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Please consider a donation if you feel the blog has helped you. A $5 donation will help me pay for the blog artwork, guest writers, etc. $15 has been donated in February 2017. I am very grateful. Dr Rich Blake

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Saturday, June 30, 2012

Video on the Shoe Flexion and Torsion Tests when Stability Important



With the big push in the shoe industry to make lighter and more flimsier shoes, I thought it only appropriate to show the how a podiatrist, physical therapist, and good shoe store manager would evaluate a shoe for stability. A shoe must bend at the exact spot that your foot bends across the metatarsals, thus the shoe industry has gone to great effort to get this right per size. Being a size 15 shoe myself, I find it a big disservice to stop making 1/2 sizes at 13. Definitely, the shoe should never bend mainly at the arch or plantar fasciitis and other problems may occur. The torsion test makes sure that the shoe has some stability across the arch area. For those with foot problems, some disabling, this stability as crucial. But, research out of the University of Virginia documenting the importance of arch stability to knee problems also. Sore knees, perhaps it is from the poor support you get from your shoes!! Here is a lasting shot of a store front ad in Barcelona where my wife and I were vacationing. The ability of the shoe to bend like this was being portraited as something good, but I doubt it!!



Hallux Limitus/Rigidus Post Op Email Advice




Dear Dr. Blake, I am an active (swim, pilates, yoga, circuit train, walk) 52-year old female with severe arthritis in hands and feet. Three years ago I had cheilectomy with osteotomy on left big toe.
Dr Blake's comment: The cheilectomy is a joint clean out of bone spurs and scar tissue and the osteotomy is to shorten the first metatarsal taking pressure off the joint.
 This relieved pain for nearly two years. I wear MBT shoes most of the day, avoid heels over 2 inches, take NSAIDs, etc. Now having severe stomach issues. No more NSAIDs. Discomfort is near-constant.
Dr Blake's comment: Switch to topical Flector patches or Voltaren gel for the top of the joint. And try to lay an ice pack 2-3 times daily on top of the joint for 10 minutes to keep the inflammation under control. You can go to PT and get 5 iontophoresis treatments with topical cortisone (dexamethasone phosphate). 
 I will try the taping procedure you recommend. Here is my question: I am scheduled for surgery July 18. Was leaning toward joint fusion, but wonder about joint replacement.
Dr Blake's comment: This type of surgery is no difference than knee cartilage tears. 5-10 years of a good result is considered normal response. Even joint fusions have 15-20% poor outcomes, and you can not do much about. I can only give you my bias, but I prefer possibly a second clean out, or partial implant (like the knee), as your next choice. Before surgery, perfect the taping, make sure your orthotics are great, and calm the joint down with a removable boot for 3 months with PT if need be. You may be very surprised how well you do. Calming the joint down will definitely help you make a clear headed decision about the next surgery. If you decide on fusion, consider occasional cortisone injections into the joint first to at least cool the inflammation down while you get some opinions.
 My doc will do either, but cautions that I will likely wear out the joint replacement in fewer than ten years, possibly a few as 5. I will then need another surgery. This makes me hesitate.
Dr Blake's comment: Do not use possible future surgery as a reason to do a more permanent procedure. The KISS principle still applies here. Think of the possible stress on other body parts if you have the big toe joint fused. Nothing is easy. Go one surgery at a time.
 Please offer your opinion. on Taping Supplies: Nexcare Product Stronger Than Kinesiotape for Foot Injuries

Additional Info: Also had Morton's Neuroma removed. No cartilage remaining. Several bone spurs and cysts. Bone on bone with severe degradation in head of metatarsal.
Dr Blake's comment: Can you send a photo of the same image from your MRI that I have placed here so I can look at it and it may change some of my thoughts?


Side view of First Metatarsal showing great bone across the joint of a T2 weighted MRI.



Hoping your taping procedure will save my right foot, which is several years behind the left! on Taping Supplies: Nexcare Product Stronger Than Kinesiotape for Foot Injuries


Dr Blake's comments: I hope this helps. Rich



Friday, June 29, 2012

Bunions: Toe Separators Are A Must!!

Dear Dr Blake:


When I was in your office on Wednesday, you expressed interest in my gel toe ring. Here’s the Amazon info on it:




"Gel Toe Spreader with Loop"
Health and Beauty; $9.99 per foot 
   Sold by: FootSmart

Best,
Emma

By the way, so far so good on my new orthotics.




You can see on Emma's feet how the ring around the 2nd toe may prove very helpful when the toes are moving out of position to hold the toe separators in place. Some of my patients complain that the traditional toe separators move out of place, so this may be an excellent product for them. 

Taping Supplies: Nexcare Product Stronger Than Kinesiotape for Foot Injuries

Hi Rich,

The tape I use is 3M Nexcare absolute waterproof.
It is much stronger than the Kinesiotape for my big toe joint taping.
It does not irritate the skin and can last 3 days.
I purchased mine at the local Walgreens.

Thanks for all your help today.

I am grateful, and so are my feet!

Steph

Nexcare Tape for Hallux Rigidus/Sesamoiditis Pain
Nexcare Tape Sideview Hallux Rigidus/Sesamoiditis



http://www.amazon.com/Nexcare-Absolute-Waterproof-1-Inch-5-Yard/dp/B001H54S82/ref=sr_1_3?ie=UTF8&qid=1340999458&sr=8-3&keywords=nexcare+waterproof


The following video on Big Toe Joint Taping have the Kinesiotape switched to Nexcare or Rocktape.

Thursday, June 28, 2012

Insertional Achilles Tendinitis: Email Correspondance


Julie is a patient I saw yesterday (name changed for privacy). She has Insertional Achilles Tendinitis and came in for a second opinion. This was the outcome of our visit where I found extremely tight achilles tendons and a prominent heel bone that can get easily irritated by the back of a shoe. Xrays did show some bone spurs which may or may not be part of the pain, but definitely influence how the medical world treats this. 


Both posterior heel spurs (where achilles attaches) and plantar or bottom heel spurs note

Back of Heel Bone Showing Boney Growth

Dr. Blake,
Thanks for taking time to answer questions and share information this afternoon.
Below is my understanding of our discussion. I have a couple of question marks where I would appreciate your confirmation/clarification.
1.       Stretch the calf 4-5x’s/day – I don’t have to try to get it stretch all the way to the bottom where it starts to hurt, don’t do stretches that lower the heel (off the curb), pulling with a towel is OK
2.       Ice 4-5x’s/day  and within 2 hours?? of activity that might aggravate the Achilles
Dr Blake's comment: Definitely a 10-15 minute ice pack within 2 hours of an activity that would predictably irritate it will allow overall less inflammation to collect and cause activity reduction over the next few days. 
3.       Use the heel lifts in the running shoes – icing can be wrapped around foot, it does not need to be localized/massaged.
Dr Blake's comment: I gave her several 1/4 inch heel lifts to use in non heeled shoes, like her running shoes, to take some tension off the back of the heel where the achilles attachs. It also changes the position of the heel against the back of the shoe, and sometimes helps take some pressure off (and sometimes puts more pressure and has to be removed). 
4.       Avoid  explosive (jumping /bootcamp type) activities for a few weeks
5.       Ok to run 4x’s/wk – Sat and Sun can be consecutive days because I will have more time to ice on the weekend
6.       Increase running methodically – flipping run/walk ratio by a minute, if the pain is flared up, I don’t need to go backward on the time flip, just hold off on running until it settles down.
7.       Try the Achilles sock
called Achilles Gel Pad made by Silipos

8.       If I do any strengthening for the calf, such as the calf raises, do it in the evening then ice and rest overnight.
Dr Blake's comment: When strengthening an injured area, at the same time allowing activities which will stress the area, it is important to do the strengthening in the evening 1-2 hours before bed to avoid weakening the muscles/tendons and then having to use them. 
9.       OK to continue ART (Active Release Technique not drawing lessons!!)  with Dr Jess
10.   Request MRI from HMO doctor
Dr Blake's comment: If you read my blog, you probably know I love MRIs. There are too many generalizations being used to treat patients, and MRIs are a great way to individualize the treatment more and understand just what is going on causing this pain. The MRI can help differentiate partial tears, excessive scarring, bursitis, bone edema, and achilles calcifications from the more common plain old ordinary once around the block standard double play achilles tendinitis. 
11.   If an activity hurts, stop, unless the pain is letting up, including running.
Dr Blake's comment: Julie has a high pain level which can work against all rehabilitation programs. Getting her to understand Good vs Bad Pain is crucial. Pain at the start of a workout that looses up and disappears is typically Good Pain. But if the pain comes back while in the workout, you have reached your physiological threshold, and you must stop. Pushing through that pain is BAD!!
12.   Cortisone injection is not recommended, topical might be OK.
Dr Blake's comment: There is four ways to administer cortisone in this patient if we are having trouble getting ahead of the inflammation. Topical with Iontophoresis in Physical Therapy, Short Acting Cortisone Injection, Oral Cortisone in a 7-8 day tapering dose, and Injection of Long Acting Cortisone. Only the Long Acting Cortisone Injection could produce some series damage including tendon rupture, but the other 3 must accompany 2 weeks off athletics which stress the tendon. 
13.   OK to check back via e-mail in a couple of weeks
A couple of other questions I did have are:
1.       If I have flared it up, do you have any concerns with taking some Ibuprofen for inflammation?
Dr Blake's comment: Ibuprofen is fine for flareups, just never take so you can mask pain before working out. 
2.       Do you think there is any benefit to using products, such as BioFreeze?
Dr Blake's comment: I think biofreeze or topical voltaren gel (by Rx) or Flector patches (by Rx) or zyflamend (OTC) are great adjuncts to the above treatments. 

Thanks! Julie

Peripheral Nerve Pain/Neuropathy and Vitamin D Deficiency: A Possible Link

This is information from Podiatry Management Online Magazine service. 

RE: Fosamax and Neuropathy? (From: Jeffrey Kass, DPM)
From: Elliot Udell, DPM

Kudos to Dr. Kass for mentioning the relationship between peripheral neuropathy symptoms and vitamin D deficiencies. In our practice, we have worked up a number of patients with severe peripheral neuropathy and found incidental findings of vitamin D deficiencies. In all cases, what motivated the ordering of the test was the finding of osteopenea in the met heads. When the patients were placed on vitamin D supplements (either over-the-counter or prescription grade), they had very rapid resolution of their neuropathic symptoms.
Hence, we now add a vitamin D 25 test as part of our work-up when we evaluate patients presenting with painful neuropathy. I want to caution readers not to interpret this as meaning that all cases of peripheral neuropathy are caused by vitamin D deficiencies, however, it should be on your differential diagnosis list when evaluating patients presenting with pedal symptoms of peripheral neuropathy.

Elliot Udell, DPM, Hicksville, NY

Wednesday, June 27, 2012

Hallux Limitus: Email Advice

Hi Dr. Blake,

      I stumbled upon your blog when researching about Hallux Limitus. I am fairly young in my early 20's and am attending university.

      I have had some pain on my foot for some years now and have decided to get it checked out. I went in today to a podiatry doctor to look at my foot. I had thought I had bunions, but he said I had Hallux Limitus instead.

      He didn't really explain much to me and really rushed through my appointment. I was hoping you could give me some insights. I have done some reading online about this condition, and I do have questions about treating and surgery.

      The doctor did examine my feet, but no x-rays were taken. He did say that I do have some limitation of movement of my big toe. I feel like I need to know how serious it is before deciding what to do.

      I know I have the option of having surgery to remove the pain or doing non-surgical methods. I am leaning towards surgery, but I also understand that surgery may not be successful. What are your recommendations? Do you know the success rates for surgery and would I really need it? 

Thank you! Anonymous

Dr Blake's Comments:

Dear Anonymous: 

     You are so far away from surgery because you need to begin treatment first. Hallux Limitus can be structural with wear and tear changes of arthritis beginning in the joint, functional due to jamming of the big toe joint into the ground with over pronation or pes cavus foot type (high arches), or a combination of both structural and functional. So, you need to find out what type do you have.

     Functional Hallux Limitus does not need surgery, only orthotics or dancer's pads (also called reverse Morton's extensions) to take the abnormal pressure off of the joint. 

     Structural Hallux Limitus has 4 stages of advancing arthritis. As the arthritis gets worse, the pain can get better or worse. Seems odd, but often as the joint gets more arthritis the bone changes cause great limitation of the joint, and the joint stops hurting. Stage 1 and 2 are truly just joint limitations, and can normally be conservatively managed. I have seen just as many Stage 3s as Stage 4s (normally called Hallux Rigidus) have surgery as not need surgery. 

     Combination Hallux Limitus has both the structural component and the functional component. You have to first treat the functional component with orthotic devices to get the weight in the middle of your foot, freeing up the joint. The health care provider needs to be skilled at designing orthotic devices for such a weight shift. Then the structural component can be treated with Morton's extensions, spica taping, carbon fiber inserts, etc.

     So, before any thought of surgery, go through this checklist. You sound too young to end up with trouble with surgery. Surgery never fixes this back to normal. So postpone the first surgery as long as you can have success with conservative treatment. The goal of conservative treatment would be to allow 0-2 pain levels, while you are fully functional (doing every thing you want to do). 

     My checklist for Hallux Limitus for you would be: (all of this is on various of my blog's posts)

  1. Have orthotic devices designed to off weight the big toe joint.
  2. Have standing foot X-rays to check on the overall health of the joint and foot in general.
  3. Get an MRI before any discussion of surgery to check cartilage status.
  4. Learn to spica tape with kinesiotape.
  5. Discuss the opinions of 3 different surgeons when one surgeon tells you that your only option is surgery from this point on. 
  6. Begin a 1 year program of daily foot strengthening exercises.
  7. Learn the self mobilization procedure for Hallux Limitus.
  8. Ice pack your big toe joint area for 15 minutes three times a daily for at least one month to reduce inflammation.
  9. Learn what shoes and activities bother it, and what activities do not bother it.
  10. Never lean towards surgery, but rather but gently pushed there when needed by a caring doctor. 
      I sure hope this gives you some focus. Dr Rich Blake


Tuesday, June 26, 2012

Women's Casual Shoe which Works Well With Orthotics

Rich,
Here's the shoes i had on today which fit my orthotics. I also attached a pic which shows the birkenstock like sole. I think they are good casual shoes, but also fit my big athletic orthotics!!
OeTZI3300

Thanks again. I'll keep you posted after 5 runs!
sarah

Original insert that can be removed to fit the orthotic devices, so that you can be in style and stable at the same time. 

Monday, June 25, 2012

Ankle Sprains: Make sure Ankle Strength Even On Both Sides!!

 
More soccer sprains when one ankle is stronger: study
Chicago Tribune
(Reuters) - Pro soccer players are much more likely to suffer ankle sprains when one foot is stronger than the other, according to a Greek study. Ankle sprains ...
See all stories on this topic »
This is a good study of a fact that the sports medicine world has known, but little has been documented. So in order to reduce the amount of sprains in the first place, or prevent further sprains after the initial incident, get those ankles strong. The blog post on Single Leg Balancing Exercise is a great way to start. 

Alcohol Injections for Nerve Desensitization for Athletics

I just saw a patient whom I am using a series of 5 injections spread over the next 5-6 weeks to desensitize a very sore Morton's Neuroma to enable him to compete at a national level in Sprint Cycling. I may get permanent nerve anesthesia, but I am hoping and should get over 1 year of significant less nerve pain. Several years ago this procedure worked well for him. Dr Rich Blake See my original post on injections for Morton's Neuromas which talks about cortisone vs alcohol injections.

Sunday, June 24, 2012

Injured: Advice for Flying



Hi,

I have a sprained ankle - xray showed no breaks. I asked the orthopedist if it was okay for me to fly, and she said yes but to except some swelling. The problem is that I didn't make clear that the flight was not a one time deal, work requires me to take 5 hours flights twice a week. On my flight this morning my ankle swelled considerably, to day 3 level swelling (right before the flight, day 8, had minimal swelling). Will having my ankle swell twice a week slow my recovery or cause further damage / scar tissue? I am on crutches, with an air cast, and used an ace wrap on the flight. If necessary I can ask to work remotely for a month, but I would prefer not to.

Thanks,

Michelle

Dr Blake's response:

Michelle, sorry I am just getting back from vacation. The repeated swelling will delay, but not prevent, your healing. Support hose at 20-30mm Hg above knee (only need on injured side) can be found at some pharmacies and definitely helpful. Do ankle pumps every 15-20 minutes on the plane (10 up and down motions while in your seat). Elevate as much and as high as possible on the plane (see if the bulkhead seats are available). Ice pack for 20 minutes as soon as you are off the plane, and one more time that night. Hope this helps. Rich

Plantar Fibromatosis or Fibromas

From: John J. Hickey, DPM
 
I've had luck using transdermal Verapamil 15% gel from PDLabs- it's a non-invasive treatment.

This information is off the Podiatric Management Magazine website.



 

Wednesday, June 20, 2012

Hallux Limitus: Post Op Advice

Hello Dr. Blake,

My name is Julie and I came across your site while researching hallux limitus surgery recovery. 

I'm a very active 48-year-old (with a 4-year-old daughter) and decided to have the procedure with my  podiatric surgeon on April 27 after dealing with the disorder for three years and having tried everything—orthotics, chiropractic, acupuncture, you name it. 

I think the procedure went well, and though I know you can't comment on my case specifically, I'm wondering if given your experience in this area, if you can give me a sense of what you've seen with patients who don't show signs of immediate improvement (given normal healing time from the procedure). It's now 7 weeks out for me, and though I seem to have a bit more flexion than I did before, the pain is worse than it was before the surgery. My doctor was hoping to see more progress at my second post-op checkup two weeks ago, but she says to remain optimistic. I'm starting physical therapy next week.

I get the sense from what I've read that by this point, the patients for whom this surgery is going to "work" have less pain than before the surgery, but pain greater than before the surgery at this point is a sign that the procedure didn't "work." (Using the word "work" very loosely here, of course).

Again, I know you can't comment specifically. I'm just hoping you might have "anecdotal" input that could help me figure out the best way to move forward (I'm considering a cortisone injection after the 3-month mark if it's still painful). I want to have the best chance of getting the relief I had hoped for from the procedure.

Thanks so much in advance for any insights you could share.

Julie
Dr Blake's comment:

Dear Julie, 

     Thank you for emailing, and, of course, there are a hundred questions I could ask you. Please email what type of surgery they performed and I will add to this email over time. First of all, all these surgeries other than fusion create a lot of raw sensitive bone which takes 6 months to 2 years (or more) to heal. You must protect this new born baby of a joint, and avoid painful activities. The raw bone is very sensitive, and slowly gets less sensitive. The things in your court to help are controlling the inflammation (icing and contrast baths), avoiding bending the toe (stiff soled shoes, orthotics, carbon graphite plates, spica taping, removable boots, etc), and time. I don't consider an MRI for 6 months, but like to wait 1 year. Surgeons like surgery, shots, and casts. Try to create a pain free environment, and then gradually month by month increase your activity. 70-80% of these surgeries work great, but you can not judge the results during the first 6 months well. Avoid cortisone with a passion--at least for the first year, unless you are not functional day to day. First priority--create that pain free environment so that you can function day to day with 0 to 2 pain level. Hope this helps with focusing on where you are at. Rich

Hi Dr. Blake,

Thanks so much for your quick response on your blog--it made me feel so much better (I've been very demoralized about this whole thing, which I know doesn't help with healing).

To answer your main question: The surgery I had on 4/27 was a standard cheilectomy (no osteotomy). 

I have my first physical therapy appointment next Wednesday and haven't yet gotten the Dynasplint prescribed (don't even know what that is yet).

I think my main question to you based on your blog response is regarding motion: after the boot came off, my doctor instructed me to manually move my toe up and down at that main joint several times throughout the day to help increase ROM. I'm wondering how that type of joint movement squares with your advice to keep the toe mobilized. Also, more broadly: wondering how walking in regular shoes (or barefoot) is different from moving the toe manually.

Since I'm lucky enough to have you close by, I'm thinking I might make an appointment to see you after I reach my 3-month mark and have a post-surgery x-ray taken. 

Thank you again in advance for all of your help. It's such an inspiration to meet someone who is so obviously passionate about his work (and helping others!).

Julie

Dr Blake's comment:

Dear Julie, 

     The standard cheilectomy (basically shaving off all of the bone spurs, but leaving some damaged cartilage) is definitely what I would try first with painful Hallux Rigidus. Your two limitations to bending the joint is raw exposed bone and the ligaments that surround the joint can get stuck down to the new bleeding bone (called adhesive capsulitis). You will gradually create motion back into the joint with walking, then running activities, but first with self mobilization (I have a video on this and the Physical Therapist can review with you to make sure you are getting it right). Any range of motion device or technique that causes pain while doing will probably make you tighter in the long run. The Dynasplint has been around, but I am not familiar with it enough to comment. Please have the physical therapist measure the joint range of motion (dorsiflexion and plantar flexion) at every visit, and especially after 6 Dynasplint sessions, to document if the range of motion is improving or not. It is crucial that the same physical therapist measure the motion each time. Moving the toe manually will be best with the 4 directions taught in the self mob video. Walking will never get the plantar flexion range of motion better than the exercises. Too many things can make the dorsiflexion range of motion less if they irritate and produce pain. So, get back to thinking about the pain free environment we need to achieve. Remember your joint will help teach you what is good and bad for it better than any doctor, blogger, or other general rules being applied. Hope this helps. Rich

     

Chronic Warts: Email Correspondence

Dr. Blake

I actually just read the following post regarding chronic warts:

I also have had chronic warts on my foot since 1999 (from 1 to as many as 20). I've tried a lot of different techniques, including freezing/shaving, surgical removal (twice, in 1999 and 2006), and most recently burning them off using an East Asian technique that is apparently common in Korea--effectively wetting finely ground grass and creating a "fuse" to the wart, and then lighting it til the fire becomes too close/painful, 10 times per session, per wart. In the first or second iteration of each of the treatments mentioned above, the warts were removed after 6-8 weeks, but each time they came back w/ greater resistance. In the summer of 2007 I had approximately 20 warts on both feet just one year after I had my one wart surgically removed in a bloody operation in '06; and my mother suggested the fire technique which, to my joy, removed all 20 warts in about 6 weeks. Several months later, a few warts appeared on the balls of my left foot, followed by one wart on the balls of my right foot. Tried the fire again, this time to limited effect. I gave up, figuring I could live w/ a couple warts. However this year I've taken on running as a more serious hobby, and the pain from the warts on the balls of my feet are a real impediment.

Can you recommend a doctor for me in the NYC or Stamford area?  Your run of the mill podiatrists want to continue to freeze and shave, but the last few incidences of freezing/shaving have only caused warts to spread. I even had one podiatrist who prescribed some herpes pills to help stop the spread of the plantar warts a few years back, to no effect.

Would very much appreciate the reference.

James

Dr Blake's comment: 

Dear James: The podiatric guru in that area has just retired, but I am sure will tell you who to see in the Stamford area. His name is Dr Michael Sabia. Here is his contact info. 


Michael L. Sabia, Jr, DPM
217 Haviland Road
Stamford, CT
Phone: 203-322-0082
Cell: 203-912-6232
Email: noodels2@optonline.net
Education/Affiliations
Graduate TUCPM - 1970; Residency Guiffre Med Center - Philadelphia, PA - 1971
Specialty board: ABPOPPM
Practice
Currently retired from practice. Was in group of podiatric medicine and surgery for 40 years. Active with civic and sports groups for all of practice life.


When dealing with warts, which are living viruses, I always think about compromises in health. My big question to you regards your overall health picture and could there be some reason that your body can not deal with the virus well. Have you had your overall health checked both with western medicine, and more naturopathic doctors? Have you had normal bloodwork? I at least would have an internal medicine specialist check you out looking at areas of immune compromise. There are some new, and probably more expensive, lab tests regarding immunity. Immunity is your ability to fight virus, bacteria, fungus, cancer, etc, anything that attacks you. Hope this helps you. Dr Rich Blake
Michael L. Sabia, Jr, DPM
AAPSM Fellow

Friday, June 8, 2012

Joseph Hamill, PhD, Challenges the Idea that Forefoot Strike Patterns seen in Barefoot Running Reduce Runer's Injury Rate

http://www.lowerextremityreview.com/wp-content/uploads/2012/05/LER-Steps_Ahead.pdf

     In the above article, Dr Joseph Hamill, PhD, UMass at Amherst, discusses research related to the benefits and disadvantages of running with a forefoot strike. Forefoot landing at impact is the key to various running techniques including the barefoot running technique. Dr Hamill is a natural forefoot striker himself when he runs.

Some of the points I thought summarized the article:


  • Whereas the barefoot running group highlights rearfoot or heel strike as the source of many injuries, running injuries are complex and multi-factorial.
  • From a pure Biomechanics standpoint, there is no benefit to run barefoot or a forefoot strike.
  • Forefoot strike decreases vertical impact peak, also called vertical ground reactive force, but there are still impact peaks just lower in her frequencies (intensity).
  • Lower impact frequencies are attentuated (absorbed or dealt with) by muscle activity, higher impack peaks by bone. Muscles are weaker at handling impact stress than bone. Muscle injuries should occur with more likelihood with forefoot strike, and bone injuries more with heel strike.
  • Loading rates may actually not be lower in barefoot running as claimed. Changing technique may be the most significant driver of change. When natural forefoot strikers switch to rearfoot strike, their loading rates went down. 
  • Even though heel strike may have more ground reactive force, it is less delicate of tissue than the forefoot, and can handle that stress.
  • There are different strike patterns for different functions. Rearfoot strike for maximum energy efficiency. Forefoot strike for maximum speed. So Forefoot strike not designed for all purposes. It will work for some, and not for others. 

Thursday, June 7, 2012

Strengthening Ankle and Foot: Isolating A Weaker Muscle


Here is a question from my video on YouTube on Ankle/Foot Strengthening (see the video below).

Why did you ask her to stop when she started to substitute?


When isolating a muscle/tendon while strengthening, it is important to strengthen that one weak muscle and not allow for substitution of the surrounding stronger muscles. Substitution means that the patient will use another group of stronger muscles to do the activity, and not use the weaker muscle (it will go along for the ride). By isolating a muscle/tendon, you can increase its strength rather quickly and correct muscle imbalances produced by strong vs weak muscles. Dr Rich Blake 
A typical example is the marathon runner who comes in knee pain. You test his muscle strength and all muscles in his lower extremities are strong except for some weak quads. You isolate the quads in your strengthening program, gradually build up the strength, and they return to running with no knee pain.


Wednesday, June 6, 2012

Mentors: We all need them!!

      I have been really fortunate in having 7 strong mentors in my life, starting at a young age. They have been so valuable in shaping who I am, I wish everyone could have one at every stage of their life. I need another one right now, to help and guide me (although my wife Patty is mentoring me daily in what is truly important in life). Yes, mentors show up in the right time and place to help and guide, and leave some permanent mark on your life, or like my dad, can be there throughout  your life, and the lessons taught are almost by osmosis. My last 3 mentors have died and I am somewhat lost without them. One was a Catholic priest, for I am Catholic, and the other 2 podiatrists, and this is my profession. Of the remaining 4 mentors, 2 are living, but are guiding me little right now, and 2 are now gone. My living mentors of old are my dad, whom I still listen to every word, and Dr James Garrick, orthopedist, whom still runs my office. I could write reams about each one of these people, but that is not my purpose here.

     Mentors keep you on the right track. They normally meet you psychologically where you need to be. But, they must be sought after at times. When you meet a mentor, you normally know it. You want to know what they know. But, do they have time for you? When I was growing up, it was my dad and grandfather, by how they acted, and how they made me feel, that made me want to be like them. My 3rd mentor, Police Sargent William Groswird, was my baseball coach in grammar school, and the father of my best friend. His influence got me jobs even in college, and drove me to pitch baseball at UC Berkeley. I feel deep respect for these gentlemen.


From Left to Right, My dad Charlie, My son Steve, My Daughter-In-Law Clare, and My Mom Dorothy


Dr Merton Root, my friend and mentor, the founder of modern day biomechanics.


     Most parents sadly realize that by the age of 14 their kids look outward for mentors. Their friends have more influence than the parents do in day to day life. Parents are emotionally abandoned for friendships and mentors in the fields they are experientiing with.We parents must allow this to happen, but continue to guide them softly. I have watched my 2 sons find strong mentors that have guided them in their fields of law and public relations which I know nothing about. As a parent, I am forever grateful.

     Mentors exude TRUST. How many people do we actually trust in life completely? Mentors can be younger, same age, but normally older. They can tend impart the wisdom we need at the time we meet them. I have been a mentor to some I know in my medical practice, but it is a relationship that goes deeper than the business of medicine.

     And, you never have to actually meet a Mentor. It could be a political, religious, spiritual figure, whose ideas capture your imagination and you immediately want to be like that person. So you read about them, study them, and put yourself in their shoes for part of your life.

    I ask you, as I did, to take an emotional count of the mentors you have had, and deeply appreciate each of them. See if you can be a Mentor to more, by just being who you are. Volunteer or just be more interested in the younger generation in your field. Reach out a little more, risk your heart at times a little more, humble yourself a little more, call someone that needed your help months or years ago. Be There a little more. It is all it takes.