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Sunday, August 2, 2020

Do Bunions (HV) cause instablility? Good Study and Perspective

As we get bunions, the functions of the big toe joint weaken. This is something podiatrists would all agree on, and documented in the article above. I am not a surgeon, and so I try to keep my athletes away from surgery until the disability from the surgery (sometimes permanent) matches the disability from the bunion itself.
From a biomechanics standpoint, we are unstable from a bunion for at least 2 major reasons. First of all, the big toe joint is at the end of the medial arch which is vital to proper strong push off from the ground. You can imagine from the photo above that the bunion is not going to make the medial arch stable, thus pronation and all it's problems will occur.
Secondly, the bunion weakened the power of the joint (as the above article clearly explains). If the big toe joint is basically out of joint, it loses its normal power to push off the ground and that also will affect the foot, ankle, leg, knee, hip, etc etc.
Therefore, one little joint is so vital to make stable, and the observation of a bunion is the first clue something is amiss. Orthotic devices to stabilize the arch indirectly help, toe separators to place the bunion back into Stage II anytime you are wearing shoes, Yoga toes, Abductor and Flexor strengthening exercises, CorrectToes, taping, and the list goes on and it adequately covered in this blog.
Hidden inside shoes normally, and normally non painful, the big toe joint may be silently screaming at you for attention. 

Wednesday, July 29, 2020

Thank You Dr. Kevin Kirby!!

     This post is a thank you to a Rock Star, so to be noticed will probably never happen!! Dr. Kevin Kirby from the Sacramento area of California has greatly influenced my beloved profession and my beloved field of biomechanics. He has his beliefs, and stays true to those beliefs, a trait I completely admire. 
     So, let me explain why this overdue thank you in cyberspace is happening today. Today, I saw a typical patient needing my biomechanical help. At 17, and a runner, he had already had his left accessory navicular removed, and was trying to avoid the same surgery on the right side. This is a small extra bone that 10% of the population has, and only 3% have on both sides. Lucky him. It is both aggravated by pronation, and can cause pronation by weakening the arch. 
     One of my measures of a patients pronation is called the relaxed calcaneal stance position or RCSP for short. This measurement is ideally vertical (standing straight up) or a few degrees in varus. For my patient he stood 6 degrees everted RCSP, so very pronated, and this matched his pronatory gait and pronatory symptoms. 
     The technique I use for this is called the Inverted Orthotic Technique. It is a highly corrected orthotic device, which I felt important for the need to let the patient run and attempt to avoid right foot surgery. These are both moderate to severe implied needs for maximal correction on my part.
The technique is based on a 5 to 1 orthotic correction to foot change. Therefore if I correct the foot 5 degrees I get 1 degree of foot change. 
     So, what happened? I gave the patient with 6 degrees everted RCSP a 30 degree Inverted Orthotic Device and the feet changed to 4 degrees everted. I realized I was a little wide with the heel cup so I lost a degree or so, but this is common when you are initially trying to grab the foot that the foot does not respond how you want it. 
     So, at last visit with the patient, I gave him the 30 degrees of correction with a 2 degree foot change, and ordered a new orthotic at no cost to the patient. I was committed to helping. I added a 3 mm medial Kirby to the existing mold (which normally gives me 2-3 degrees of change when added to the Inverted Technique). I called the dad a week later just to see how he was doing and he said that the new orthotic (that I was unhappy with) was far superior to his previous orthotics and he was really enjoying running in them painfree. 
   Today, I dispensed the 30 degree Inverted with 3 mm Kirby and his heels stood straight up and down at vertical RCSP. This was then reflexed in his gait walking and running. At times it is the Kirby Skive that makes the most difference, and at times the Inverted Orthotic that makes the most change. So, we are inseparable (since I invented and the trustee of the Inverted Technique) and I thank you Dr. Kirby. This is how Dr. Kirby works in the shadows in my office daily, and why his technique has been vital now for over 30 years. 
Thank you Dr. Kirby for always being there for me!!

Tuesday, July 28, 2020

"How I Approach Problems": Heel Pain, Sudden Onset, Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

With the description of heel pain, sudden onset (you can remember the day), and swelling, you are not dealing with plantar fasciitis, but either a heel bone stress fracture or plantar fascial tear. The post today will look at the calcaneal (heel) stress fracture and the thought process in treatment. 

In the 2 MRIs above, the patient's sudden heel pain with swelling was diagnosed as a calcaneal (heel bone) stress fracture. The xrays taken the week before were completely negative. This case completely resolved with the repeat MRI 6 months later.
     When you talk about any stress fracture, or gross fracture for that matter, you have to ask yourself if the patient deserved the fracture by how they treated their foot. By this I mean, did they seem to overdo or over stress the foot, and seemed to get what they deserved. If your answer is no, then you have to look for other reasons a bone would break like low Vitamin D, low bone density, eating disorders, celiac's disease, history of osteoporosis, etc. Even if they seem to deserve it, over 50 years old, I get a bone density, and ask about family history of osteoporosis, and a personal history of low Vitamin D or funny diets.
     I am going to attach the original video I did on heel pain so you can see the examination of someone pointing to a heel stress fracture. Heel stress fractures are treated very differently than plantar fasciitis as the patient was initially diagnosed due to heel pain. Heel stress fractures need soft cushions, perhaps custom Hannaford orthotic devices, bone density and Vitamin D blood levels, possible bone stimulator, and occasionally they break all the way through and need some surgical pinning. Making the correct diagnosis at the beginning of the process saves alot of time.

Dr Larry Huppin: Shockwave for Posterior Tibial Tendonosis and Tendon Dysfunction

If you have been suffering from chronic posterior tibial tendon issues, consider the non invasive shockwave therapy presented here from my friend and colleague, Dr. Larry Huppin.

Thursday, July 16, 2020

Gout Should be Re-Branded to Urate Crystal Arthritis

This abstract, sent to me by Dr. Craig Payne (Australia), really runs true. I make the diagnosis of gout, and maybe five year later their primary puts them on the appropriate drug. During this 5 year period, many joint destructive gout flareups may occur. Rich

Monday, July 13, 2020

How I Approach Problems: Plantar Fasciitis with Sudden Onset and No Obvious Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

           Plantar Fasciitis: Acute in Nature and without Swelling

Most heel pain is diagnosed as plantar fasciitis, and everyone knows the ice, stretch, and support protocol. But what if it is not plantar fasciitis. One subset of patients that I see have a sudden onset of pain (not plantar fasciitis), and without swelling that I can note on exam, and therefore fall into one of these 2 diagnoses.

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms)
Plantar fasciitis can morph into bursitis due to chronic low grade inflammation, but this is not the type we are discussing. The heel pain that is sudden with a plantar heel painful palpable mass, is called infra calcaneal (heel) bursitis.  There may or may not be a reason for the bursae to swell causing the pain that the patient will remember (like stepping on a rock barefoot at the beach). There is a bursal sac that is there when needed to protect bony prominences (like side of hip, front of knee, under the metatarsals), and only gets sore and swollen when irritated.

You can perhaps make the diagnosis with barefoot walking. Plantar fasciitis typically hurts the worse at push off, so walking on the toes may hurt. Heel bursitis hurts more when asked to walk on the heels alone (bursitis sufferers usually do not like this at all).

Heel neuritis can be local (Baxter's nerve entrapment) or referred pain from the tarsal tunnel or higher up (low back and even cervical issues). Like any peripheral nerve problem, you always have to think that it could be from higher up the chain (called Double Crush syndrome). In Double Crush, the nerve would be irritated at the heel (say a pes cavus foot with bony heel and no fat pad---the perfect storm), and is being irritated at the back, piriformis, behind the knee due to a baker's cyst, or in tight hamstrings or calves. What complicates this is that there is no test that confirms that the nerve is irritatable. Nerve tests like nerve conduction studies are looking for damaged nerves not excitable nerves.

 This photo may be alittle difficult, but it is of all the nerves on the bottom of your foot. Look at the nerves just under the heel bone. Any of these can get irritated locally or from a signal from higher.

So, when heel pain, initially diagnosed as plantar fasciitis is not getting better from plantar fascial treatment, you must start looking for another working diagnosis. When there is no obvious swelling, typically ruling out problems like plantar fascial tearing and heel stress fractures or bone bruises, you should look for heel bursitis and heel neuritis.

My next posts will go over the treatments for each separately.

Wednesday, July 8, 2020

"How I Approach Problems": Plantar Fasciitis with Heel Pain with Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

     Heel Pain with Swelling: This is Not Plantar Fasciitis

The “itis” from plantar fasciitis is deep swelling and inflammation that is really hard to feel. The patient does not appreciate any swelling or fullness to the tissues. So, when a patient presents with heel pain, with or without the previous diagnosis being plantar fasciitis, and there is obvious swelling in the tissues, the injury is not plantar fasciitis. From my last post, here is how I summarized Acute heel pain (pain that comes on quickly). 

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:
  1. Plantar Fascial Tears
  2. Heel (Calcaneal) Stress Fractures
With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms
Therefore, an acute onset of heel pain, with the presence of swelling is either a Stage 2-3 plantar fascial injury or a boney injury to the heel (commonly a stress fracture). MRI is the image of choice, and even though the treatment is 3 months of immobilization for both, it is different thought process in treatment when the injury is fascial or bone. 

With fascial injuries, you made need to use plantar fascial treatments of taping, orthotic devices, and physical therapy after the period of immobilization.

With calcaneal heel bone injuries, you have to think about bone stimulators, overall bone health, bone density testing, Vit D, and the extent of the fracture up into the vulnerable subtalar joint. 

My next post I will discuss the protocol of plantar fascial stage 2 or 3 injuries, also known as partial or complete tears. 

Monday, July 6, 2020

“How I Approach Problems”: Plantar Fasciitis Not Responding to Treatment

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove to be more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

                    Plantar Fasciitis Not Responding to Treatment 

Many heel and foot problems are called plantar fasciitis when they are not. Plantar fasciitis is a Grade or Stage I Ligament Sprain. It is inflammation from being pulled on too much in some manner typically in an overuse fashion. In the last blog post we talked about what is and what is not plantar fasciitis. And even though there are always exceptions to every rule, most of these are true. Plantar Fasciitis has the hallmarks of:

  • Gradual onset of pain
  • Worse in the morning
  • Pain after prolonged sitting
  • Minimal to no swelling
  • Typically at the heel 
  • Responds well to treatments of stretching, icing, and taping 
  • Responds well to some forms of arch support where the weight is transferred forward off the sore heel
Therefore, it is good if the patient or yourself has this pattern of symptoms, and you are probably correct at calling it Plantar Fasciitis. But what happens if your initial treatment of stretching, icing, and taping does not help. And one or two forms of arch support are not helpful or even seem to make it feel worse. I personally like to follow my patients monthly and I expect if I have made the correct diagnosis, the patient begins to improve. Each visit I have with the patient after the first will show steady and gradual improvement. It is hard to measure time to complete success, as some patients want to pin me down. But, progress is key month by month if your treatment and diagnosis are in sync.

Each diagnosis has very different treatments so it is important to make an exact diagnosis when you are not improving. What are some of the typical signs from the patient that the problem may be something other than plantar fascia?

  • The Onset of Pain Happened on one day
  • The worse may is not when you first get out of bed in the morning
  • The involved heel is more swollen than the other side
  • The pain radiates into the arch or toes
  • It hurts more when you walk on your heel then when you lift your heel
With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:
  1. Plantar Fascial Tears
  2. Heel (Calcaneal) Stress Fractures
With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms

So, I have tried to show the myriad of patients who are not improving in their treatment of plantar fasciitis, typically because their heel pain was called  plantar fasciitis and it was something else. That something else, needing totally different treatments, was either:
  • Plantar Fascial Tearing or Fasciosis
  • Calcaneal Stress Fractures
  • Plantar Calcaneal Bursitis
  • Infra Calcaneal Neuritis
Each of these problems will be discussed separately in posts later. 

Friday, July 3, 2020

Sesamoid Fracture Advice

Dr. Blake's comment: The patient's mother kindly sent the MRI CD for me to review which I did not until 6/29/2020.

Hello again Dr. Blake,

Thank you for reviewing L's MRI.  Here is a recap of my initial email with updated/new questions.  We look forward to hearing from you and are very thankful for your time and expertise. 

L is a competitive varsity cross country and track athlete with her high school.   In February of this year she sustained a left metatarsal stress reaction (diagnosed via MRI) during track and field training.  She was immobilized for 8 weeks in a CAM boot, sat out the track season, received PT and did aqua jogging and swimming to maintain cardio fitness.  She had a  full blood panel and everything was WNL. Vitamin D was WNL, but in the lower range (we  live in South Florida and she gets plenty of sun on a daily basis). She supplements now with Vit D.   She is a very healthy eater, healthy weight and has regular menses. After a slow progression to return to running over the course of months she has been pain free in the left foot and doing summer training with her cross country team.  She has always run in HOKA Cliftons, but does rotate with Mizuno Wave Rider and Brooks Adrenaline during cross training.  She currently uses the customizable NB2400 (by Aetrex) shoe inserts in her left shoe.  
Dr. Blake's comment: I love the routine change in shoes to vary the stresses.
On June 11th after a practice she complained of R foot pain in the big toe region.  Due to her previous injury, we did not waste time diagnosing and the next day visited her foot and ankle specialist and had an MRI of the right foot the same day . They placed L in a CAM boot to be worn at all times until her follow up July 22nd (approx 6-7weeks post injury).  She has started Exogen bone stimulator 1x day x 20 mins, has had 2 out of 6 scheduled ESWT treatments , and has begun 2x week acupuncture.    She does not complain of any pain. 
Dr. Blake's comment: I would have to see what the literature says about ESWT for acute fractures. Please ask the doctor if there is anything for us to read.

1. How long would you recommend she remain in the boot? 
Dr. Blake's comment: My general rule is 3 months, however at 2 months you can begin to gradually wean out of the boot into bike shoes with embedded cleats or Hoka's with the rocker sole. You have to maintain the 0-2 pain level. 

2. Do you allow patients to remove the boot for gentle ROM of the ankle (the boot is driving her crazy with c/o foot cramping) ?
Dr. Blake's comment: Yes, it is a removable boot for walking. She does not need to wear it when she is not walking. Many patients find that around the house they can walk flat footed in soft sandals and avoid the boot since they can avoid toe bend and still protect. 

3. When should foot strengthening be initiated?   and massage to desensitize?
Dr. Blake's comment: Foot Strengthening is now!! Massage is now!! The massage is best done by the patient since she can make sure that she is avoiding pain. Each massage should b 2 minutes with some massage oil or topical gel like mineral ice. The foot strengthening she should don is metatarsal doming, single leg balancing with a float for the big toe, double and single heel raises also with a float for the big toe joint. 

4. Do you recommend she incorporate a dancer pad (or similar sesamoid cut out)  in her CAM boot? should we add a cluffy wedge with this? 
Dr. Blake's comment: Depends on her pain level. You place pads in like dancer's or cluffy wedges if you need to get the pain to 0-2 within the boot.

5. She is wearing a Darco Toe alignment splint while in the boot.  Do you prefer spica taping over this?    Do you use spica tape and dancer pad at the same time?
Dr. Blake's comment: If the boot gives 0-2 pain, no need for anything else. If not, you have to see what works to drive the pain down. Typically, dancer's and spica taping are used in the next phase as she re-introduces her activities. She should be cross training with cycling, or swimming without pushing off, etc. Some patients can use the eliptical if they stay flat footed. 

6. When could she attempt pain free short bouts of WB for mineralization?  
Dr. Blake's comment: Typically, this is a weight bearing boot, even if you need to off weight with dancer's padding. Around the house, you typically need the boot off to do the contrast bathing and, as long as you do not bend the toe, and you have dancer's padding and overall cushioning in a slipper, you can meander around. Keep the pain low!! At 8 weeks, if the patient is doing great, symptoms are where they should be, you begin to spend more and more time in a Hoka shoe or other stable but cushioned shoe. You need your orthotics with dancer's padding made by then. 

7. At what week post injury do you recommend beginning Physical therapy?   Aqua jogging?   or Swimming?   (we would like her to get some kind of cardio exercise when safe to do so)
Dr. Blake's comment: Agua jogging in the deep end of the pool is now just not emphasizing the toe motion. Swimming also great without fins and without pushing off the wall. Cycling without cleats with the pedal on the arch, not ball of the foot. Eliptical with Hokas flatfooted is fine without using the arms. 

8. Do you have a preference regarding  HOKA Clifton's vs Bondi?
Dr. Blake's comment: No, but it seems that the Bondi is more stable. With Hokas, each shoe has a different rocker point. So, I would make the decision based on how she feels the bend protects the sesamoid. If they both feel the same, go with the one that feels like it has the most toe box area. You will need it for all the sesamoid protection. 

9. At what part of the recovery do you initiate getting fitted for custom orthotics?
Dr. Blake's comment: This should be done as soon as possible. You need to have a good supportive and protective orthotic device, which could take adjustments or re-dos, when she is trying to wean out of the boot at 8-12 weeks. 

10.Do you have any recommendations for a physician in the Sarasota/Bradenton Florida area?
Dr. Blake's comment: I trust Dr Brian Fullem (Clearwater) and Dr. Matthew Werd (Lakeland) and Gerald Cosentino (Tampa). You can call their offices for a closer referral. 

11. We have been advised to avoid any icing and/or contrast baths at this time while she receives the shock wave therapy. Would she still benefit from it 6 weeks from now? 
Dr. Blake's comment: Shockwave is meant to inflame, but help in the healing. I have no experience with it for sesamoids. Sorry. I assume that icing and contrasts are fine after that stops. 

12.  As this is her second fracture in less than one year, do you think we should request a bone density test for her?
Dr. Blake's comment: Our doctors have gotten bone densities at her age and use the same values as the 20 year olds for understanding of the bone density. It is a test if she has low Vitamin D levels repeatedly, if her eating habits are suspect, if her menses is irregular, or if she is slow at healing bone. Did everyone feel she healed the metatarsal fracture fine and in the normal time length? 

13. Are we missing anything?    The MRI report  references sesamoiditis, so does she have a double whammy or will the fracture treatment help with the sesamoiditis?
Dr. Blake's comment: Heal the fracture, heel the itis part with the icing and contrasts and protection. 

Running is a big part of L's life and we want the absolute best care for her. We would like to be aggressive with her treatment to prevent a more chronic problem, however I want it to be within safe guidelines.  Her team is her family and it is hard on her to be away from them for weeks as she heals. 
Thank you!  

ps. on a side note, I should also mention that L was an idiopathic toe walker and as a toddler wore AFO's and spent years in PT.  She was a very difficult case to treat (we avoided surgery), and still has very tight calf muscles and poor dorsi flexion, which is more than likely pre-disposing her to her injuries.  Are you familiar with Aaaron Mattes and his stretching therapy?  He is in Sarasota and L was treated by him years ago for her toe walking.  His sessions are very costly, but if you are familiar with his techniques and feel it would benefit her, please let me know.  
Dr. Blake's comment: Tight achilles is a huge reason for athletic injuries to the front of the foot. You should do what you can to help stretch out the achilles and I will look at Aaron's work. On a ironical note, the tight achilles gives her power to do sports where you are up on your toes. 

Sunday, June 28, 2020

New Series: How I Approach Problems: Plantar Fasciitis

     This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.
                                                           Plantar Fasciitis

So, you have made (or been given) the diagnosis of plantar fasciitis (inflammation of the thick ligament under your arch that runs from your heel to your toes).

It is typically at its attachment at the heel where it is palpably sore on examination. If the soreness is somewhere else than its attachment, then the diagnosis should be in question. Since rare cases occur elsewhere, and if you are certain, the next diagnostic test will actually be the treatment to be prescribed. Plantar fasciitis should respond to this treatment.

The next test of the diagnosis is in the symptoms. Plantar fasciitis progressively gets sore over weeks and months. If the onset of pain is sudden, and the pain is under the heel bone, it is not plantar fasciitis. My next “How I Approach Problems” will be on sudden onset heel pain which is definitely not plantar fasciitis.

Plantar fasciitis also is always the worst in the morning when you get out of bed. Even though you should never use always in medicine, this is a pretty accurate rule. If the pain is not worse in the morning, it probably is something else. Again, we should see how it responds to treatment for plantar fasciitis.

Plantar fasciitis should have little to no soft tissue swelling. The patient typically can not feel heel swelling, but a doctor or therapist should. If there is significant swelling between the two sides of the body, it is probably not plantar fasciitis. Again, one of my next posts on “How I Approach Problems” will be on heel pain with swelling.

Plantar fasciitis should respond to typical treatments of ice massage, plantar fascial stretching, and taping. It can take a few months, but you should feel better and better each month. I love patients to continue doing activities that they can keep in the 0-2 pain range, even if it hurts more after. You do not run again until you are at the base line pain.

Treatment #1: Freeze a sport water bottle after filling 1/2 full of water. Roll over the painful area for 5 minutes 2-3 times a day with a towel on the floor as you sit and roll.

Treatment #2: I love the 2 achilles and 1 plantar fascial stretches described in the video below. These are typically done 3 times a day, especially before and after exercise like running.

Treatment #3: Tape the arch to immobilize the pull of the plantar fascia. I have replaced the time-consuming, but wonderful, low dye taping with Quick Tape from Support the Foot. This is typically left on 5-7 days at a time.

Plantar fasciitis always gets a lot better with this regimen. If there is little to no improvement, I doubt the patient (you) have plantar fasciitis at all. Next blog post will go over the decision making of no treatment response. If the patient gets 50% or so improvement but plateaus, we typically have to increase the treatment. Tomorrow I will discuss this scenario with partial success with plantar fascial treatment or no treatment success.

Plantar fascial treatment should allow full, but modified, activities. A non-response to treatment for plantar fasciitis, typically means that there is no plantar fasciitis but it can take a month of treatment to know that. A partial response to plantar fascial treatment typically means more specialized treatment is needed with inserts and PT.

Wednesday, June 24, 2020

Problems with Removable Boots and Swelling

Hi. Dr. Blake,

I wanted to get your take on my situation. I started having pain which turned to swelling at the end of Feb. 
I have very high arches (I have custom orthotics) but had not started wearing them yet. I went to a podiatrist who said that I needed to wear a boot. 
I wore the boot for about 4 weeks but still had some swelling. 
She suggested doing a MRI. During the time I was wearing the boot she said it was okay to walk around in the boot and so I was going for short walks with my son. 
I ended up seeing another podiatrist via tele med. He suggested Physical therapy. 
I did physical therapy for about 4-5 weeks. The PT hurt my foot and after the first visit I had swelling after I thought my foot was better from the boot. 
I continued the exercises and it felt like my foot was finally getting a little better but then he had me do some twisting balancing exercises that again really hurt my foot and made me think I re-injured it.
 He sent me back to the second podiatrist who did an MRI. 
He said I had a lot of inflammation and a small tear needed to wear the boot again, stop all PT and take  MEDROL or do a cortisone shot. 
I opted against cortisone, am wearing the boot but finding that my foot is swelling up again even though I am not walking and laying off it. 
I was also icing. I feel like the icing and the boot are hurting it. Is this possible? Maybe it's not getting blood flow.
 Before I got the MRI I was wearing my Dansko shoes at home and my sneakers and walking around an it felt better. I am really confused.
 Any sugggesitons?

Dr. Blake's comment: First of all, swelling can be inflammatory (typically painful), part of the healing/reparative process of an injury and chronic since it can last months and months after an injury (typically not painful), and related to venous insufficiency (veins having trouble removing fluid from feet and generally also not painful). 
So, when you say swelling, I need to know if this swelling hurts or not. 
Chronic symptoms, over 3 months, start to strain the venous return and swelling can get harder to drain out of your foot. You may need compressive socks or, at least, some period daily of elevation. Boots can begin to work against you and trap in the swelling due to the immobilization and Velcro strap restriction of the venous return. 
Icing controls inflammation, but usually does not get rid of it. Contrast bathing can be the best at removing inflammation and swelling produced by that inflammation. 
So, recommendations: Are we sure the tear needs to be protected? That is the million dollar question here. Inflammation is better served by contrast bathing not ice, no boot, some elevation, motion that does not cause more than 0-2 pain. I sure hope this rambling helps you. Rich 

Monday, June 22, 2020

Posterior Tibial Tendon Dysfunction (left side only)

Left Posterior Tibial Tendon Dysfunction with Arch Collapse and Heel Valgus

Here the actual degrees of Valgus is measured

I am designing him the first of three orthotic devices. The first orthotic will correct 7 degrees, the second orthotic up to 10, and the third orthotic up to 13-14. This is utilizing the Inverted Orthotic Technique based on heel valgus measurements. 

The Subtleties of Testing

There are many subtleties in tests ordered by doctors. This can be from brain scans to simple routine blood work. In my practice, foot X-rays and MRIs are a commonplace as the socks in my drawers. However, there can be subtleties in reading these well represented by this x-ray. While the report documented normality, the subtle signs of mid foot arthritis abound. Plenty of spurs and bone irregularities mark the painful area. For this reason, I always want to see the X-rays, and actually prefer to read them before I review the report. Many times I only get the report faxed to me and have to have the patient go out of their way in retrieving the CD of the actual images. I think it is worth it!!

Floating a Sore Spot on the Bottom of the Foot

 From the Image above you can tell where the patient is hurting. She took this image right after icing and was amazed at the color changed in the sore area. My schema is of the padding that I actually applied to the shoe insert that give her great relief. This is one of many patients whom the shelter in place has allowed for more walking, but that increased walking has brought out that some problems. She will continue to ice 5 minutes 2-3 times a day, and tape her 2/3 or 3/4 in a downward position. Another post covers that type of taping with KT tape or Rock Tape. 

Saturday, June 20, 2020

Vasli Dananberg Orthotic for Plantar Fasciitis and Functional Hallux Limitus

Hi dr Blake
I am 56 year old woman with plantar fasciosis of 2 years now since oct 2019 functional hallux limitus. In general have you found Vasalyi dananberg orthotic helpful if both  plantar fasciosis and hallux limitus Present .none of my sports med, ortho, podiatrists that I have seen  are familiar with it. Does it have any liabilities in your opinion. I read your blog am -doing the toe mobilizations and bought a toe spacer ( siliipos one)
Thank you

Dr. Blake’s comment: I am in favor of this design overall. The arch is deceit and the release of the first metatarsal to push off great. It will work less and less as the pronation syndrome gets higher, but a good place to start for sure. Rich 

Friday, June 19, 2020

Hallux Limitus/Hallux Rigidus: Conservative Thoughts

Let us start the discussion on avoiding surgery for Hallux Rigidus as our first option. Let's try conservative care for awhile. Here is my original Blog Post way back in 2010 on this subject.
Here are 2 PTs discussing mobilization of the joint. I typically do not recommend putting a rigid hard device under the toe that hurts initially, and I typically avoid the standard dorsiflexion and plantarflexion motions, but it is okay to see how it feels.

Sore on the Bottom of the Foot

Here is a patient from today's clinic. Yes, I am back after so much time off. Now, let's not blow it and forget our masks and social distancing!! I know I sound like your parents!!

     It is so important to off load sore areas on the bottom of the foot. This patient had a deep seated callus under the fifth metatarsal which I tried to dig out. Then I attempted off loading with my 1/8 inch adhesive felt. Thick moleskin also works, and you may have to layer to get the right thickness. 

Thursday, June 18, 2020

The Inverted Foot: What to Do?

I treat many patients that are inverted aka varus aka supinated. This is a great foot for me to help. Even though the exact numbers do not mean much, this is a patient with 10 degrees of genu varum (bow legs) with 10 degrees of tibial Varum. You can tell this patient likes to walk on the outside of their feet, however the compression forces are at the inside (medial) aspect of the ankle and knee. 
     As the patient stands they are inverted to the ground. You will want to perform the block test or have them rotate internally with the leg to see if there heels get to vertical. This patient easily had the range of motion to get to vertical. 

     Treatment wise you may decide on holding the patient inverted (say in the case of lateral meniscus injury or sesamoid injury) although allowing pronation for shock absorption, or getting the patient back to near a vertical position (say in a lateral ankle instability patient trying to avoid surgery, or chronic medial meniscus pain trying to avoid knee replacement. I will talk more on the inverted foot in the next few days. Rich

Sunday, May 31, 2020

Pronated Left Foot: New Orthotic Device to be Made (Posterior Tibial Tendon Dysfunction)

This patient presents with a collapsing left arch for several years. I inherited the patient from my retired partner (Dr. Ronald Valmassy) who kept him going on a 20 year old orthotic device. However the patient has noted a change in the last year with a collapsing left arch and more left arch pain. He has no pain in his right side. He tries to walk 3-4 miles daily, but the last 6 months has been limited to very little walking. 

I am going to start with my highest correction of 35 degrees Inversion for the left foot. I am only making a new left for 3 reasons: only has pain on left, the right orthotic device seems excellent, and he has no insurance and is paying for this himself. 
     This is actually a typical stage 3 PTTD patient. The RCSP (resting heel position) was 17 everted or valgus standing on the orthotic device. The highest correction I do is 35 degrees initially which should push the patient into more varus by 7 degrees (5 to 1 plaster inversion to actual foot change). I will go up from there after he is used to it. I am always hoping for more than the 7 degrees change, but sometimes it will be less with the first correction. 3 months after his new left orthotic device is dispensed, I will either push the orthotic correction 3 or 5 degrees more.      

Monday, May 25, 2020

Nerve Pain helped by Neuro One Topical

Neuro One is a topical that you can order through Amazon and other places. It has L-Arginine and Vitamin B-12. It is one of the medications, along with neural flossing, warm bathes or 5 min ice, non painful massage, metatarsal support, and foot mobilization, that I use routinely for foot nerve pain of any sort. This can include Morton's Neuromas, peripheral neuropathy, sciatica, etc. I advised this particular patient to reduce the Neuro One to once daily to see if we get the same great results. 

Hi Dr. Blake,

I hope that you and your family are keeping well! We are muddling along without too many problems.

You suggested that I check in by email right around now.

The only question that I have right now is whether you want me to change my NeuroOne routine.

I have been using it for about 14 weeks, twice a day, on my left foot.

The neuroma “pain” is diminished by about 50% on both feet since I starting using the NeuroOne in February. Now on both feet it’s in the 1-2 range, and the predominant sensation when I walk is something like having the ball of your foot brushed by a vegetable brush.

Also, I have stopped icing the balls of my feet at night. Now I just ice the boney ridges on the tops for 10 minutes in the evening, which is more relaxing than anything else.

I haven’t gotten up the courage to try any shoes other than my Chaco sandals. Sheltering in place (with daily walks between 90 and 120 minutes) doesn’t require any footwear more stylish then Chaco’s.

So, there you have it: the NeuroOne question, plus I’d be happy to hear any other suggestions or advice.

Thanks, and take care!

Sunday, May 24, 2020

Chronic Big Toe Joint Pain: Turf Toe?

Dr. Blake,

I have been reading your blog for several weeks now and have watched many of your videos. I am emailing you on behalf of my daughter who is a 16-year-old soccer player (who will be a junior this fall) with the potential to play soccer in college. She has been suffering from an injury and is desperate to feel better and hopefully be able to continue playing the sport she loves. I am hoping that if you have some time you could give me your thoughts. I completely understand if you are unable to do so. 

She suffered an ankle injury in September 2018 while playing soccer. The orthopedic surgeon at the time said she most likely had torn the ATFL. She was put in a cast, then a boot and then went through PT for several months. She was cleared to play soccer in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to PT and then was released to play again in April. Right at that time, she started to develop pain in the ball of her foot. She continued to have pain for several months until an MRI in June 2019 diagnosed turf toe. She was put back in a boot for several weeks and then went through PT for a few months. She returned to play in August but by October she started to develop pain in the same area after playing back to back games of 90 minutes each. All this time she continued to have pain and swelling in her ankle as well as the pain in her foot. She continued to play soccer until the date of her surgery on November 22, 2019.

After a year post injury, it was decided she would need ankle surgery. In November 2019, she underwent a modified Brostrom procedure and the doctor found that she had 3 torn ligaments in her ankle. I believe two were repaired with anchors and the third was reconstructed. (Note: this orthopedic surgeon was not the original doctor we saw when she suffered her injury in 2018) Once she was allowed to take her first weight-bearing steps weeks after surgery, she had immediate pain in the ball of the foot. The orthopedic surgeon had hoped that the rest after surgery would help and prescribed PT for both the ankle and the foot Jan-Feb 2020. We took her to a podiatrist in March of 2020 after continued pain in the foot. X-rays in the office were negative for any fractures or abnormalities of the sesamoids. He diagnosed her with sesamoiditis. He made her orthotics and shortly after she received them, the Corona virus hit and we were unable to see him for several weeks. During that time, we sought another opinion by an orthopedic surgeon specializing in the foot and ankle. He performed x-rays as well and found them to be negative also. An MRI was performed with the following results:

----There is very subtle bone marrow edema of the head of the second metatarsal. There is
no other bone marrow edema, marrow replacing process, or acute fracture. The
sesamoid bones of the first digit have a normal appearance with no signal or
morphological abnormality. The flexor digitorum tendons, flexor hallucis longus, and flexor hallucis brevis tendons are intact without edema or tenosynovitis. The extensor tendons are intact without edema or TR synovitis. The plantar fascia has a normal appearance without
inflammatory change. The muscle volume and signal is normal.
There is soft tissue edema in the interspace of the first and second metatarsal heads
tracking around the lateral sesamoid bone of the first digit.
1. Mild bone marrow edema of the head of the second metatarsal with surrounding soft
tissue edema extending into the first interspace and around the lateral sesamoid bone.
Findings likely relate to chronic stresses/ superficial repetitive trauma.
2. No evidence of fracture or osteomyelitis. No soft tissue fluid collection.

Dr. Blake's comment: Many patients have irregular sesamoids on xray, never get an MRI like your daughter, and due to the chronic pain have the sesamoid out sadly. So, I am so glad you did get an MRI. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I am confused that the MRI did not document turf toe, but maybe it was a severe stage 1 or mild stage 2. If we treat the MRI only, this should be all healed by now. 

He put her on a Medrol pack, showed her how to tape her toe (like the videos on your blog) and told her to wear a boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol pack. He did not recommend a cortisone shot or surgery. Shortly after, the podiatrist called us back to the office. He modified her orthotics. He took her out of the boot because he felt her muscles would atrophy and would require more PT to rehab her back.  He found her hamstring and calves to be very tight so he instructed her to stretch 3 times a day and ice afterwards for 20-25 minutes. She is to do this for several months. She just started PT this week. The therapist said she is strong in both the ankle and foot but is still weak from her surgery as she was never able to start conditioning due to the pain in her foot. She is wearing Merrell hiking shoes for more support. I put a J-pad under her foot and she did feel a little bit of relief. However, the podiatrist does not want us to use this...maybe because he wants the orthotics to start working to redistribute her weight naturally? She is continuing to tape her toe as well. Per your blog, we will file down the cleat right beneath the ball of the foot and will also purchase turf shoes for training and play when her outdoor cleats aren't needed. 

Dr. Blake's comment: This is wonderful. Dancer's padding (J Pad) are a must, and I will use on the orthotic and also on the foot. You typically need 1/4 inch sesamoid float to take pressure off, so you can see how much the orthotic does. It is time for her to get at least 5 things that are working for her: taping, orthotics, J Pads, cluffy wedges, icing, contrasts, stable shoes. Can you get a pair of Hoka One One to try to see if the rocker eliminates some stress? 

The podiatrist would like to see her back in a few weeks to determine her pain level. If she isn't getting much relief, he said he would consider giving a Cortisone shot. He also indicated that if she continues with conservative treatment for a few months without much relief, and the fact that she's had this pain for over a year, he would consider surgery. While he said this is the last option, he did say she could recover well from it because it's the lateral sesamoid that would be removed. He felt that she would be able to return to playing soccer about 4 months after surgery. My concern is the health of the remaining sesamoid and keeping it healthy for the remainder of her life. I have read what can happen if both sesamoids are removed.

Dr. Blake's comment: Whoa!!!! There is no problem documented in the lateral sesamoid, and cortisone into a chronic turf toe may be okay, but may be not. Turf toe, which I think is our working diagnosis, is a tear or stretch of the ligaments. It can make the joint unstable, and I do not know if she is already naturally loose. She may consider an arthrogram of the joint where dye is injected into the joint to see if it leaks out, although have not seen that test for years. If a lachman test for turf toe has been done, find out what it was. She made need a couple of sutures placed into the big toe lateral collateral ligament if that is the case. Convince me that this is not ligament instability due to turf toe. Sorry, I know this is hard. I sure hope this helps your daughter some what.

I am reaching out to you because my daughter is starting to feel hopeless that she will ever recover. She had to stop playing basketball a year ago because it was all too much for her ankle. She will be devastated to have to give up on her dream to play soccer in college. 

If you are able to provide any thoughts or advice, I would greatly appreciate it. I feel that the orthopedic surgeon and the podiatrist have conflicting ideas and a third opinion (hopefully yours) would possibly help us with our next steps.  I have been doing a lot of research and stumbled across your blog. By far, your site provides more information about this condition than anything else I have found. Thank you for all you do for the health of others.


Saturday, May 16, 2020

Application of Temporary Kirby to Achieve more Pronation Support

Typical Patient with Custom Orthotic Device giving less than optimal Correction
The Green Wedge has been skived prior to application to lessen the abruptness of the Transition
This is also a great way off adding more support without placing it in the Medial Arch
The surfaces of the wedge and orthotic device are glued

Since this is the left foot, this wedge is on the medial side, called a Medial Kirby Skive or Medial Heel Skive

The final trimming has been done

Friday, May 15, 2020

Cluffy Wedge and Dancer's Padding for Sesamoid Injuries

The famous Cluffy Wedge for sesamoid help, named after Dr, James Clough from Oregon, is typically a 1/8 to 1/4 inch square of adhesive felt worn directly on the foot

Foot Bone Schematic seen from above the foot looking down on the right foot

Here the same schematic shows a dancer's pad to off weight the sesamoids with 1/8 to 1/4 inch adhesive felt or other soft material glue to the shoe insert or orthotic device

Here the same schematic with a cluffy wedge also used for the sesamoid protection