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Monday, March 31, 2014

Monday's Images of the Week: MRI views of normal and injured plantar fascia

These are some of the MRI images I look at when evaluating the plantar fascia for injuries. I wanted to show mainly the coronal images which typically show the injury the best. 


On this first view we see the sensor is just under the medial slip of the plantar fascia which is healthy when dark black as in this case. The "itis" of plantar fasciitis is seen by the white under the darker plantar fascia.

These next views follow the medial slip of the plantar fascia about 3 inches in front of the heel towards the arch. So, this image is closer to the arch than the first one I showed.



Check as normal plantar fascia gets closer to the arch it will thin out, but remain dark black. The area under and around the sensor is the normal fat pad of your heel. The heel bone is dark black above the plantar fascia. 






As we go further out into the arch, the wonderful arch muscles and veins and tendons all come into view. 




Here is the final coronal view of the plantar fascia. We have traced it from under the heel forward into the arch. You can appreciate all the incredible structure in the arch.

Same patient but now we are looking form the side. See how the plantar fascia starts under the heel and goes into the arch. It should look solid, consistent, and one thickness. 

Unfortunately this is on the opposite side. See the plantar fascia above the sensor is very dark on the bottom and irregular/gray on the top. This is an old plantar fascia partial tear which has somewhat healed.

This is the same patient from above with the old plantar fascial tear. Compare this side view with the image 2 above. See in this image the plantar fascia is thinner by the heel, then gets thick, then thins out as you go into the arch. This thinner area by the heel is the first hint something is wrong. We know by looking at other images that that area was injured and attempting to heal.

Here is another patient with an acute (just happened) plantar fascial tear. The plantar fascia has just exploded from the heel. 

Same patient from above. Missing plantar fascial medial slip due to recent tear. We will now follow this forward into the arch. See how the plantar fascia starts to show normalcy as we move forward. 




Sunday, March 30, 2014

Sunday's Video of the Week on CRPS: Wonderful Lecture by Dr Deepak Chopra

I had the pleasure of attending this great lecture in 2013. It changed my treatment thoughts on CRPS. It may me favor Ketamine Infusion over Spinal Cord Stimulator in severe cases. And now Calmare Pain Therapy seems to have a valid place. As a podiatrist I can only recommend some treatments, but this is in the world of pain management specialists rightfully so. 

http://youtu.be/6_NzhnAXX2c



Saturday, March 29, 2014

Saturday's Exercise of the Week: Bunion Joint Strengthening


As you begin your treatment to maintain your bunions in an attempt to avoid surgery, think about all the possible treatment choices you have available. 

My common checklist for my bunion patients includes: (and my blog is full of these tips)

A) Toe Separators

B) Yoga Toes

C) Digital Stretches and possible Night Splint

D) Shoe Selection (so as not to push too hard)

E) Padding to Off Weight the Bunion Area

F) Icing as needed

G) Abductor Hallucis Strengthening (this video shows the patient attempting to train the toe to pull down as straight as possible)

http://youtu.be/V487w7IM_2c



H) Taping occasionally

Friday, March 28, 2014

Friday's Patient Problem of the Week:Supination and ankle problems

Good Evening Dr. Blake 

    I am a 33 year old  young man living in Los Angeles CA. I have been having ankle inflammation in my right ankle which started about 1 year and 7 months ago. It was a pretty simple episode that I got ankle cramp and I manipulated my ankle with my finger and got inflamed for over 8 months.
Dr Blake's comment: Inflammation in the ankle in somehow who stands like you do is very very common. It normally is a combination of muscle fatigue and mechanical stresses (flat feet, high arches, loose ligaments, tight muscles, etc). Typically, you place yourself into some logical problem of rest, bracing, anti-inflammatory, and stretching and strengthening. The rest part is activity modification where you try to sit more at work, or at least get a soft mat to stand on, and use weekends (days off) to recover. 

   During this time,  I was trying to not put pressure on my right ankle so I was putting my body pressure on the left foot. The inflammation was not going down with taking lots of Ibuprofen 800 mg twice to 3 times daily. I was having burning sensation and warmth feeling around my ankle all the way down towards my heel.
Dr Blake's comment:Burning can be from a lot of causes---neurological coming from local or as high as your spine, vascular with poor circulation, and inflammatory with marked swelling. Unless there is more swelling than you describe, this burning may be from some stress on the nerves, however could be from swelling deep within the ankle joint.

    I have high uric acid level which is approximately around 9.2 or little less over the past 12 years, and while suffering from burning and discomfort,  my ankle would get a warmth feeling when I was wearing shoes. I saw couple of podiatrists where one gave me lidocaine injection to increase blood flow to reduce the inflammation, but it did not help me. 
Dr Blake's comment: Nothing in the history you give sounds like gout, although there is mild versions of it. Typical Gout is red, hot, and swollen area, where you worry that there could be an infection in your workup. The high uric acid blood test could have just been a red herring. 

   Over the phase of 1 year I received 3 cortisone shots in my right ankle that it finally helped with the inflammation going down. When my ankle was inflamed, I was experiencing tingling sensation around my ankle which the tingling would be less when I was laying down on my bed.
 Dr Blake's comment: So, your tingling was probably from deep swelling putting stress on the tarsal tunnel nerves. Nerve pain is so debilitating, and your body goes quickly into a self preservation mode to relieve it. However, this preservation mode normally produces way too much muscle atrophy and severe weakness settles in. 

   After about 1 year my left foot started burning around the ankle and I have changed many shoes but I would feel the burning getting worse as I wore every shoes. My wife noticed that I walked not straight and she brought it up to me every time I walked. After reading and doing a lot of research online, I came to conclusion that I have severe supination and I still have a little inflammation on the right ankle with the burning sensation and tingling.
Dr Blake's comment: Best to send me a photo of you standing, barefoot and in shoes, from the back of the heels. The photo should be from 2-3 feet behind you in good lighting. This will help me understand the severity of your severe supination. Supination, with the lateral instability it causes your ankle, could explain all of your symptoms. That would be nice. 
http://youtu.be/bc2PRrtwemM



http://youtu.be/hxsNaBXT_ug



    I have been seeing physical therapy for couple of sessions and they have gave me stretches and some work out but I need your help Dr. Blake. Please respond back and try to eliminate my pain and suffering that I am having for the past 1 year and 7 months. My job is a Pharmacist and I stand on my feet over 8 hours. Please please get back to me to find a solution to my suffering. I would really appreciate your concern and attention Dr. Blake if you can make my wishes of walking normal without any pain. GOD may bless you and your family for helping a young married man gain back his strength and be pain free.

my cell phone number is XXXXXXXXX  please contact me if you have to and please help me with all my suffering.

Dr Blake's response:

     Thank you so very much for your email. I have tried to give it some attention. I am glad you are going to the Physical Therapist since they can be my eyes in my attempt to help some. 

The questions I would have from them:
1. Are you excessively supinating and, if so, can they design an inserts that completely eliminates that stress?

2. Do they think you have inflammatory pain or neuropathic pain? Neuropathic pain is true suffering. Ask them to teach you neural flossing and test for low back involvement. 

http://youtu.be/Xs8Cl39LXQg



3. Can they give you an Air Cast Ankle Brace for more stability but not a lot of compression?

http://www.betterbraces.com/aircast-sport-stirrup-1

4. If it is neurological, you should have a doc involved that can give you oral meds, topical medications, and be able to order MRIs, EMGs, etc as indicated. All your pain can be coming from the low back because it is so hard to stand in spine neutral constantly in your job.

http://youtu.be/E0E60NpOSHg



5. Ask the  physical therapist if an ergonomic evaluation of your work place can be done to make sure you know all the tricks at keeping your ankles and back healthy and minimally stressed. 

I sure hope this helps you some. 


Dr Nancy Sajben, pain management extrordinaire!!

I recently had a patient who saw Dr Sajben for her chronic debilitating nerve pain (she flew down from San Francisco where I live to San Diego). Dr Sajben gave her advice and a RX for LDN (low dose naltrexone). This has been a miracle to restoring her function, giving her back the life she had lost. I just called and talked to the patient's husband. The reason the patient was not able to get to the phone was because she was on a 4 mile hike, something the last 8 years would never have happened. Chronic pain sufferers do not give up hope. There are some answers out there that many help you. When you see Dr Sajben's website you will see how many options are out there and that implies hope. 


http://painsandiego.com/

Thursday, March 27, 2014

Thursday's Orthotic Discussion of the Week: Asymmetry in Orthotic Control is Best


When you take impressions of patient's feet, there will always be differences in the overall foot structure. Study the casts and appreciate these differences. Decide if these differences, like more or less forefoot deformity, is important to correct fully. Orthotic labs overall love to even out the tilts, but these tilts may be important. Work with your lab on making sure they only even out when you prescribe, not routinely. Most of the time I see totally symmetrical orthotics, even when both feet look totally different, so I know this evening out occurs (and possibly not for the patient's best interest).

The true reason for this post is the asymmetry in the correction that so many feet need. Correcting asymmetrically, like the photo above, is needed often. This occurs since one foot may pronate more than the other, supinate more than the other, require more forward pitch than the other. The photo above shows more pronation (arch) support on the right, and more supination (outside) support on the left. Be critical of your orthotics, work with your labs, dare to be more asymmetrical in your Rx.

The goal really is to make both feet function close to symmetrical, and stable, no jerking, very smooth. With asymmetries, just make symmetrical orthotics will not feet function even. This is an old theory from the 1970's. Perhaps it worked more in rigid rohadur orthos and oxford or wingtip shoes. But, not in 2014. Think asymmetry for RX to make the feet function more symmetrical. 

Wednesday, March 26, 2014

Wednesday's Article of the Week: Gait Changes Post Big Toe Joint Fusion

So many of my patients with Hallux Rigidus do not like the thought of big toe joint fusion, and I share that thought. I have only two patients in my practice and they are doing well post surgery. I present this article abstract to help with pro/con list we all create when trying to choose between different treatments. I would still recommend joint fusion in only small instances, but when I do recommend the procedure articles like this help me feel better that the patient will do well afterwards.

Below are the foot x ray images of my patient who is doing very well with her big toe joint fusion. The hardware is scary, but she is stable, pain free, and comfortable walking. She is 2 years post fusion by our podiatrist Dr Remy Ardizzone. Dr Ardizzone is very skilled at cheilectomies (joint clean outs) and implants, but felt fusion due to the severe joint arthritis was the best option. My patient is happy with the results.





http://www.ncbi.nlm.nih.gov/pubmed/17296132?dopt=Abstract

New Website for Heel Pain Sufferers: I hope it helps millions!!

Hi-
I wrote to you a couple of months ago and asked if you would mind if I embed one of your videos onto a website I was building about heel pain. The one showing the plantar fasciitis wall stretch is the one that I wanted to use.
Just letting you know that the website is up and running if you want to see how it came out. Your video is located at:

http://heelpainrelief.net/physical-therapy-videos/
Hope you like the way it turned out. I have a link to your site also. I could add another one or two videos if you want; let me know if there is one specifically that would fit.
Again, thanks for your help. I really like your work...
Sincerely,

Calmare Therapy: A Rising Star for Nerve Pain (even CRPS)!?

Hi Dr. Blake, I have some very exciting news to share. I have been on the East Coast having some experimental treatments for the last three weeks. A new generation of electronic device that delivers healthy nervous system signals to the brain, somehow erasing old pain pathways.
I was very skeptical initially, seemed like one more silly Tens kind of gizmo, but I have been completely astounded at the results.

The technology does not rely on the Gate theory  of pain, but rather on a different kind of signal theory.

Almost all of the pain and allodynia has been eliminated from my foot.
It is like a miracle.

I don't know how long this improvement will endure. Most patients experience some regression over time, and need additional treatments. and I also will have a lot of rehab to do to get a normal sock and shoe on that foot, and very gradually rebuild strength and endurance in walking.

But for right now it has given me so much hope to have relief from that horrible neuropathy that was like the worst kind of torture.

The name of the machine is called Calmar. There have been some small scale studies demonstrating efficacy, and larger scale trials, including at the Mayo Clinic, are now underway. It is effective with CRPS, post herpetic neuralgia, diabetic neuropathy, and post chemo therapy neuropathy. Goodness knows these are all patients who need help and hope.

I know you care so much about your patients and have been trying very hard to find solutions for me and others. I will send you more information when I get home.

Unfortunately my L5 – S1 disc issue, which was a sleeping tiger, has been set off by the travels, so I am having very painful sciatica now And  will have to get that calmed down. But even that is nothing compared to the CRPS.

I'll be in touch with more information about Calmar, when I'm home and doing a little better.

I hope you are doing well and thank you again for all your care and concern.

Best to you, 


http://youtu.be/GzbbkS-Imm0







Tuesday, March 25, 2014

Tuesday's Patient Question of the Week: Posterior Tibial Tendon Dysfunction

Dear Dr Blake: 
Thank you for your wonderful blog and devotion to truly mastering your craft and helping others! Here is a patient question-of-the-week(I know you may not answer!)

I've had five years of dealing with chronic re-injury of the posterior tibial tendon and achilles.I've never let it go too far, but stop and rest for three weeks to three months, incorporating taping and strengthening until it feels strong enough and no pain.

After twenty practitioners and thousands spent on modalities and orthosis, I am no further ahead, although my first orthotic had a flange up the side-back of the heel that stabilized the foot and healed it more quickly. My longest time without injury was when I went minimalist, stuck to a soft trail and did steep hill workouts(I've loved running for 25 years;  I miss it so very dearly). 

I wonder if this strengthened my PT and achilles enough to stay running?  I greatly reduced mileage.I  went back to roads due to winter conditions on the trail and within months was injured again. It is so anxiety-provoking to live this crippled. Could a leg length discrepancy be at fault? I also have a pelvic tilt, according to my chiropractor, and hyper-eversion(valgus) of the affected foot at the ankle bone.And hip arthritis and OCD lesions in the knees, but the PTT is a deal-breaker. It seems I cannot keep this foot neutral, no matter how much work I do on my gait or core.I know the ankle seems "loose".

 Will it help to build up my own orthotic(currently, a custom SOLE) How do I find the material and tools, and can I use duct tape?:) I am willing to experiment; I have done a lot of it with shoes and insoles, but feel a bit out of my league! Do you think you could make me an orthotic that works? I am 50 years old, but it is the new 80! I don't want to be in a wheelchair in ten years.
Thank you so much for your earnest blog and practice!
Marina (name changed)


Dr Blake's comment: Marina, thanks for your wonderful compliment. I have a wonderful love hate affair with Posterior Tibial Tendon Dysfunction. Developing the correct orthotic device is a crucial first step in stabilizing you, along with arch taping, PTTD Braces and then tons of posterior tibial strengthening. Check out the many blog posts on this site on PTTD. It takes alot of work to get the right orthotic, so I would be happy to try if you want to come to San Francisco. Not a bad place to have a two week vacation. The minimum time would be an initial Fri afternoon visit for evaluation and orthotic stuff, followed by a dispense visit on Monday AM. This has to be all arranged. Perhaps followup can be done locally by a podiatrist or orthotist. Contact me directly through by email and I will arrange things, give me 2 or 3 weekends that you can do this. If their is someone locally that can at least adjust my work, that would be wonderful. The video below discusses this problem. 

http://youtu.be/PeD-lG3383A



http://youtu.be/pKWOKCgJVDQ

Monday, March 24, 2014

Monday's Image of the Week: Stretching a Very Tight Achilles

Patients whom have very tight achilles tendons can use this technique to stretch out very gently in a relatively short time. An exercise band (like this yoga strap) is used to place a continuous stretch on the achilles tendon. The strap is anchored around the waist so that the patient does not need to stand or hold the band during the prolonged stretch. A towel is placed under the foot to protect the foot. Then, heat is applied under the calf for 20 minutes, and then switched to a 10 minute ice pack. The secret is to hold the stretch consistently and painlessly for the entire 30 minutes. You need a friend/partner to help with set up and to change the heat pack to ice pack at the 20 minute time interval. Dramatic increases in flexibility are noted within several weeks. Typically this is done every third day, with normal stretching 3 times per day on the off days. It is important to protect the knee while holding this stretch by rolling a towel under the knee to keep it slightly bent. You must make sure your spine is stable as you rest against a firm supportive surface. Stop if any pain develops anywhere. Review with a physical therapist to make the exercise safer for you. 







Sunday, March 23, 2014

Sunday's Video of the Week: Pain Management using Lasers

Later this week I will share 2 emails from patients with severe nerve pain both helped recently with laser treatment. I am going to research these topic to bring to you as it seems like a quantum leap forward in the treatment of many problems.






Monday, March 17, 2014

Drawing Salve: Help to pull out problems out of your foot

Hi Dr. Blake,

This is the CPA with the dog hair stuck in her foot!  Sorry it took me a while to email you, but here’s a link to the drawing salve I told you about:


Update on my foot - After I saw you, I soaked my left foot every night and after a few days, the hole started to get red and it hurt again.  I continued to soak, but after soaking and rinsing off, I bandaged it with this drawing salve for 4 or so nights.  The pain went away and I think the hole in my foot is closing up nicely now.  One other thing, do you remember right before I left, I told you I thought I had another hair in my other foot, but we both didn’t see anything?  It turns out I did have something in there!  I started to feel a bump a day after I saw you.  I soaked it for a week or so along with my left foot and whatever it was came out!  Thanks!

Monday's Image of the Week: Infected Ingrown Toenail




'



This ingrown toenail involved both sides and had been present for over 3 years. The nail discoloration is from some attempt at using Silver Nitrate to shrink or cauterize the swollen tissue. The nail borders can not be seen due to the swollen borders. The patient is wrapping the toe for compression, soaking 1-2 times daily in salt water, and hopefully the infection will be cleared. 

Sunday, March 16, 2014

Sunday's Video of the Week: Personal Story of the development of CRPS

I am all too aware of this devastating problem. The smarter I become at understanding, the dumber I feel. I recently caused a flare of a CRPS patient by attempting some injections proximal (above) the area. I will be forever sorry for inflicting this on my patient. It has caused multiple sympathetic blocks in the spine to help calm down, and it is still not back to its pre-injection state. These problems are the some of the most serious treated by the health care profession. I am hoping they get recognized quickly in the process, so it has an easier time being quieted. The word easier is not really appropriate.



Saturday, March 15, 2014

Golden Rule of Foot #1: Treat Every Patient with the Same Respect, Kindness, Care and Concern

     I have all of these Golden Rules I try (many times fail) to follow in my life. I love these rules of nature, of life, of love, of soul. My Golden Rules are sacred to me and I am miserable (or at least uncomfortable) when I break them. They extend into every facet of my life, so why not into my version of the practice of medicine. It is called the practice of medicine may I remind you all out there. I am practicing an art with my Golden Rules. Not a perfect art but full of the reasons that the word HEART has ART in it. These rules are sometimes taught in the medical schools, but mainly taught in the school of life. They really have no order, but society demands some bullet points, some indexing. Every person has their own golden rules, so think of your own as you reflect on mine. One of the keys is not to compartmentalize them, thus using drastically different rules in apparently different environments--like work versus home. As I meander through them with various posts, I hope you will stop for just a second reflecting on your own similiar golden rules.





Golden Rule of Foot #1: Treat every patient with the same respect, kindness, care, and concern.

     This is #1 because it is at the very soul of medicine. If you think of your relationships with others you realize this is impossible at first glance. We are only human. We like some people more than others. Those we like we tend to treat better. Those we like better tend to get more respect, more kindness, more care, and more concern. But, we must continue to work towards this truly Golden Rule. It is sacred. It will bring out all of the values we hold true. As you try to follow this rule with someone you really don't like, humility and emptying of self must surface. A health care provider with humility, an interesting concept!! Can it be a reality? Trying to follow this rule will allow humility to begin, and true caring to unfold. Try, fail, try again, and keep trying throughout your life.

Friday, March 14, 2014

Treatment can be affected by Looks

I think you'll like listening to this podcast from yesterday on NPR radio in which people talk about, and call in to describe reactions from friends, family, and strangers, to their "Invisible Physical Disability".  Just click on the link and then hit the little yellow arrow on the upper left of the page.


Thursday, March 13, 2014

Thursday's Orthotic Discussion of the Week: Root Balanced Technique evaluated in a left Positive Cast


Dr Merton Root in the late 1960's developed many methods to stabilize feet. He developed a way to cast feet to achieve a reliable, reproducible foot. This cast, called a negative cast, was taken using plaster of paris splints and the foot was held in a certain way, and this became the Golden Standard of making orthotic devices. Once the cast was taken, the heel was placed straight 

Wednesday, March 12, 2014

Wednesday's Article of the Week: Posterior Tibial Tendon Dysfunction: Regaining Strength is Crucial

Posterior Tibial Tendon Dysfunction is a devastating injury. Stage II is when the damage is not too great and the chances for a good rehabilitation are great. It is so important to combine Phase I of rehabilitation: Immobilization and Anti-Inflammatory with Phase II: Restrengthening. Start restrengthening the tendon is what ever way possible as soon as you can, but it has to be pain free!!!



 2008 Sep;29(9):895-902. doi: 10.3113/FAI.2008.0895.

The effect of Stage II posterior tibial tendon dysfunction on deep compartment muscle strength: a new strength test.

Source

Ithaca College - Rochester, Physical Therapy, 1100 South Goodman, Rochester, NY 14620, USA. jhouck@ithaca.edu

Abstract

BACKGROUND:

The purpose of this study was to compare isometric subtalar inversion and forefoot adduction strength in subjects with Stage II posterior tibial tendon dysfunction (PTTD) to controls.

MATERIALS AND METHODS:

Twenty four subjects with Stage II PTTD and fifteen matched controls volunteered for this study. A force transducer (Model SML-200, Interface, Scottsdale, AZ) was connected with a resistance plate and oscilloscope (TDS 410A, Tektronix, Beaverton, OR) to the foot. Via the oscilloscope, subjects were given feedback on the amount of force produced and muscle activation of the anterior tibialis (AT) muscle. Subjects were instructed to maintain a plantar flexion force while performing a maximal voluntary subtalar inversion and forefoot adduction effort. A two-way ANOVA model with the factors including, side (involved/uninvolved) and group (control/PTTD) was used.

RESULTS:

The PTTD group on the involved side showed significantly decreased subtalar inversion and foot adduction strength (0.70 +/- 0.24 N/Kg) compared to the uninvolved side (0.94 +/- 0.24 N/Kg) and controls (involved side = 0.99 +/- 0.24 N/Kg, uninvolved side = 0.97 +/- 0.21 N/Kg). The average AT activation was between 11% to 17% for both groups, however, considerable variability in subjects with PTTD.

CONCLUSION:

These data confirm a subtalar inversion and forefoot adduction strength deficit by 20% to 30% in subjects with Stage II PTTD. Although isolating the PT muscle is difficult, a test specific to subtalar inversion and forefoot adduction demonstrated the weakness in this population.


)

Tuesday, March 11, 2014

Tuesday's Question of the Week: Do you have video links to help with an Ankle Sprain

Common compression wrap with felt horseshoe applied to the ankle after a sprain. The hole of the horseshoe should be over the bone with more compression over the ligaments and tendons around the bone. The tube compression is pulled over the top and every attempt is made not to have wrinkles. 
Rich. My young Cousin in is Berlin w a stained ankle. Do you have any video links to care?

Best Regards,

Hey, Here are 4 of my youtube videos that are for ankle sprains. Rich


Monday, March 10, 2014

Monday's Image of the Week: Abnormal Heel Wear as a Sign of Gait Problems

As this patient walks, his right heel scuffs the ground terribly causing tripping and foot slap. This is a neurological problem related to his low back. It is seen primarily at the heel of his right shoe (on the left side of the image below). As a podiatrist, I am trained to look for clues in shoe inserts and shoe outer sole wear patterns. Usually the clues are more subtle. This patient was having major nerve problems in the right low back, and the nerves were not firing appropriately. 




Sunday, March 9, 2014

Sunday's Video of the Week: Introducing the Footfunnel: Could it solve the shoe horn problem?

So many of my injured, disabled, patients have a hard time getting into their shoes. Long shoe horns help, but not always. The Footfunnel may be a podiatrist's dream invention. Check it out. 

http://youtu.be/kFRyZaun0Rg

Saturday, March 8, 2014

Saturday's Exercise of the Week: Single Leg Balancing with Resistance Band Variation

I am always in search of wonderful and safe exercises that help us keep our lower extremities strong. This is a great exercise and a great addition to my original video on Single Leg Balancing. As we improve in our strength and stability, we need to find ways to make these exercises more and more challenging. It is easy to pick up these exercise bands (our office uses Theraband).  Good luck.

http://www.amazon.com/Thera-Band-Light-Set-Resistance-Exercise/dp/B001EU9M1S/ref=sr_1_1?s=hpc&ie=UTF8&qid=1394342843&sr=1-1&keywords=theraband


http://youtu.be/mfTQIUWTMBo

Friday, March 7, 2014

Friday's Patient Problem of the Week: Measuring Range of Motion 2nd Metatarsal Phalangeal Joint

A patient presented post operative 2nd metatarsal phalangeal joint. The joint was very stiff and painful and she wanted advice on increasing the range of motion and minimizing the pain. As she walked, she felt that the bottom of the base of the toe would stay against the ground and cause pain. She felt that the toe would not move up as she walked through her foot. Even though the pain was on the bottom of the toe at the MPJ, she felt that the restriction to bending the joint was in the top of the joint. 

2nd MPJ with healed surgical scars, but too much restriction at the top of the joint. Patient started on joint mobilization (like with Hallux Limitus) and cross frictional massage with a Blaine Scar Treatment Kit.


Tin Foil is used to give the patient a reference point before and then after treatment. With the toe bent upwards as much as possible, the tin foil is massaged into the skin to represent that area. About a 6 inch strip of tin foil is used and folded on itself to get some rigidity. 

Once the tin foil is removed for the skin, the patient can observe the angular relationship to the toe to the metatarsal (here before mob and massage). I can measure this as a 19 degree angle. 


After mobilization and massage, the angular relationship is remeasured and the patient can see how their treatment is working. Doing this multiple times a day (2-3) for several months (3-6) can give a consistent improvement. Remember no pain in this treatment. Here I measured the same patient at 40 degrees post mobilization and gentle cross frictional massage of 2 minutes. 





Wednesday, March 5, 2014

Wednesday's Article of the Week: Leg Length Differences Following Hip Replacements

If you are going in for a hip replacement, try to get the most information you can about how you can avoid or minimize a short leg. I have found only a few hip replacements to have no residual short legs, and so it is standard of care to have a short leg after. But, this means, lifts for the rest of your life in shoes or added to the bottom of shoes. I have many posts in my blog on the topic of treating short leg syndrome. This wonderful article below kindly discusses the problem. With supposedly 80% of the population having a short leg, it does mean that at least 80% of these surgeries will leave a short leg and need for a lift guy/gal like me to help post operatively. This is complicated by the fact that any surgery will temporarily weaken the joint involved. When it comes to the hip joint, when that area feels week, it throws off the gait, and makes it feel either long or short. Standing AP Pelvic Xrays post hip replacement can tell you what side of the body to place the lift, and it may not be the side you feel is short.

http://www.ncbi.nlm.nih.gov/pubmed/15190563




http://youtu.be/WRD62QspZtw

Tuesday, March 4, 2014

Tuesday's Patient Question of the Week: Advice for Plantar Fascia Injections

Hi i have plantar fasciitis in both feet and have been told i need injections but i am terrified of needles. I was wondering how much it actually hurts, and whether you can return to work the following day?

One Image to give yourself if you are going to get an injection is that the injection is going to make you more beautiful inside and out. 


Dr Blake's comment:

Shots for Plantar Fasciitis are normally done from the side of the foot where the skin is softer. So, it would be more painful if injected from the bottom of the heel. I use Ethyl Chloride skin coolant to numb the skin before the actual injection, and that typically helps alot. You should ice for 20 minutes just after the shot and several more times that day. People go back to work after the shots, but no running for 2 weeks. You can inject long acting steroid into the bursae under the heel, but typically not into the plantar fascia itself. All these fine points are really up to the doctor, and most based on what he/she finds and is trying to accomplish. I have given heel shots that feel like a little prick to sharp pain, so have someone hold your hand, and definitely do not look. Bring music and earplugs so that you can relax before/during the shot. I pray you will not feel it at all. Look at the video and ask the nurse to see if some of these tips could be used. The Emla Occlusion is wonderful, but requires getting the medication and you coming one hour beforehand.  Rich



http://youtu.be/t1qGGtZMFzI

Monday, March 3, 2014

Monday's Image of the Week: When One Foot Being Longer can cause Chronic Symptoms

I am hoping one of these 3 photos clearly captures the longer left foot. These inserts were removed from the shoe to check why the left second toe was continually being irritated. He was sent home to check other shoes to see if this was a consistent pattern. This will help in my recommendations on shoe buying. With some situations, patients with this problem need to buy 2 pairs of  different shoe sizes and chose one from one pair and the other from the second pair.