Pain Scale and Its Importance

     For over 15 years, and probably longer, the pain scale of 0 to 10 has been both a valuable and mis-leading part of medicine. For those who read my blog regularly, you know that I relie on patients keeping the pain scale between 0-2 in my rehabilitation programs. It is in the 0-2 range out of 10 that I am insured that the patient is most likely not hurting themselves further, and most of the time allowing the injured tissue to heal. I try to get the pain down to 0-2 as quickly as possible, and hold pain level until they are back to complete function. 

The illustration above shows many of the ways to show this sliding scale with the green area pretty much where I need to advise patients to be functioning within. As the pain gets into the next real level of 3-4, the situation goes from tolerable to distressing. 

     Yet to ask a patient what their pain level is, is really asking them to do the impossible at times. Pain levels vary during to the day due to many factors, so I think we need minimum of 5 points during the average day to adequately assess. These points may be: first thing in the morning, during the morning, as the day goes on, with exercise, and after exercise. So, you can see that 5 points may really be 10, and it can get very complicated for an office visit. 

     In our physical therapy department, the patients are always asked how they feel before, during and afterwards. The goal of course is to have the patient feel better, in other words, have their pain go from 5 to 3 during the session. What has this to do with anything? I just think if you are really trying to rehabilitate a patient you should know more than just the average amount of pain they experienced that day. 

Stubborn Plantar Fasciitis: Email Response

Hi Dr. Blake,

I've been dealing with bilateral foot pain for more than 2 years and treating it as plantar fasciitis.  My primary care doctor ordered MRIs and had them sent to the foot and ankle clinic at a local university medical center.  (I have a podiatrist, but he was not supportive of MRI.)

Anyway, the foot and ankle clinic reviewed the MRIs and determined that it was just a stubborn case of plantar fasciitis.  They offered to give me a cortisone shot and left it at that.

Anyway, I declined the shot for now.  I'm about to start PT again with someone who does active release technique.  Nobody has told me whether the plantar fascia tissue looks healthy or degenerated.  Is this something you can discern from looking at the MRI images?  

I am curious about the integrity of the tissue for two reasons:

(1) If I get the cortisone shots, is there a risk of rupture?

(2) Am I a good candidate for shockwave?  If the tissues still look healthy, then I wouldn't want to bother with the expense of shockwave.

I did some shockwave in the past and found it very effective.  However, I did not have the other components in place -- flexibility and biomechanics -- to make the results last.

Let me know if I am not sending you useful images.  There were so many to choose from.  And I would love to know if you think this could be something other than plantar fasciitis, such as nerve entrapment, bursitis, etc.

--M

P.S. Thanks for your help.  Your blog has been the greatest resource.  I just made a donation.

Dr. Blake's Response:

Hey, just not enough images. Take photos of all T2 images (probably 10 or more from different directions) that show the plantar fascia and heel. The T2 are the ones where the bone is dark. Rich 

Patient's Response:

Thanks Doctor.  Here is a selection of the ones not marked T1.  There were quite a lot, so I did some guesswork.

Dr. Blake's Response:

You did well, the ones with the bone dark are the T2 images. No inflammation and no fibrosis (thickening) is seen. The plantar fascia looks normal on these images. The cortisone is for the inflammation and the shockwave for the scarring, so neither seem indicated. It does appear nerve. Consider 10% alcohol shots (typically a series of 5 once a week) for the nerve, along with a topical like nerve compounding cream and neuro flossing. Sometimes, TENS units help since you can do 3 times a day. Send me the report so I can read. See the video below. Also, do you have low back or spine problems that can cause nerves to be sensitized. Rich 

https://youtu.be/plbBvPASXwM

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Types of Orthotic Devices

The following is from my upcoming book "Practical Biomechanics for the Podiatrist" coming out in 2022. 

Orthotic Type:

1.     Functional 

2.     Sports 

3.     Dress

4.     Accommodative

 

     How can we truly differentiate these orthotic types? It is difficult on the surface, but let me tell you how I look at these. Every custom orthotic device I put in a shoe is functional by the fact that I am trying to have the orthotic device perform a function. However, being functional by those who manufacture orthotic devices means that function is changed by the orthotic material itself due to changes made to the custom foot cast. This is called intrinsic correction, the positive cast from the patient’s mold or foot scan, is changed to influence a new shape to the foot. Only in this arena, 3-4 degrees of forefoot varus means a lot to the manufacturing of the orthotic device, or a plantar flexed first metatarsal is treated differently than a metatarsus primus elevatus. Functional orthotic devices grew out of the necessity to help patients so crippled that they could not walk, or at least they were having a lot of symptoms. And yes, the Inverted Orthotic Technique, Root Balanced Technique, Dynamic Support Insole System, DC Wedge, Kirby Skive, Mueller Posterior Tibial, and Bi- and Tri-Axial Devices are all functional. Any repetitive motion or standing position can be the subject of change from a functional device. Therefore, motions like cycling, running, walking, rowing, golf, elliptical, etc, are all subject to predictable changes with orthotic devices. Activities like tennis, basketball, squash, etc, would be put into the sports orthotic category for sure. Therefore, if some measured degree is important when you make an orthotic device, you are probably making a functional one. 

     Sports orthotics have some element of the patient’s foot shape, but deviate from those truly functional by adding both a full length aspect and cushion full length or only in one area (like the heel). The motions in sports are so much more varied than straight walking. Both the predictability and the unpredictability has led to designs for various individual sports like ballet, basketball, tennis, soccer, etc, with relative incredible success. The full length aspect is so crucial since many athletes spend the majority (or over half) of their time just on the balls of their feet. Sports orthotics have their origin from a totally different place than functional orthotic devices. The function that the provider is attempting to fix is less a foot problem (like the degrees of forefoot varus or valgus), and more a sports problem (like the amount of heel cushion needed for a runner). A great example would be the orthotics made for ice-skating boots or ski boots that can only have a small forefoot correction and no rearfoot posting if they are to fit into a tight fitting boot. In this individual case, the boot itself gives so much support that less can be needed from the orthotic devices themselves. However, so many sports orthotic devices are so functional, and so sophisticated, that the phrase “sports orthosis” should not imply less support or “less function” by any means.

 

     Dress orthotic devices typically are just smaller versions of functional orthoses and can be made lower in the heel cup and a narrower cut. Of course, custom foot orthotic devices are always narrowed from the medial side, as it is crucial to be in full contact with the lateral border of the foot. Normally, thinner materials like carbon graphite or fiberglass are used so that the orthotic device takes up the least room possible. It is important to already know that there are no adjustments needed, as these thinner materials can not be adjusted for high spots. They can be adjusted for length and width. I typically tell my patients that I will make the athletic pair first, and based on the response and corrections needed, decide if I can use the same cast for the dress pair. With the advent of removable inserts, bigger versions of dress orthotic devices can now be made, and sometimes even an athletic cut orthosis can be fit into a “dress” shoe. So many sports, or at least foot deformities, need a great deal of correction. These corrections are built into the mold normally that is used for all orthotics. The practitioner must decide if the same mold can be used for a dress version as the correction may need to be reduced due to the bulk created. I prefer separate molds for athletic and dress orthoses when there are major corrections in the athletic cut. Some shallow shoes can not tolerate the use of a rearfoot post in dress shoes. Men’s shoes are more adaptable in general. Some of my women patients require hybrid orthoses like “cobra style” which cup the heel and support the medial arch some. 

     Accommodative orthoses protect the foot by off weighting and cushioning. These are the two big functions of this orthotic class. Probably, the over the counter diabetic insole was the first version, but I find that some customization really makes this type of orthotic device so much more effective. I typically will both take an impression cast and even do the corrections that I want in a functional device. The material that I make the orthotic device with will be soft like EVA, plastazote and poron. The EVA or plastazote becomes the heat moldable base that the orthotic device is made off, whereas poron or Spenco are just added layers like top covers for more cushion. Accommodative orthotic devices can be made in both athletic or dress versions, or standard orthotic length, sulcus length, or full length. The Hannaford device is one such full length accommodative orthosis that is very special to my practice. Multiple layers of plastazote, softest against the skin, are utilized to make this device. This device can be made off a corrected or uncorrected impression cast. Since there is no plastic, it can be adjusted in any way that fits the patient’s needs: thinned, narrowed, made stiffer, sweet spots added, varus or valgus wedging, metatarsal support, various top covers, and the list goes on and on. 

     

     In this book on Practical Biomechanics, it is hard to get away from foot orthoses. So, how do we all get better at prescribing this modality. I always feel that you should have a range of options when prescribing orthotic devices. It is important first to decide the type you will prescribe: functional, sports, dress, or some type of accommodative devices. When the patient sits in front of you, and you have just taken some form of image of their foot to send to a professional lab, first ask what do you need to accomplish. Here is the list of questions to help you make that decision?

1.     Do I need to change foot function by supporting a measurable degree of deformity, like 4 degrees forefoot varus or 5 mm metatarsus primus elevatus (Functional)?

2.     Do I need to change foot function or position not caused by a measurable degree of deformity, like correcting heel valgus from posterior tibial weakness or equinus forces (Functional)?

3.     Do I need to change the stresses occurring in sports, like dampening the impact force at the heel causing heel pain(Sports)?

4.     Do I need more stability in a narrow dress shoe (Dress)?

5.     Do I need to off weight or cushion a specific spot or the entire foot (Accommodative)?

The answers to these 5 simple questions should help you begin. 

     

 

Gout: Our Office Handout

Gout: Treat the symptoms Immediately

 

By Richard L.Blake, DPM

 

  Gout can affect many patients in a podiatry practice. The number one location for a gout attack is the big toe joint, but the other foot joints, the ankle, and the knee can have the excitement of an acute gout attack. In the photo below, the man's left big toe joint is slightly enlarged with some run of the mill wear and tear, and a prime suspect for developing gout in the future. Gout attacks have a propensity for affecting already damaged joint surfaces.

 

 

    I look at the source of a gout attack from 3 angles (or a combination of all 3): the kidneys for some reason are not flushing out the uric acid from the blood stream well enough, there is a systemic reason for increased metabolism which is producing more uric acid into the blood stream (uric acid being a normal breakdown product of nucleic acids called purines), and a recent diet of food rich in purines (which breakdown to uric acid).

 

    Common food concerns include:

1. Limit organ meats, herring, mackerel, and anchovies
2. Limit red meat such as beef, pork, and lamb (only 4-6 oz daily)
3. Limit fatty fish and other seafoods such as tuna, shrimp, scallops, and lobster
4. Limit beer
5. Limit white bread, cakes, and candies
6. Limit high fructose soft drinks and sodas
7. Increase use of plant based proteins
8. Increase use of low fat and fat free dairy
9. Increase 100% juices
10. Use of 5-10 ounces wine daily okay
11. Use complex carbs such as whole grains, fruits and veggies
12. Use of 4-6 cups of coffee for men seems to be helpful

 

 When you get an acute gout attack, your involved joint is normally red, hot, and swollen. The health care provider asks about your kidneys, your overall health, medications you are taking that may affect uric acid metabolism, any recent crash dieting, any recent changes in your diet like a vacation of eating rich foods, beer, etc, and possible infections anywhere that could have seeded the sore area, like a sore throat. A Gout Attack Looks Like An Infection. To help in the diagnosis of possible infection, the lab is asked to get Uric Acid, CBC with differential, and Sed Rate. The last 2 help with infection evaluation. Patients with an infection also may have systemic signs of fever, chills, malaise, etc, not seen with gout attacks.

 

 It is extremely important to know that once you get a gout attack, uric acid levels in your bloodstream drop as the crystals go into the joint, and your blood test is read as normal. But, you are still high normal, and you still did have a gout attack. At my hospital, Saint Francis Memorial Hospital in San Francisco, 8.7 mg/dl is still normal. When a patient comes into the office after a gout attack, the lab may read between 6.5 and 8.0. This patient has gout in my mind. I ask them to get a repeat uric acid test in 1 month and then 2 months to see what the uric acid levels are doing. In a patient whom has suffered a gout attack, even if they are mindful of their diet, their uric acid levels begin to go back up over the next 2 months. It takes these 3 blood tests to get a feel of how unstable the uric acid levels are for this patient.

 

 When a patient has a gout attack, any anti-inflammatory medication helps, like Advil, but I prefer to use indomethacin, but not advised in the elderly or children or those with a history of GI problems. In a normal size adult, you can use 75 mg 3 times over the first 24 hours as a loading dose, then drop to twice daily for the next 9 days. After these first 10 days, it is obvious how easy or hard it is going to be to get the symptoms under control. Most of my gout attack patients are placed into a removable cast to minimize the bending of the big toe joint, with EvenUp on the other side. The patient is advised to take food with indomethacin since it can be hard on the stomach. Gout attacks can occur from 2 days to 3 + months, so you need to treat quickly. Icing is important to both reduce blood flow to the inflamed joint and for pain relief. I prefer the ice slush, but how cruel can I be!! Patients are told to drink, and drink, and drink water to hydrate, deluting the concentration of uric acid quickly in the blood stream. They must also become familiar with foods rich in purines, and try to minimize the ingestion (not eliminate) on a daily basis. Injections into the involved joint to analyze the crystals seem too academic to torture the patients initially, but if the pain is not subsiding in 4 or 5 days, then aspiration and injection of steriod may be appropriate to reduce the inflammation quickly. Since cortisone takes 3 to 7 days to work, and the acute aspect of the gout attack may naturally be over by then, it takes some sixth sense to know who should have the joint aspirated. Ask anyone with an acute gout attack and they will say that the injection was somewhat draconian!!

 The blood level goal has always been 6mg/dl, but to accomplish that your primary care doctor is normally reluctant to place you on kidney eliminating drugs for the rest of your life like Allopurinol. So, most doctors prefer to counsel their patients on hydration (the more dehydrated you are, the higher the concentration of everything goes in the blood stream including uric acid), exercise for weight reduction, sensible dieting,  and medications to possibly change.

 

    To summarize: the top 10 initial treatments for gout are:

 

1. Begin a series of 3 uric acid levels.
2. Rule out infection with history, evaluation of area, and blood work up.
3. Immobilize the joint involved.
4. Ice the involved area 3-5 times daily with various forms of cooling.
5. Begin using an oral anti-inflammatory medication like indomethacin or ibuprofen.
6. In very severe cases, or if symptoms are not calming down quickly, consider an oral Prednisone Burst, or cortisone injection into the joint. To use cortisone you must be sure that you are not dealing with an infection.
7. Hydrate well (4-8 glasses of 8 oz water daily).
8. Understand what foods to avoid.
9. Discuss the possible role of any new medications started before.
10. Discuss overall health and weight loss/gain situation.

 

    

 

Tap Dancing and Diabetic Foot Health

I have to thank Dr David Armstrong, leading expert on wound healing, to show this article on the positive health advantages of tap dancing with an emphasis on diabetics. 

https://www.podiatrytoday.com/blogged/could-patients-tap-their-way-better-health

Great Video on the Importance of Vitamin D

If you are an athlete, you sort of know that Vitamin D plays a role in whether you break a bone or not while training for your sport. The following is a great reminder to keep our Vitamin D levels in its normal range. Low normal is 31 so I prefer my athletes to be near 50 to stay out of trouble. Here is a pre-quiz for you based on the information in the video?

1. Vitamin D is metabolized by the kidneys. True or False

2. Sunlight typically destroys our Vitamin D stores, so we must take supplements. True or False

3. The active form of Vitamin D is 1,25 Dihydroxy D3. True or False

4. Salmon and other oily Fish along with Mushrooms are great sources of Vitamin D. True or False

5. The thyroid helps control the body’s manufacturing of Vitamin D. True or False

https://youtu.be/KeiSnvf2Q3U

 

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Okay, I will Admit it, I always wanted to be a Legend!!

https://youtu.be/wzj062C69-c

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Timing of Hallux Rigidus Surgery: Now or Can We Wait and Get more Information

Dear Dr. Blake,

You can imagine my surprise when a podiatrist here in Davis, California just told me that the bunion bothering me is Hallux Rigidus! 

Apparently my daughter whom you have seen inherited this condition from me. Since you took such super good care of her I really hope you can see me too. The first available appointment with your reception is April 16. I plan to be in NM visiting my grandkids March 18-April 15, and since those visits include tons of hiking I would greatly appreciate it if you can somehow see me before I go.The x-rays today showed NO cartilage left, and the doctor suggested fusion surgery and orthotics. Apparently I should have been using orthotics for years now, but the podiatrist I saw for the bunion in 2015 told me simply to wear shoes with a slight heel lift and I’d be fine. Hmm...I went to today’s appointment because the toe area often hurts and clicks as I walk. I still play tennis 5 days a week and am generally very active, so I dearly hope you can help me!

Thanks,

Dr. Blake's comment: 

Thanks for your email and compliments. For sure I should be able to see you. Call and make sure you are on the wait list. Surgery can always be done, so if you can put it off indefinitely, that would be nice. Right now surgery and your symptoms make no sense. Rich
If you can make it, tell them I can see you 11:30 on 3/5 Friday

Addendum: The patient was able to schedule at that time. Rich 

Dr. Blake's further comments: I am not a surgeon although trained as one. Just not my interest, so I gave it up to be home more when my kids were small, but also to focus on sports medicine and biomechanics my true loves in podiatry. In situations like this, meaning problems that may need surgery at some point, I love to be able to work with a surgeon so the patient understands the whole process. The assessments I routinely use in this scenario are:

• Assess when the health of the patient needs immediate surgery (like in alot of fractures we see in sports medicine)
• Assess if the risks of surgery are less than the patient's problem (said another way----the patients disability now has to be worth the disability short and long term from the surgery)

If we use this rationale, yes, the patient may need surgery, but their activity level now is too high to warrant that surgery. They should know about the surgery, but what if there is a complication and the patient can not play tennis again? 

Some of this reminds me of how doctors get in trouble giving too many pain pills. Some of it is because they do not want the patient to have pain. Some of it is that they do not want to be looked at as a bad doctor. This is why I search for ways daily at getting my patients in the 0-2 pain level out of 10 consistently. If they can not accomplish this, we can talk about surgery and definitely get some opinions. Just because the xrays or MRI indicate a problem, does not mean we have to address that problem with surgery. Rich 

Review of Oral Medications Used in Peripheral Nerve Pain

https://www.neurologyindia.com/article.asp?issn=0028-3886;year=2019;volume=67;issue=7;spage=32;epage=37;aulast=Lovaglio

Summary: 

• Lyrica (pregabalin) and Neurotin (gabapentin) are Calcium Channel Ligands and the fixtures of first line treatment
• Tricyclic anti-depressants, especially amitriptyline and nortripyline, are normally mixed right after maximum dose is achieved with the first line.
• Other anti-convulsants (carbamazepine and clonazepam or lamotrigine) may also be added, along with other neuroleptic drugs
• The goal is to drive this pain down (8-10 VAS to 0-2 VAS) and then maintain the dosage for several months before beginning the wean process
• Based on the Pharmacological principle of Potentiation Synergy 2 or 3 drugs are so much better than one 
• Therefore, Tricyclic + Lyrica or Neurontin = First Line then add Anti-convulsants 
• 2nd line anti-depressants are venlafaxin and duloxetine
• Gaba usually 300 mg daily for 3-4 days then gradually built to 1200 mg 3 times a day
• Or, Lyrica (which works both peripheral and central) start with 50-75 mg day and gradually increase to 600 mg which is spread over 2 or 3 doses
• Anti-depressants (also called serotonin-noradrenaline reuptake inhibitors) are started at 10-25 mg at bedtimes and slowly increased to an effective dose of 50-150 mg/day
• Topicals (lotion or patches) tend to have lidocaine
• However Capsaicin topical also works on some (from peppers)
• Other non-pharm options are: alcohol or marijuana, psychotherapy, hypnosis, occupational therapy, PT, acupuncture, and TENS 

Use of Bike Shoes for Immobilization of Various Foot Injuries: And a big help for bad backs

https://bike.shimano.com/en-US/product/apparel-accessories/shimano/SH-CT500.html

One of my patients just tore her plantar fascia and needs to be immobilized. We have to stop impact stress (so no running for now), and we have to stop the bend of the ball of the foot (which puts stress through the plantar fascia back to the heel). These patients have been traditionally treated with removable boots (aka cam walkers). Even with the use of EvenUp type shoe accessories for the other foot, these removable boots tend to put a lot of stress on the back. Like me, so many of my patients have back problems, and so these bike shoes that do not bend (and look fairly normal) can be a God-send. 

Heel Pain Overload Syndrome Review

The following comment was placed on my You Tube video today on examination of heel pain.

https://youtu.be/plbBvPASXwM

Dear Dr. Blake:

I was diagnosed with heel pain overload syndrome by an orthopedic surgeon. How do you treat that condition? pain is more on the outside bottom of the foot, and same area at the heel.

Dr. Blake's comment: Thank you for your comment. This is a new diagnosis label I have been seeing lately. The diagnosis implies the heel itself is overloaded or overwhelmed by the stress asked of it and soft tissue injury occurs. The attached link here reviews this problem.

https://footeducation.com/overload-heel-pain-syndrome/#:~:text=Patients%20with%20overload%20heel%20pain%20syndrome%20describe%20the,also%20be%20a%20source%20of%20significant%20heel%20pain.

In my video above, I point out the areas of pain other than plantar fasciitis (the most common cause of heel pain). Heel Pain Overload Syndrome is a syndrome since the same overload can cause multiple injuries: heel bursitis (both superficial and deep), deep heel bone bruising (MRI diagnosis), plantar nerve entrapment (Baxter's neuropathy), and heel stress fractures (again usually only seen on bone scans and MRIs).

The following photos should give you an impression of the treatments. On my blog, type heel pain in the search engine and start reviewing other links. I hope this helps. Rich

The patient has to decide with immersion in ice water for 10 minutes or a 5 minute frozen sports bottle ice massage feel better.

With heel overload syndrome, there is a role both for heel pads for straight cushion, arch supports to transfer the weight off the heel and into the arch, and entirely soft based orthotics which do both. The above are unfinished Hannaford soft orthotic devices runners wear.

Here I have added a soft rim to an orthotic to take pressure off the bottom surface

Why do you develop this? What is the Root cause? That should be investigated so this does not happen again! Is it a poor fat pad, high arches with a prominent heel, over striding with running and slamming the heels down too hard, poor padding in the shoe choice, etc, etc.

I love support the foot tape, at least one application to rule out plantar fascia symptoms. Buy at www.supportthefoot.com

This emphasizes that it is the transference of weight into the arch that typically is more important than heel cushions. But it is good to try both.

We can not forget the nerves that can get locally irritated, or the irritation is in the back or another part of the spine and the symptoms just present at the heel. Of course, combinations of the two exist called "Double Crush Syndrome". Yes, another syndrome.

An MRI image of the side of the heel showing intense inflammation of the bottom one third of the heel (all white and it should be dark). This was ruled a stress fracture and needed 3 months in a walking boot.

In this walking boot, since there was still heel pain in the boot, I applied 1/2 inch adhesive felt to float the heel 80% which really helped.

Here I have customized a pair of Sole OTC inserts by adding as much arch as the patient can tolerate.

And softening the heel with first grinding out the hardness of the red material, and then adding a 1/8 inch heel cushion.

Gout-like Pain Post Vaccine Shots: Common Symptom for a Podiatrist to Hear About

Hi Dr. Blake,

It has been over 2 years since we have been in touch and I am happy to report that I have recovered well from my accident. I am very active again, including long bike rides and even jogging 3 miles once a week. However, I have new and debilitating pain in my right big toe that I think must be related to the Shingrix vaccine.

I had the second dose of the Shingrix vaccine 9 days ago. When I stepped out of bed the next morning I noticed I felt like I had stepped on something. When I reached down there was nothing there but a swelling under my right big toe. At first this wasn't really painful unless I stood on it, at which point it became a bit of a pressure point. I have been resting, icing, and taking ibuprofen but over the past week it has gotten worse, much worse now so that I cannot sleep. It still is not painful to move the joint, but there is a sometimes constant pain and a sharp burning pain when I touch the skin or put pressure on my toe. It seems like pain has radiated from the original spot (most distal toe joint) out towards the distal end of my toe. There is some swelling but not a lot to see. With all my past injuries, I need to stay active or things deteriorate fast, but right now I can't do much.

I had not exercised the 2 days before my shot and onset of symptoms, and also with the unusual symptoms, I am sure this is not a typical trauma or repetitive stress injury like I have had in the past. Due to the sudden onset after the vaccine, I think whatever is going on is due to the vaccine. I looked online and found that the Mayo Clinic website (link below) says contact your doctor immediately if you have "Ankle, knee, or great toe joint pain" after this vaccine. I have had a video call and a phone call with my doctor and now have a video appointment with a podiatrist, but so far nobody has been able to say anything about why this may be a vaccine side effect or what it means. Unfortunately I had to switch to Kaiser this year for financial reasons so my podiatrist appointment is not with you.

Have you ever heard of anything like this? Any experience with this type of reaction to Shingrix or what the implications are of such a reaction? I am at a loss. I realize you cannot diagnose my toe without a visit but I am wondering whether you have any experience with or knowledge of similar issues, because I am not finding any useful information that may explain what I am experiencing.

Kind Regards,

Zoster Vaccine Recombinant, Adjuvanted (Intramuscular Route) Side Effects - Mayo Clinic

Dr. Blake's Comment: Sorry this happened to you. I am seeing alot of this post Covid 19 Vaccine. I am treating it like a gout attack, which it may be. Gout attacks are brought on by changes in the metabolism something that can occur dramatically with vaccine shots. If you were in my office, I would take an x-ray but that will be inconclusive (however an important baseline). I would have you super hydrate next week (at least 4 eight ounce glasses of water minimum), 3 advil 4 times a day for next 5 days, and the important ice soak 10 minutes (cold water with ice cubes) three times a day. I would fit you for a removable boot and apply a dancer's pad to float the big toe joint just so you can get around. If it was not feeling a ton better in a week, I would order both uric acid levels and an MRi (as you could have a stress fracture say in the sesamoids under the big toe joint or just some arthritis popping up). I sure hope this helps. Everyone (about 5 patients so far) that have got this post Covid shot immediately got better with this approach. Rich 

Pain in the Back of the Heel: Could the Pain be from this big spur when the Pain is only 10 days old?

This patient presented to me several weeks ago with pain in the back of her heel for 10 days. No prior history of pain and could not remember what started it. She was really limping as she did not want to put her heel down. There was no swelling (which is a sign of an inflammatory response) and the patient did not feel it the patient was nerve related (no numbness, tingling, electrical, buzzing, burning, radiating). I placed her on some achilles stretches and heel lifts. As she did not improve, I took these xrays showing the heel spur posteriorly (back of the heel area). This spur has been there forever, so really did not explain the sudden pain. An MRI taken a few days ago shows marked internal swelling in the soft tissue, spur, and achilles tendon, but not in the heel bone deep to it. I will rest the heel in a removable cast this month and send her to PT for both calf mobilization and heel anti-inflammatory measures. Wish her luck! Of course, in situations like these, you are not sure if she will calm this right down, or the spur will need to be removed. Or, if it is really the achilles tendon that is failing, and won't respond. Surgery is spur removal and achilles clean up to make sure it is healthy. 

Assessing Correction with the Inverted Orthotic Technique

This is the right foot of a patient with posterior tibial tendon dysfunction. She is trying to avoid surgery as her foot has begun the damaging process of collapse. As the arch collapses, the heel everts to the ground, and the foot gets more and more dysfunctional ("apropulsive" in the Podiatry world). Even though this foot would look better in the shoe, from the walls of the shoe holding the foot some, this is the image of a pronating right foot through the orthotic device. The right foot is still everting at the heel and sliding laterally at the heel on the orthotic device, collapsing the arch, and abducting the fore foot on the rear foot as the front of the foot moves laterally. 

In this particular patient, the RCSP was 11 degrees everted to start on the collapsing right foot, and 4 degrees everted on the left. The patient was given a 35 degree Inverted Orthotic right (7 degree change with that orthotic technique), but only responded by inverting 4 degrees. Therefore the photo above shows a 35 degree inverted orthotic device that does not have enough power now to invert the heel enough, so the pronation still wins. Therefore the patient's right heel went from 11 everted to 7 everted (a 4 degree positive change) instead of the 7 degree change I desired. Failure? No!! The mold that made this orthotic device is back in the lab for 4 major changes: 3 mm Kirby medial heel skive, slight increase in the proximal medial arch, change in plastic from 5/32 inch to 3/16 inch (this one I should have done initially), and a full length 3 mm or 1/8 inch extrinsic varus wedge. From each of these variables, I should get 1-2 degrees more extrinsic supination moment to help center that heel at vertical (the whole 11 degrees). I think it is easy to at least see by this photo how the medial Kirby will narrow the medial heel area and let the orthotic device grab the foot better. 

The Effect on the Knee and Hip with the Inverted Orthotic Device

This is one of the closest articles to date on the positive effect of the Inverted Orthotic Technique on knee and hip problems. When I lectured at the University of Virginia, 2007, this is the results they got, although I never saw their study published. Rich

https://core.ac.uk/reader/71975935?utm_source=linkout

Sesamoid Fracture Article Review

https://pubmed.ncbi.nlm.nih.gov/31109214/

Most of these fractures (90%) do well without surgery

Average to complete return to sports 5 and 1/2 months

10% require surgery by this study

Average healing for me is the center of a bell shaped curve. Only 1 in a thousand are not healed in one year. 

For sesamoid injuries, the 1 and 1/2 month is -4 on the graph, 2 months is -3, 3 months is -2, 4 months is -1, 5 and 1/2 months is average, 7 months represents +1, 8 months +2, 9 months +3, and 9 and 1/2 months +4. If you give or take 3 months for delayed diagnosis and inadequate treatment then 12 months is pretty normal for my slow healers. This study matches up with my understanding and treatment of this injury. Good treatment for one year, with little change on repeat MRIs, and continue symptoms normally need surgical treatment. If you are in this process, you know that there are many ifs, ands and buts. Rich 

Balance: More Exercises to Up Your Overall Stability

Please scroll down on the article below until you get to the 6 balancing exercises: static and dynamic 

These will improve your lower extremity tone and coordination. These are crucial if there is any lower extremity instability: fall prevention, chronic ankle sprains, etc. 

https://www.outsideonline.com/2421075/100-most-cited-sports-medicine-studies

Below are several blog posts I have made regarding this topic.

https://www.drblakeshealingsole.com/2012/01/balance-extremely-important-exercise.html

https://www.drblakeshealingsole.com/2017/07/tips-to-improve-balance-bravo.html

Static Stretching Helps Hamstring Flexibility: Research Proves

https://pubmed.ncbi.nlm.nih.gov/27458757/

     The above article documents the long held belief that static stretching (holding a stretch for a certain length of time) helps with hamstring tightness. The hamstrings, calf/achilles, quadriceps, and iliopsoas are the most common muscle/tendon complexes that a podiatrist has their patients stretch. I have added a video I made on hamstring stretching. 

https://youtu.be/KEFpJaMwEtQ

<iframe width="560" height="315" src="https://www.youtube.com/embed/KEFpJaMwEtQ" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" allowfullscreen></iframe>

Below are a few other posts about hamstrings:

https://www.drblakeshealingsole.com/2010/05/hamstring-stretch-various-positions-can.html

https://www.drblakeshealingsole.com/2020/09/article-on-hamstring-tightness-and.html

https://www.drblakeshealingsole.com/2011/08/hamstring-stretching-variation-for.html

General Approach to See Patients

I thought I would share the general thought process I take with patients day in and day out. This 14 step approach has served me well (and of course complexed when a patient has multiple injuries and problems at the same time). Still the process of talking, evaluating, making decisions, and then seeing the patient in followup is time tried and true. Rich   

First, let’s review the general biomechanical approach for the first few visits (this can be accomplished in 1-3 visits based on the time you are allowed per patient). These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:

1. History and Chief Complaint of the injury and the patient’s understanding why they were injured.

2. Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches). And, if you are fortunate to use a computerized system it can help you here. 

3. Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic).

4. Physical examination of possible biomechanics involved.

5. Is there biomechanical asymmetry? 

6. Tentative working diagnosis made (your best guess).

7. Common Differential Diagnosis: common not rare (a good possibility, not all of the distant possibilities).

8. Occam’s Razor (simplest solution is most likely the solution)  and the Rule of 3 (3 most common causes and their treatment) for initial treatment help.

9. What Phase of Rehabilitation is the patient in at this visit? Immobilization, Re-Strengthening, Return to Activity. 

10. Should we do Imaging at this point?

11. 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.

12. Second Decision: How Much Inflammation needs to be Addressed?

13. Third Decision: Is there any neurological component that should be treated?

14. Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal? 

                               Patient #1

     History and Chief Complaint A 22 year old ballet dancer presents mid season with right big toe joint pain.

The rehearsals for Swan Lake had been very intense the last few weeks before her pain began. She feels that she just bruised it somehow and that it is really no big deal. She never had this problem before and can not remember doing anything. The pain is aching, not sharp. The pain is the dorsal joint, not medial or plantar. She would describe pain as 4-5 when performing, 3 when getting out of bed, 1-2 when walking around with a feel that she is walking on the outside of her foot a little, and 0 at rest. 

     Gait Evaluation In this case, a ballet technique examination may be necessary if the problem is recalcitrant or keeps reoccurring, as this sounds like a ballet overuse injury.  At the initial visit, the patient wore some flip flops as it was her day off, but barefoot she was a mild pronator, and she did not appear to limp. She did not bring in her ballet shoes for evaluation. Even if you do not know ballet well, the shoes can help in the wear patterns right to left both in the ballet pointe shoes and ballet slippers.  

     Physical Examination The examination reveals slight big toe swelling, no redness, no palpable pain, mild stage 2 bunion, and negative tendon and ligament stress tests. The patient had hypermobile metatarsal phalangeal joints, with over 90 degrees of big toe joint dorsiflexion, and a long first toe only on the injured side.                                                     

     Cursory Biomechanical Examination  and Asymmetry Noted Different from the normal physical examination of the injury, this looks further into the biomechanics of the patient that could have caused the injury or will slow down the rehabilitation, or just allow the problem to come back over and over again. The cursory biomechanical review included excessive ranges of motion allowing possible excessive big toe joint stress (as noted above), a pes cavus foot type with slight hallux hammertoe, forefoot valgus foot type, callus formation under the first and fifth metatarsals, first ray motion more than 10 mm but abnormally plantar flexed, a relaxed calcaneal stance position 5 everted right 3 everted left, no tight achilles tendons, pronation worse on the injured right side, great FHL strength. Therefore, marked biomechanical stresses (which will be discussed below), which could all be related in some way to our injury cause and upcoming treatment plan. 

     Tentative Working Diagnosis (your best guess) is based on your experience, historical review, and physical examination. Definitely ballet can overuse the big toe joint. My best guess would be a sprain of the big toe joint as a stress fracture would be more swollen. 

     Common Differential Diagnosis (2ndary Working Diagnosis) is not a list of the 10 possibilities in a standard differential, but the next best guess if proven that the tentative working diagnosis is wrong. For me, in the sports arena, overuse injuries are stress fractures or stress reactions until proven otherwise even though the examination does not match her pain level. 

     Occam’s Razor and Rule of 3 Occam’s Razor to me means the simplest solution is usually the solution. In this case, the simplest solution is to stop ballet until all the symptoms are fine, and then gradually wean back into ballet. Here is where the Rule of 3 helps out tremendously. Most ballet dancers would seek care elsewhere if told to stop dancing. The Rule of 3 means that we need to find 3 treatments based on our examination of possible causes that should help the patient progress. And, you can add 3 more next visit also if needed. The joint was sore and the dancer probably sprained her joint, so taping the joint to immobilize some is one good treatment. With a bunion deformity and a long hallux, the big toe joint typically gets stretched medially and pinched laterally, so the taping can try to correct that. Since the patient has a plantar flexed first metatarsal (typically causing more pressure on the first metatarsal), a dancer’s pad (aka Reverse Morton’s Extension) can help. And #3, using a Hapad adhesive felt arch support in all her ballet shoes, and her day to day shoes can both off weight the sore area and prevent the excessive pronation she presents with. Therefore the Rule of 3 helped us start treating based on her specific biomechanics. 

     What Phase of Rehabilitation? This patient is typically like so many patients really between phases. She needs some activity modification (in an attempt to get her pain more consistently 0-2). She also needs to ice, and will get some daily PT for anti-inflammation since she is in a ballet group. These are Phase 1 treatments, but she will continue to dance as we experiment with padding, taping, etc, so I would put her in the Return to Activity Phase 3. She is hurt, but she can dance completely, therefore she is definitely Phase 3. Phase 1 you are completely restricting her activity, and Phase 2 she can not dance professionally but you are working her through her sports routines. If she worsens as we attempt to get a handle on the injury, we may have to put her into Phase 1 or 2. Sometimes this is a big rehab failure, when the patient is not put into the right phase of restriction when they present with worsening symptoms. The patient should improve each visit, or changes are needed. 

     Should We Image? This is presenting as a minor soft tissue injury, so imaging will be delayed. 

     First Decision: How to Reduce Pain 0-2 This is for everything. The pain 4-5 when performing is too high. We have to reduce her rehearsals, and experiment with the above treatments to see if the pain can be reduced (our local dance medicine expert Joey Levinson had her get wider shoes just after her visit that helped). I prefer not to use NSAIDs at all as it masks pain and slows down bone healing (which we presently do not know if she has). Therefore my standard anti-inflammatory cocktail is icing twice daily, and contrast bathing each evening. 

     Second Decision: Inflammation Concerns This blends into the first decision as working on any inflammation (swelling, sudden stiffness, redness) found is crucial at helping these patients. If inflammation is found, and there was only a slight amount of swelling in this case, it needs to be addressed. My icing twice daily (especially just after she aggravates it) is important. 

     Third Decision: Any Nerve Component? This appears hard for patients and doctors to assess. Nerve pain can be numbness, radiating, electric, buzzing, vibrating, sharp, and just a hyper-sensitivity. Chronic pain (pain over 3 months) can lead to nerve hyper-sensitivity or tissue neural tension. The pain from nerves alone rarely swell, and it is characterized as pain out of proportion to the physical findings. In this case, no nerve pain was discovered or considered.  

     Fourth Decision: Initial Mechanical Changes This is now I end my initial visit with the patient--with 3 or 4 easy but effective mechanical treatments. Many times they are in a prescription to purchase. Sometimes, I am able to dispense something I have in my laboratory, or show them some tape technique (I pretty much love to tape all of my patients if I can find something to help them). Some of these treatments will be temporary until a more permanent fix can be found or made. Some of these day one treatments are forever (like toe separators for bunion improvement). In this case, the initial mechanical treatments were spica taping with an effort to straighten the bunion deformity, dancer’s padding instructions for her to attempt (luckily she had a PT who worked half days at the ballet), and medium Hapad longitudinal medial arch pads for pronation control and off weighting. 

     For this individual patient, the initial treatment was completely successful. It did take about 4 weeks with reduced dancing (50%) to really get her symptoms in control. For this injury, I did see her one other time for ballet slipper and pointe shoe application of arch supports (Hapad adhesive felt) and dancer’s pads. She was advised to wear medium gel toe separators long term for her bunions. Due to the pronation right greater than left, I had wanted her to get orthotic devices for her daily shoes (athletic and fashion casual) but I am not sure if that ever happened. That was for long term prevention.