Otto Beck)
  5. Learn to spica tape
  6. Get orthotics to off weight the big toe joint
  7. 3 times a day do something to produce an anti-inflammatory effect.
  8. Good luck!!

Hallux Limitus/Rigidus: Email Advice

Thank you for your wonderful website, which is a godsend! I hope you can guide me: I have been running with hallux rigidus (limitus) in both big toes for some 20 years, finishing 51 marathons. Over the years I have gotten a lot of orthotics custom-made, but none have brought relief to my left big toe. Recently, I have developed Ledderhose on the facia of both feet. Would you have any suggestions about orthotics which would accommodate my problem feet? I am really looking forward to your reply!


I forgot to mention that I have hallux valgus (left big toe) as well as hallux rigidus (both big toes) and Ledderhose (both feet), and some pain in the other toes of the left foot. Which orthotics would you recommend for running shoes ?

Dr Blake's comment: 
     First of all, congratulations on 51 marathons, quite a feat (47 more than me!!). Also, for those that do not know, Ledderhose is disease where the plantar fascia gets very scarred and thickened. Typically, Ledderhose can be injected with cortisone without fear of rupture due to the severe scarring, but I am sure there are exceptions. 

     When you are designing orthotics for a situation like this there are many factors to look at. Let us look at one at a time. 

  1. Hallux Limitus: Need enough of arch support and inversion to get the weight into the middle of the foot at push off. The padding in the metatarsal area should be to off weight the first metatarsal (dancer's padding). Occasionally the reverse needs to happen with padding under the first metatarsal to limit the motion (called "Morton's Extension). Also, how stiff should the forefoot be of the shoe? Should you use the New Balance 928 with a stiff rockerbottom sole? Should the orthotic be full length and stiff, like using a Sole OTC orthotic, and then making the forefoot of the device even stiffer. Should you use a carbon graphite plate under the orthotic to get your stiffness?
  2. Ledderhose: This is tricky with arch sensitivity. How much pressure can the arch take from an orthotic? Should cortisone be used to reduce the soreness before the orthotic is made? Do you need the arch support part of the orthotic or can you simply use a varus wedge to shift weight for the hallux limitus/big toe joint pain? 
So, these are all the ways you are experiment and begin to individualize the biomechanics for your unique situation. I hope it helps somewhat. Rich

Here is the patient's response:

Dear Rich,

Thanks for your reply. You hit the nail on the head: my problem is that stiff insoles hurt the Ledderhose (of the right foot), while other insoles don’t offer sufficient support and relief to the left rigid hallux. I’ve even tried a stiff (Langer) insole in my left shoe (with a cut-out under the first metatarsal, which mimics Morton’s extension) and a less stiff one in the right shoe: that worked for a couple of mid-long runs but I suspect wouldn’t be advisable, what with sending different signals to the brain, etc.

I’m now using dancer’s padding with fairly pliable orthotics in my Brooks Adrenaline (a shoe which has stood me in good stead over the years—and which I desert for Nike Air Zoom Elites only for the actual marathon races), but that does not offer as much relief as stiffer insoles do.

So I’ll take your advice and start experimenting, investing in a pair of New Balance 928s and in carbon graphite plates; I’m also going to try a real Morton’s extension.

I won’t give up until I’ve done my 100th marathon!

Thanks for your very welcome advice. May I keep you posted?
Dr Blake's comment: Defintely!! And good luck, one at a time. Rich


Calcaneal Fracture: Email Advice

Hi Dr. Blake,

Eight years ago I had two calcaneal fractures and plates and screws on the outside of both heels.  About two years ago, my left foot became very supinated, and I had to quit bicycling because of the overloading on the outside of my foot. I recently had the painful left heel plate removed, and it was discovered one or both of the peroneal tendons was diseased and torn (rubbing on the plate).
Dr Blake's comment: When the peroneal tendons, which pronate the foot at the heel, are injured it creates an imbalance with the tendons that supinate the foot, and the foot goes into supination/inversion. This is a pathological situation and must be corrected. 
The strange thing is that two weeks ago, my right foot was not supinated, until I started doing calf raises in order to rehab the left foot.  Almost overnight, the right foot became very supinated.  Could this extreme supination be caused by damaged or irritated peroneal tendon(s) becoming tight or shortening?  Thanks.
Dr Blake's comment: Definitely, the calf raises were probably the straw that broke the camel's back. The peroneal tendons are accessories to the calf muscles to lift the heel off the ground. If you get into a situation were the calf muscles are fatigued, the peroneals try to help, and if already injured, they are vulnerable to tearing. 

Bill (name changed)

Monday, August 25, 2014

Blister Treatment: Email Advice

Hi Dr. Blake
I am a long time patient of yours. I doubled my running mileage and had slight pain in my second toe as I finished. When I got home I saw the toe was black. I taped it and this morning I noticed blood on the tape.
Should I make an appointment? Stop running for awhile (how long?) or pay no attention?
Your advice is greatly desired

Bonnie (name changed), 
      The blood means that you got a blood blister. If you can find the opening keep antibiotic ointment over it for 5 days and cover with several band aids. Soak each evening for 30 minutes to 1 hour for the next 4 days in warm water with a tablespoon of salt. Leave air exposed while sleeping, and then recover before placing shoe on the next am. Do not stop activities unless you get sharp pain or limping occurs. Hope this helps. Rich

PS. The toenail may be loose at the cuticle causing the bleeding. If so, after the first few days, when the need to use soaking and antibiotic ointment is over, gently tape the nail down 24/7 with a bandaid to see if you can get the nail to restick to the nail bed below. If not, you will lose this nail, but a new one is growing as we speak to take it's place. It is also a great time to check the length of your shoes. Standing in your shoes with socks, at the end of the day (after 6 pm) you should have a thumb width from the end of the shoe to the end of you longest toe (in your case the first). If there is any question, go up a 1/2 size or at least learn power lacing to hold you back in the heel as you run. 

Saturday, August 16, 2014

Plantar Fascial Tears: Top 10

Plantar Fascial Tears

The top 10 treatments for plantar fascial tears:

1.  3 months removable boot or shoes to avoid toe bend
2.  EvenUp with opposite shoe if removable boot utilized
3.  Pain-free environment should be created by 2-3 weeks
4.  No plantar fascial stretches for 3-4 months
5.  2 to 6 week weaning process from boot full time into protected shoe gear with orthotic devices
6.  Orthotic devices should emphasize weight transference to arch and soft heel
7.  Gradual introduction to foot strengthening as long as pain is not produced
8.  Frozen Sport Bottle ice roll 2 times a day through arch for gentle stretch and anti-inflammatory
9.  Physical Therapy to strengthen and handle any sore areas typically at 3-4 months
10.  Deep Tissue Massage, like ART, is occasionally needed if the scarring process is too substantial


Friday, August 15, 2014

Sesamoid Fracture: Email Advice


     I was hoping to get some advice from you. I had a stress fracture in my sesamoid bone almost 3 years ago when I was running 45 miles a week. I was in a boot for 8 weeks, took about 1.5 years off of running. I tried running on and off again with orthotics, but the orthotics actually made it worse and I could never run more than a few miles a week.
Dr Blake's comment: There are so many factors that can be considered in making orthotic devices for a patient suffering with sesamoid pain (under the big toe joint). Unfortunately, there can be a lot of art in the process, which can drive patients and health care providers crazy. But, in the end, if everyone is willing to stick with it, a proper device can be designed. These factors/components are:
  1. Amount of arch to use
  2. Amount of stiffness across the ball of the foot 
  3. Amount of dancer's pad to use to off weight sesamoid
  4. Amount of varus cant at the heel (inversion) to center the weight as you push off 
  5. Amount of softness
  6. Amount of stability needed from the shoes versus orthotic devices

     I finally started running consistent mileage in March of this year. I was only running about 12 miles a week and only running every other day. I ran a 10k race and had no pain. I decided to start training for a half marathon. I only made it a few 6 miles runs and my foot pain is back. I was careful to progress slowly and only went up by 10 % each week. I'm assuming it's sesamoiditis or could it be that my fracture never really healed? (I know the blood supply is poor to the area).
Dr Blake's comment: If you do not have the right orthotic in my mind, you are doomed to re-aggravate the sesamoid again and again. Once injured, it can heal, but the original injury shows that it is a vulnerable spot in your body (weak link in the chain!!). I am hopeful that this setback will get you on the road to finding the right orthotic for you. That is paramount!!

     I'm not sure if I should be considering removal of the sesamoid or if it's normal to have flare ups and I should just accept this and when it happens, rest, ice, strengthen calves, etc? My hip has also started to hurt so I can tell that my gait is altered. 
Dr Blake's comment: Removal of the sesamoid without the proper orthotic post op, which is the same orthotic you would use pre-op to hopefully avoid surgery is not a great option. It is done so so often, but there is a reason why your sesamoids are a weak spot. We do not know why it is vulnerable, but it is. You need to find out from your treating docs why it is vulnerable--plantarflexed, over pronation, hallux limitus, etc. 

I should mention that in the past I tried ice massage, contrast bath, orthotics, dancers pads, minimalist shoes, turf toe taping, and that it actually feels better when I'm barefoot (which is different from most people it seems). 
Dr Blake's comment: You bring up a good point. Our biomechanics are different in every environment--shoes, shoes and orthotics, barefoot, etc.  Many problems are related to motion or shock absorption or stiffness. It is up to you and the treating docs/physical therapists to decide how safe you are in various environments with various activities. Some activities are better barefoot, some with shoes, some with shoes and inserts. I hope this helps. Rich
Any information you could give me would be great.


Thursday, August 14, 2014

Lipitor and its Link to Diabetes

Diabetes is on such a rise in the United States with all it's harmful complications. Unfortunately, for those of you who need Lipitor for high cholesterol you may not have a choice. But, it is worth a talk with your internist.

Wednesday, August 13, 2014

Complex Regional Pain Syndrome: Lessons learned so far

Lessons learned from the treatment of Complex Regional Pain  Syndrome

Dr Rich Blake (podiatrist)
Saint Francis Memorial Hospital, San Francisco, CA

I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots, and hopefully I can help with direction and technical issues. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, you are scared. The doctors and therapists who treat you are scared for you. The quicker the diagnosis is made and appropriate treatment is started, the better the response, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling co-morbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

The Mainstays of Treatment are:
·       Identifying Source of Pain
1.      MRI/CT Scans
2.      Bone Scan
3.      Diagnostic Injections (local or into the back)
4.      Nerve Conduction Studies
5.      Lab Tests
           §         Sed Rate
           §         CBC
           §         Free T4 and TSH
           §         Vit B12 and D3 Levels
           §         HgbA1c
           §         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle
1.     Mechanical Means
           §         Roll A Bout Scooter
           §         AFO (Ankle Foot Orthotic)
           §         Crutches
           §         Tibia Wt Bearing Brace (Freedom Brace or Zero G Types)
           §         Activity Modification
           §         Custom Made Orthotics to stabilize an injured area (Hannaford based orthotic with memory
                      Foam best to start). Some patients can take no arch pressure initially and need some
                      Version of taping to get support.
           §         Taping (Kinesiotape or Support the Foot, but no complete enclosure)
2.     Oral Medications
          §         Anti-Seizure (ie Lyrica)
          §         Anti-Depressant (ie Nortriptyline)
          §         Others through Pain Management Specialists
          §         Low Dose Naltrexone (1-4.5 mg/day)
          §         Sublingual Ketamine for flare-ups

3.      Topical Medications/ Applications (gels and lotions best for ease of application)
          §         Warm Compresses
          §         Non Painful Massage
          §         Parafin Wax (Target sells, but heat must feel great)
          §         Chinese Herbs
          §         Lidoderm Patches (especially for sleeping, can be above the sore area)
          §         Neuro-Eze (OTC applied 3 times daily—buy online)
          §         50% DMSO cream 99.9% Pure (mixed with other medicines as below)
          §         Multiple Compounding Medications which include (usually not all of these):
                     ü      Ketamine 10%
                     ü      Clonidine 0.2%
                     ü      Gabapentin 6%
                     ü      Baclofen 2%
                     ü      Nifedipine 2%
                     ü      Lidocaine 2%

4.     Alternative (only in category, very main stream for this condition)
          §         Biofeedback (Thermal to increase circulation)
          §         Hypnosis
          §         Meditation (30 minutes to 1 hour per day)
          §         Acupuncture (can be to opposite limb or ear)
          §         Graded Motor Imagery (laterality flashcards and mirror therapy)
          §         Somatic Experience technique

·       Nutritional (next 3-12 months)
1.      Alpha Lipoic Acid 300mg 2x/day
2.      Acety-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B1 (5-30 mg/day)
5.      Vit B6 50mg/day
6.      Vit B12 1000mg/day
7.      Vit E (up to 1,600units/day)
8.      Vitamin C (500 mg/day for 45 days)
9.      Vitamin D 3  (1000 units/day)  --have blood level drawn and get to 45-50 level
10.    Thyroid Natural Supplements

·       Rehabilitation of Limb Function
1.      Lower Extremities (keep strong as long as pain free) Physical Therapist must be skilled in Neuropathic Pain treatment, not just musculo-skeletal.  There are times to Honor Pain and times to Push through Pain, that can change from day to day.
2.      Core (support feet and legs from above with less pressure on feet overall)
3.      Cardio (improve overall circulation and health)
4.      Whole Body (must address physical, emotional, spiritual sides together)
5.      Swimming in a Warm Water Pool is one of the best forms of rehab out there for CRPS
6.      Patient must learn how to avoid triggers (sometimes cold drafts, loud noise, etc).
7.      Patient must have thorough understanding of the concept of neural tension and how to protect the sciatic nerve (or how not to irritate).
8.     Neural Gliding or Flossing 3 times a day with Spine Neutral
·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal
1.      Part Time Work
2.      Volunteer
3.      Projects

·            Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration
                   ü      American Chronic Pain Association
                   ü      American Academy of Pain Management
                   ü      Reflex Sympathetic Dystrophy Syndrome Association
                   ü      How To Cope With Pain blog
Psychological Workup/Treatment for Biofeedback/Depression/Anxiety

·        Other Important Treatment Options
1.     As the symptoms from the CRPS calms down, focus again may be necessary on the original injury which could serve as a trigger for flares.
2.    Sympathetic Blocks are crucial in the first year, and their effectiveness wanes more and more as time goes on.
3.    Consider Ketamine Infusion and Calmare Pain Therapy (if there are centers in your area) over the more aggressive Spinal Cord Stimulators. Both of these require initial 10 day commitments, but have great potential. 
4.    Neuro Prolotherapy injections are a great help to patients. 

Monday, August 11, 2014

Achilles Tendinitis: Email Advice regarding strengthening and running

Hi Rich;
I'm not up to 100 stretch sessions yet but I'm getting close (at which point I will make another appointment with you).

In the meantime, I just wanted to keep you abreast of what's going on.

I've been running every other day and doing the stretching regularly and leg strengthening exercises faithfully. I am now up to 50 straight leg both legs/25 bent legs, as well as 50/25 on each leg separately. I do, however, break the individual legs into sets. 25 straight leg on my right, 25 on my left, second set of 25 on my right and left, the 25 bent knees on both. My calves really start to burn at about 21 but I have the strength to power through them. I feel like they're really helping me with some burst energy when I run,which is good news.
Dr Blake's comment: I am having this patient each evening do two sided calf raises both straight and bent knee to warm up, and then straight and bent knee single leg calf raises to tolerance (pain in the calf/achilles, or burning. She has slowly worked up to this level. Sounds like she is successfully squeaking in a few more after the burn. She is also doing more since she is breaking them up into 25s for the straight knee. The goal in rehabilitating achilles is to build up to 50 one side straight knee, and 25 one side bent knee. 

This past weekend, I deviated from the "run only every other day" by running two days back to back. I ran 7.5 miles on Saturday at a relatively fast click (for me) and then a little slower on Sunday for 6 miles. I found after yesterday's run that my achilles reminded me that I needed stretching (we sat in the car a while) so I made sure to stretch whenever I could.
This morning, I felt the normal tightness in my achilles, but after my regular morning calf stretch routine it feels completely fine.
Question: I have a half-marathon coming up in 7 weeks and I would like to start being able to incorporate two things:

Running 4 times a week rather than 3
Running longer runs.
I want to get a sense from you whether those would be OK. The 7.5-miler was a test; I felt fine afterwards but I made sure to ice and stretch afterwards.
No crazy big miles for any of the runs but I would like to be able to run at least a couple of 12 milers in the next 5 weeks. Do you think that's reasonable?
By the way, I have started taking a yoga class once a week and I find that it is very helpful.


Dr Blake's comment:

     Sounds great, but you can do the 1/2 marathon better with every other day runs when you are recovering from an injury. That gives you 4 times one week, and 3 the next. It will honor the recovery phase better, and when you are increasing mileage (especially the long runs), it makes a big difference. Hope it makes sense. Keep up the hard work. With 7 weeks to go, run 8 miles the first weekend, 9 miles the next, 10 the next, 11 the next, and 12 the next. You will be more than ready.  Rich

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