Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. Please email your questions to rlb756@gmail.com. Please consider donating to this blog if I was able to help in some way. Rich
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.
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.
IMPRESSION:
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. https://www.physio-pedia.com/Turf_toe
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.
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
Here is the patient with knock knees or Genu Valgum and Rear Foot Valgus deformities. In an ideal world, the subtalar joint could stay in neutral where the foot and ankle lined up although everted.
If we were to measure this patient, the heels would be everted to the ground the same degrees of genu or tibial valgum.
However, reality sets in, and one of two things happens. The subtalar joint supinates to bring the heel vertical or close to that position (as shown on the right side), or the foot collapses more medially with subtalar joint pronation getting more everted than the tibial valgus position as seen on the left side. The right foot needs an orthotic that allows for contact phase pronation and I set it to typically pronate from 6 everted to 10 everted by using the inverted orthotic device of 20 degrees or a 4 degree change and then grinding 4 degrees of motion into the rear foot post. The left foot needs to get them close to their everted neutral position of 10 degrees everted typically with a 25 degrees inverted orthotic device.
This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are:
Unilateral pronation placing a strain on the posterior tibial tendon
Some inherent weakness in the tendon
A Habit of wearing poor quality non supportive shoes
When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories?
An Orthotic Device with some inversion
A varus foot wedge external or internal to the shoe
A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
Stable shoes, stability or motion control, with some heel elevation
It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include:
Anterior Tibial Tendon
Intrinsic Musculature
Peroneus Longus
Gastrocnemius and Soleus
Sartorius
Lateral Hamstrings
External Hip Rotators
And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation?
Mueller TPD orthotic device
Inverted Technique with Kirby Skive
Modified Root with Kirby Skive
DC Wedge
This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.
What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are:
Too much correction in the heel fat pad for the body to tolerate
Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
You modify the Kirby skive, or the medial arch, for comfort losing support in the long run
The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support.
I recently broke my sesamoid bone walking in a new pair of work shoes. As you can see in the xrays the fracture gap seems wide to me. How does one bridge the gap? And should removal surgery be on my mind. I am three weeks into the boot and just ordered a stimulator. I am hoping a couple months on the 0-2 level promotes healing. What are your thoughts? Is full recovery possible after therapy? Thank you for your videos and time.
Very Respectfully, Dr. Blake's comment: Thank you so very much for the email. I am glad you are in the boot, and should stay that way for 3 months. The bone stimulator should be a 9 month ordeal, even if you are back running by then. Here is some advice that holds true from another post.
Put your foot on an ice pack 3 times daily for 10 minutes to reduce inflammation. You want to have all some symptoms from the break and none from the surrounding inflammation. Avoid anti-inflammatory meds since they can slow down bone healing.
Talk to your podiatrist about getting a bone stimulator from Smith and Nephew called Exogen. You place on your foot 20 minutes twice daily. The bone stim company will work with you insurance company so you know what you have to pay beforehand. The bone stim will probably for the next 6 months.
Discuss you Calcium and Vit D levels/intake with your internist to make sure they are not a problem. I would consider a bone density screen, and especially if you have any family history of osteoporosis. Get your Vit D 25 levels.
Make sure you can make that removable boot into a painfree environment. All podiatrists know that one well.
Learn how to do spica taping as shown on the video above.
Get a baseline MRI. Plan on another one 3 or 4 months later.
Have a PT show you some simple strengthening exercises to start doing now. Everyday you are losing strength, and it will take longer to get better the weaker your foot is, but you can not produce pain. My blog has ample exercises that you can review with the physical therapist including playing the piano, metatarsal doming, flat footed balancing, and inversion/eversion resistance band exercises.
Surgery is needed in 10% of the population, for many reasons. From 6-12 weeks in the boot, you will need to find someone to make good orthotic devices to protect you as you wean from boot to shoe. Some will use the rocker on the Hoka One One shoe to help, others just find the traditional athletic shoe is fine. Try to get some Dr. Jill's dancer's padding to begin using. You will need some protection, even slight, for up to 2 years at times, so the Dr. Jills can be used in sandals, high heel shoes, etc. Xrays are a small help, but MRI is crucial I think, especially if it gets to the point of deciding on surgery. I hope this helps you. Good luck in your journey as the country gets back to some normalcy!! Rich
Hintermann published a paper in 1996 about a clinical test to help him decide whether a patient needed surgery for posterior tibial tendon dysfunction. It was based on the fact that with the patient standing, when the heel is inverted (or the leg externally rotated), only in the 21 patients that had posterior tibial disease (not necessarily ruptures) was this test positive for leaving the first metatarsal off the ground. It is now known more as the First Metatarsal Raise Test. When I read the article many thoughts crossed my mind, and I need to do this test some, but I need other podiatrists to give me feedback on their successes and failures. So, what bothered me about this test? The things that bother me are:
100% of the patients were positive even though the surgical findings were all over the place (from tendinitis only to complete ruptures)
100% of the patients without post tibial tendon disease were negative, but they do not go into any of these patients (allow they implied the test was being done over 4 years)
They made no reference to what type of orthotics were being used preop to avoid surgery and whether the tendon being strengthened thoroughly before (there was no mention about posterior tibial strength at all)
They seem to have no knowledge of deformities like rearfoot varus, rear foot valgus, forefoot valgus and forefoot varus. Any of these common deformities would greatly affect this test.
In most of my patients with PTTD, with 10 degrees of heel eversion, and 10 degrees of positional forefoot supinates, when I put the patient into heel varus the first metatarsal is going to be way off of the ground. This does not mean I need to do anything but rehabilitate them.
I hope you are doing well and staying healthy during these crazy times!
I have been thinking of writing you for quite a while, but my question is quite lengthy.
I have attached some x-rays and photos to this email, but I also have a CT cat scan
and an MRI of my foot if having those would be better.
Dr. Blake's comment: Yes, send those to Dr. Rich Blake, 90 Beachmont Drive,
San Francisco, CA, 94132 to see if those are revealing.
I have developed a hallux claw toe in my right foot after I had a bunionectomy
and tibial sesamoidectomy in 2014 and I am wondering
if I should get surgery to prevent a joint fusion surgery in the future.
My toe does not bother me terribly now. Every other day I can go on a 1 mile walk,
with minimal discomfort. However, I have noticed that as time has gone on
it has become progressively more sensitive
(able to walk less and less mileage without the next day hurting)
and I want to maintain a relatively active life as I am 33 and a mom.
My right big toe does not really touch the ground, and my other four toes
on the right foot are starting to develop hammertoes.
My left foot also has hammertoes so I know I am prone to them,
but they are still relatively mild on both feet.
I have been recommended two different surgical techniques to prevent further problems
down the line with my foot, and am wondering whether you think
1) surgery is a good idea, and 2) if so, which surgery you think I should opt for.
History:
Initial Breaking of Tibial Sesamoid with subsequent Surgery: I have high-arched feet,
and have worn orthotics since age 13 or 14.
I broke my tibial sesamoid after wearing heels to a party in 2013.
It was described as a freak accident (as I guess most bone breaks are!)
but people had always remarked at how high my arches were,
so I guess the pressure was too much. 7 months later
I was told there was no healing and it was recommended I have a tibial sesamoidectomy
as well as a bunion surgery (chevron osteotomy),
as I already had a bunion but the broken sesamoid was accelerating its progress.
I wish I had found your blog back then, as it was described as a relatively easy surgery
with minimal complications. After the surgery I went to physical therapy.
It was always hard for the physical therapist to get my big toe to touch the ground even then.
A year after the surgery I noticed my right big toe no longer touched the floor when barefoot.
As long as I wore orthotics in shoes I was pain-free and comfortable
and could go about my daily life. Walking barefoot was uncomfortable
because the ball of foot was pushed into the floor without weight bearing from the big toe.
Dr. Blake's comment: This is a common problem with the tibial sesamoid removal which weakens the short flexor under the joint. This enables the tendon on the top of the toe to win, called the extensor.This dynamic imbalance pulls the toe up starting the hammertoe. With the pes cavus or high arched foot, you probably even before surgery had a tighter extensor ready to pull the toe up. With this being said,
it does not explain why the PT could not get the toe down which let this get out of hand.
Most Recent Setback: In May 2019 I wore a pair of heels on date night
and walked about 10 minutes on the cement sidewalks. (No heels allowed in my closet again!)
The next day my fourth toe and especially my big toe were very inflamed,
and it took 5 months of me wearing a boot and daily icing in order for the symptoms
to calm down. This is when I found your blog. During those 5 months
I visited multiple podiatrists and two orthopedic surgeons to try and figure out
why it was taking so long to heal. It was determined that I stretched the collateral ligaments
in my stiff big toe. The second orthopedic surgeon had a nerve-conduction ordered
to ensure I did not have charcot-marie-tooth disease, due to my high arches,
raised toe, hammertoes and slight atrophy of right-side calf muscles.
Luckily it was determined I do not have the condition, but both orthopedic surgeons
commented on how raised my big toe was, and were concerned about how my foot
would handle such biomechanical stresses for the duration of my lifetime.
Both of them suggested some surgical techniques to prevent the further deterioration of my foot.
I know you are not a proponent of “preventative surgery”, but I am wondering
what you recommend in my case.
Dr. Blake's comment: All we know right now in this correspondence is that you have a very sensitive
big toe joint. I think everyone, except a few surgeons, would agree that an operated on joint, is and will
be forever a weaker joint. When you do hip surgery, and slightly less with knee surgery, you can
establish great stability on the surgical site with the surrounding muscles. You
have great opportunity to really tone them up. The foot has some crucial
muscles to help, but as podiatrists we mainly have to rely on shoes, orthotics, accommodations, taping,
etc, and physical therapy to breakdown scar tissue, remove inflammation, and stretch and
strengthen the muscles up the leg to the hip.
Current Pain and Issues:
1) My current symptoms are that my toe is quite stiff at the MTP joint,
and semi-rigid at the IP joint. I have good range of motion with the toe going upwards
but pretty limited motion when trying to force my toe down.
The bottom of my big toe is sore (scale of 2 out of 10) if I go on a 1 mile walk or more.
If I go on these walks for more than a couple of days I have to take the next day off.
Furthermore, the side of the top of my big toe gets sensitive too if I go on long walks
or walk barefoot on hardwood floors. I have noticed this is because my big toe
actually turns into the rest of my foot, in addition to the claw toe.
It feels like the bone is pushing out? This varus has been increasing over time.
Dr. Blake's comment: So, if you were in my office I would have you practice and get really good at
spica taping to hold the toe down for the next 8 weeks. Patients usually can advance from the easier KT
or Rocktape to the 3M Nexcare Waterproof tape. You should have a PT over the next month to year
(when corona quarantine is lifted) measure the amount of plantar flexion of the big toe joint which
Welcome to my Google Document that I shared with my Podiatry Students at the California School of Podiatric Medicine Samuel Merritt University Oakland, California. This was my first Zoom teaching, so I over prepared, and dropped everything else I was doing last week, but I think it went well. I will be putting the answers to questions on this on request of student doctor Diksha Mohapatra by April 17th, 2020. The videos are great to watch if you want to learn about gait evaluation. Rich Biomechanics Workshop Outline (4/10/2020 1-3 pm)
Introduction of Students and Dr. Rich Blake
Allison Ma
Amy Lau
Andrew Rasiah
Diksha Mohapatra
Maksim Rukhalskiy
Shane Hall
Usman Khokhar
Yona Mizrahi
2 Classes from Dr. Rich Blake Gait Evaluation 4/10/2020
Orthotic Devices on 4/24/2020
(we will start next session with the discussion of the assignment below on Golden Rules)
I hope to teach you that Gait Evaluation is much more than pronation or supination of the foot. Look at the whole body. We use gait evaluation as a clue to find out what is wrong with a patient, and how to help them.
Right Foot
Some of your patients will like this video, so you should know how to treat them and we will go over orthotic devices next session.
Allison: What are the 2 separate parts of gait called?
Amy: What are the 5 components of stance phase?
Andrew: What are the 3 components of the swing phase?
Diksha: With what you know of the contact phase as the ankle is plantar flexing, what is the heel doing in the frontal plane and the knee doing in the transverse plane?
Maksim: How does the patient prevent foot slap gait with drop foot?
The common findings in gait that you as a podiatrist will see in regular practice is less pathological and more subtle, but still very important. Looking to see how to help each patient mechanically.
Ability or Inability to Walk (First and Foremost)
Structural deformities like pes planus, pes cavus, bow legs, knock knees, genu valgum, etc.
Signs of Asymmetry
Signs of Pronation
Signs of Supination
Signs of Limb Length Discrepancy
Signs of Tight Muscles/Tendons
Signs of Weak Muscles
Signs of Poor Shock Absorption
These are all problems that we can make mechanical changes to help
Maksim: What would be a sign of pronation?
Shane: What would be a sign of supination?
Usman: What would be a sign of short leg syndrome?
Yona: What would be a sign of tight muscles?
Allison: What would be a sign of weak external hip rotators?
Amy: What would be a sign of weak achilles tendons?
Andrew: What would be a sign of weak peroneal tendons?
Diksha: What would be a sign or weak posterior tibial tendon?
Maksim: What would sign of poor shock absorption?
Below is a video with a more podiatric approach with less emphasis on the aspects of gait, and more on what can cause injury that we can help.
Shane: What are the 4 main gait findings that may suggest short leg syndrome?
Where does gait fit into our General Approach to Injuries and Pain Syndromes?
14 Step Approach to a Injury or Pain in Office Visit
These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:
History of the injury and the patient’s reason why they were injured.
Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches)
Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic)
Physical examination of possible biomechanics involved
Is there biomechanical asymmetry?
Tentative working diagnosis made
Common Differential Diagnosis: common not rare
Occam’s Razor and the Rule of 3 for initial treatment help
What Phase of Rehabilitation is the patient in at this visit?
Should we do Imaging at this point?
First Decision: What do I have to do to get the pain consistently between 0-2? This is the real reason that the patient has to be put into Phase 1 of Rehabilitation where PRICE rules. The 0-2 pain level realm is where injuries can heal.
Second Decision: How Much Inflammation needs to be Addressed?
Third Decision: Is there any neurological component that should be treated?
Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal?
Since I can never get enough on gait evaluation, here is another video.
Symmetry of Arch Collapse (Right more vs Left more)
Digital Clawing (Right or Left or Both)
Angle of Gait (Right—internal, straight, external, Left—internal, straight, external)
Other Structural Variations: Pes Cavus, Pes Planus, Tibial Varum, Genu Valgum, etc
Correlation to Symptoms: _____________________________________________________________________________________________________________________________________________________________________________________________
Other Observations: ______________________________________________________________________________________________________________________________________________
Allison Question #1: In assessing gait in an adult, the finding of a head tilt to the right suggests which leg is possibly longer?
Amy Question #2: When you observe a patient walk, and you note that their right shoulder is lower, what should you ask them and where should you next observe?
Andrew Question #3: Asymmetrical shoulder motion is typically reflected in asymmetrical arm motion. If a patient has a sore right knee, what is the normal arm swing variance seen, and how can that cause neck pain?
Diksha Question #4: As we continue to evaluate gait, what are the signs now that the patient has a possible treatable limb length discrepancy?
Maksim Question #5: How does the correction of 12 degrees of forefoot valgus deformity help with back pain from muscular tension?
Shane Question #6: What does it mean for you to observe Hip Hike?
Usman Question #7: Watching the beltline of a patient as they watch back and forth in your clinic typically gives you 3 observations that you may be able to treat. These observations are:
Yona Question #8: The normal knee motion is a reflection of hip motion. What would it mean if the knee started central or straight, and externally rotated to an external position during the contact phase?
Allison Question #9: How can a patient maximally pronated in gait due to genu valgum and weak posterior tibial tendons be a poor shock absorber and present with knee pain?
Amy Question #10: A patient complains of lateral foot pain recently. They have observed that their foot was out toed more in the last several years. They have some back pain also. What is the possible diagnosis?
Andrew Question #11: Excessive internal rotation of the knee is a common gait finding. What 3 areas of treatment should be addressed?
Diksha Question #12: As we learn to watch gait, what motions are found with the motion of heel eversion and heel inversion?
Maksim Question #13: When a patient with pes cavus walks towards you, you do not observe any flattening of the medial arch on the right foot, but marked arch collapse on the left side. We understand that there are pronatory forces occurring on the left, but what could be happening on the right?
Shane Question #14: In gait we may observe that the toes tend to claw. This can be bilateral or occasionally unilateral. What are 2 common reasons that weak achilles tendons can cause this? What is the acid test for achilles strength?
Usman Question #15: As we watch a patient walk, one of the last observations will be the angle of gait. It is really important for children to know what the reasons are for the internal or external angles because of our abilities to cast or brace young children to improve this transverse plane issue. If you observed in gait that the knee was straight, but the foot 30-40 degrees externally rotated, what are several common causes?
Yona Question #16: The general rule used in shoe stores is that pes cavus feet supinate or underpronate. What percentage of pes cavus feet supinate?
Shane: What are the 2 types of overpronators they described?
Yona: What does the term Underpronation mean?
So, here is a summary of the gait findings I find daily in my patients associated with the common mechanical syndromes that I can make correlations to their symptoms and then treat mechanically.
Common Signs of Short Leg Syndrome
Limb Dominance where the patient spends more of their time over one side
Asymmetrical arm swing (long leg can have the arm closer to the body)
Shoulder drop is usually to the long side (when compensated with the spine)
Head tilt is usually to the short side (also when compensated with the spine)
More pronation or more supination on one side
Belt height is angled up towards one side
Amy: Which statements are false in leg length discrepancies?
The typical limb dominance is to the long leg
A true shoulder drop finding has lower fingers on that side
The more pronated side is the shorter side
The Standing AP Pelvis x-ray without lifts is the most important x-ray
Common Signs of Excessive Pronation
Internal rotation at the knees is excessive
The medial prominence of the ankle
Digital clawing in midstance
Abductory twist seen in propulsion
Heel eversion is sometimes seen
Arch collapse is noticeable as the patient walks toward you
Allison: What would not be considered abnormal pronation?
Pronation after heel contact too rapid
Pronation after heel contact too prolonged
Pronation after heel contact excessively internally rotating the knee
Pronation to heel vertical in 10 degrees of tibial varum
Pronation to a 2 degree everted position before the midstance phase
Common Signs of Excessive Supination
Lateral shift of the body weight following heel contact
Heel Inversion at heel contact is sometimes seen
No patellar internal rotation at heel contact
Gait sometimes appears very rigid
Sometimes shock wave up calf and thigh seen
Lack of arch collapse at contact
Andrew: Which of these problems is not related to overuse of the peroneal tendons trying to decelerate abnormal heel contact supination?
Peroneal Tendonitis
Fibular Stress Fractures
Inversion Ankle Sprains
Tibial Stress Fractures
Common Signs of Poor Shock Absorption
A loud sound of heel strike
Shuttering of the muscles (especially calf and thigh) following heel contact
The rigid appearance of lower extremity
Excessive subtalar joint supination at heel contact
No Subtalar Joint Motion Observed
Diksha: A patient with lower back pain and limb dominance noted on gait evaluation may be caused by what problem?
Limb Length Discrepancy
Excessive Unilateral Pronation
Excessive Unilateral Supination
Poor Shock Absorption
More than one cause
Common Signs of Equinus
Early Heel Off
Bouncy Gait with heels barely touching
Genu Recurvatum with excessive straightening of the knee
Excessive pronation typically with out-toeing gait
The collapse of the midfoot after heel off
Maksim: Severe equinus forces can cause severe pronatory forces on the foot needing to adapt. Discuss the concept of a “double heel lift” occasionally seen.
Common Signs of Typical Severely Weak Muscles
Medial arch collapse with weak posterior tibial tendon
Lack of heel lift with weak achilles complex
Excessive internal patellar rotation with weak external hip rotators
Lean to one side with weak hip abductors
Contact Phase Lateral Instability with weak peroneal tendons
Yona: Posterior Tibial Tendon Dysfunction can be treated conservatively even in some Stage 3 patients. What are 3 major functions of the posterior tibial tendon that may need help in the rehabilitation, and the 2 functions helped with corrective custom made orthotic devices?
For next class, I am assigning this presentation on the 20 Golden Rules of Athletic Rehabilitation. Please be ready to discuss the ones assigned to you.
This is the assignment for the next 2 weeks. You need to email Dr. Blake your answers and please do not all wait until before the next class!! LOL
Examples of Gait Findings and Treatment Options
Example #1
A runner presents after developing left knee pain on a long training run preparing for the San Francisco Marathon that was to be two months later. Gait evaluation walking revealed a dominance (or body shift) to the left side suggesting at least more weight bearing on the injured left side and perhaps a short leg syndrome. This dominance to the injured side is also significant due to the fact it is opposite of mere favoring to take the load off the injury. The left knee had more internal rotation at heel contact on the side of the runner’s knee complaint. The heel was actually inverting at heel contact (opposite direction of the knee internal rotation). The patient was then asked to run up and down a long hallway with the running shoes that they brought into the office. It was a brand new pair, as they had purchased in hopes it would clear the knee problem. I asked the patient to bring in the pair she was wearing when she hurt the knee.
Remember the Rule of 3 in evaluating these overuse injuries (from Chapters 1 and 2). Any injury, where the tissue is so overstressed that it begins to complain, typically has at least 3 causes (yes, you do not need to stop at three). This is why one patient with overuse, or overpronation, or wears inadequate shoes, can develop knee pain, another shin splints, another foot pain, and so on. It is a fun investigation and of course, should be started on the first visit on the new problem or new injury. In this case, the left knee pain was being stressed by:
An inadequate training program (she was up to 15 miles only two months after starting running)
A dominance to the left probably placing 20% or more weight on the left side (later found that the left side was the long leg of a ¼ inch)
Excessive internal patellar rotation caused by very hip external rotators (yet, quickly improved with an appropriate strengthening program)
Unstable athletic shoes with poor support and cushion (discovered at the second visit)
I also think that when the knee is going in one direction (internal) and the foot going in the opposite direction (external) there must be terrible unnatural twisting motions whose stress must be taken up somewhere
Other components discovered were weak quadriceps, tight hamstrings, and low Vitamin D (not sure if there was a relationship here).
Also, she lived on the bottom of a huge hill in San Francisco, and her running loop always had her run the last mile down hills when her legs were the most tired.
So, gait evaluation pointed the way to several key components that were easy to correct in the long run. This particular patient would go on to run several marathons over the next few years with strong external hip rotators and quads, a good training problem, and Brooks Glycerin Shoes for her supination. She knows she has one leg longer, and someday that may be addressed. She reversed the Vitamin D deficiency, and if she breaks anything a bone density will be ordered. Her primary care physician thought at 32 years old, and no history of fractures, a bone density scan was not called for in this case. It took 6 months to get the external hip rotators strong, and initially, the therapist was not isolating the external hip rotators enough and not stretching the tight upper part of the medial hamstrings. When you imagine that the average runner quits running within a year, runners really appreciate this type of approach towards wellness and long-term prevention. This example also points to the fact that you do not need to always correct everything at first, but I love my patients to definitely know what is going on.
All Students: Utilizing the Rule of 3 for gradual sesamoid pain developing in a hiker, what are some common causes in an overuse situation? Email me answer at rlb756@gmail.com
Example #2
This 76 year old noticed pain in the lateral side of her left foot 6 months before the initial office visit. The problem has been getting worse and more limiting. She also noted some flattening of her left foot in the last few months. Gait evaluation showed markedly more pronation on the left foot compared to the uninvolved right foot, with heel valgus only seen on the left side. She noted swelling medially, but the pain was only lateral. We are obviously dealing with posterior tibial tendon dysfunction but it is not the usual location of pain. By again using our Rule of 3, the examination found (more than 3 or sure):
Very weak posterior tibial tendon
Very weak Achilles’ tendon with overstretched length
12-degree heel valgus resting position measured, and 3 degrees valgus or everted on the right side
The tendency to wear heels or flats with no support
30-year-old left ankle sprain with questionable rehabilitation
Not an ounce of athletic sense or body awareness when discussing rehabilitation with her
Overweight
Inactive her whole life (busy professional until retirement)
Gait evaluation pointed to the pronation problem left greater than right. The significant heel valgus would have been missed without gait analysis with the asymmetry very important. She had been dealing with weak muscles for a long time, but the heel valgus was causing lateral ankle impingement (between the calcaneus and the fibula). MRI showed some irregularities in the tendon but no tear. She really had pronation pain, not posterior tibial tendon dysfunction pain. She knew she had neglected her health, but fought diligently to take stress off the lateral ankle and was quite simple to treat in some ways. The 6 things that turned her symptoms around:
Stable shoes and ⅜ inch varus wedge (¼ inch for the uninvolved right side)
Joined Weight Watchers and lost 22 in 3 months
Began a one year program of posterior tibial, Achilles, single leg balancing, external hip rotator strengthening (probably had doubled her initial strength in the first 2 months)
Icing 3 times daily for anti-inflammatory
Leukotape with coverlet to prevent heel eversion (helped the varus wedge)
Several dressier flats, that could not hold the varus wedge internally, had ¼ inch varus outsole wedging applied full length by a local cobbler on the left and ⅛ inch on the right side.
I am not mentioning the functional orthotics she received in the modalities that turned her around because she was so much better months before they were dispensed, and I actually never saw her wear them except at the orthotic dispense visit 4 months into our journey together. She was given highly corrective orthotics for the left (35 degrees, and 20 degrees for the lesser pronated right foot). Both athletic and dress versions were made, and because Medicare does not pay for them, she self-paid for this and only this part of the treatments. Chapter 13 on custom orthotic devices will go into the rationale of how many degrees of correction to order. She said they will be used in some hiking boots, but she always came into the visits in dress shoes with the outer sole with the varus wedge.
I said that she was easy to treat in some ways because the real reason I remember her is that the first podiatrist she saw immediately used the “S” word. This podiatrist did watch her walk, and saw the pronation. She was immediately placed into the adult acquired flat foot reconstruction category, and without MRI or a lot of thought, had scheduled her for flat foot reconstruction with the breaking of the heel bone, fusion of some joint, and repairing tendons (patient’s description to me). She only saw me because a friend had seen me and told her to at least get another opinion. I only saw her five times, about one month apart. The first visit was for an hour and we talked about the surgery for 45 minutes of the visit, the next visits were 30 minutes each and each visit we talked about the surgery a little less and less. The last visit, she was completely out of pain, walking 30 minutes daily, no discussion of surgery until as she left the office she turned around and said: “how will I know when I need surgery?” The power of a word. I saw her one year later for follow up and an ingrown toenail, she looked 20 years younger, 37 lb weight loss overall, exercising regularly and did not say the “S” word.
All Students: Research to find out how much inversion I would put into this foot using the Inverted Orthotic Device initially. Email answer rlb756@gmail.com
