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Saturday, April 29, 2017

Can We Make This Blog Better?

In March 2010  I started this blog now 7 years ago almost to the day. I want to thank all my readers for your encouragement these many years. Your thoughtfulness and kind comments have actually helped me immensely get through some rough times. I had a stroke last year, but am doing very well. I still have a strong practice, around 90% of before my stroke. I am a glass half full kind of guy, but this really threw me for a loop. I feel better and better and hope to keep going. Any thoughts you all have on making the blog better are really appreciated. Thank you for being part of my life!!


Link to purchase my book for great tips on healing:

https://www.amazon.com/Secrets-Keep-Moving-Guide-Podiatrist/dp/1483586553

Friday, April 28, 2017

Never Give Up!!

Hey Readers, I do not always do everything right, or get my patients well. I am willing and able to make referrals for a good thought process, especially if I have not seen something before, or someone has more experience that I know about, or my patient is not getting well. This was a kind letter from a dad that I had treated, and who talked his daughter into seeing me. She has a difficult problem, but some initial simple but common sense treatment helped her. And she is still doing much better months afterwards. So Keep Trying to get well! Docs and PTs, etc, all use general rules that may or may not apply to you. We all get tunnel vision. I am an old podiatrist with 36 years of experience and definitely have fixed ideas. But, I can still learn from patients, and articles, and I generally have good common sense. I remember one year or so ago I saw this patient with severe nerve pain on the bottom of his foot. He had hundreds of thousands of dollars of nerve testing, biopsies, and consults from very smart people. But he still could not walk, even with boots, crutches, special shoes. I put alittle lipstick, my favorite shade of red, to mark the sore spot on the bottom of his foot. I then had the mark transfer to his shoe insert by stepping on it. I then fashioned a $5 off weighting pad to float the sore area. He walked down the hall with no pain for the first time in 2 years!!

Dear Dr. Blake,

     I can not thank you enough for your wonderful, thoughtful care of my daughter, Melissa. She was sure that things would go as they did with roughly 5 prior podiatrists..... no listening, let alone solution, to the pain she experiences other then surgery, orthotics, etc. But you evidence not only compassion and listening but have the gift and mastery to offer simple solutions that have profound consequences. Hours after meeting I received a text from Melissa stating that the simple intervention of some padding under her toe was already relieving pain, enabling her to walk better and use her foot. She actually texted "I'm crying because I'm so happy".... she had given up on there being any help and that she just had to resign herself to a life of pain!! She found that massage work was not either as physically exhausting or pain inducing as it had been (doing it on one foot!). It would not be possible to overestimate how profound this is and the difference it will make in her life. I suspect that the connection to John King might also prove to make a big difference. I can't begin to thank you and express my appreciation.... you are the consummate doctor and healer I experienced... and we are very fortunate to have crossed your path. best,

Articles on Positive Effects of Bicycling and Parkinsons Disease

Some of us are unfortunate to get a neurological disease like Parkinson's. More and more research is pointing to exercises to help with muscle loss, or help activating the correct muscles when you are active. Here is a few of these articles that give us hope.


http://www.foxnews.com/health/2012/04/24/bike-riding-helps-parkinsons-patients-ease-their-symptoms.html


Saturday, April 22, 2017

Strengthening the Hip External Rotators: The ClamShell with Resistance

As a patient walks or runs or bikes or skis (or any straight line repetitive motion activity), following the heel contact, the knee should internally rotate slightly, and then the strong external rotators begin to correct and pull the knee strait. If the external hip rotators are too weak, this does not happen. As the body moves over the knee as you move forward, the knee is out of normal alignment and pain ensues. Here is another of the common exercises used to strengthen this important muscle. 


Here the runner is maintaining good knee position





Here the runner's left knee is too internally rotated


https://youtu.be/CiqvDV8pzRk

Thursday, April 20, 2017

Discussion on Avascular Necrosis of the Sesamoids: Email Advice

Hi Dr. Blake,

I hope all is well ! I read over your blog and focused on the AVN posts, which were helpful.

About a year ago, I started noticing a dull pain in the ball of my left foot, but nothing unbearable. This must have been from walking around in a bad pair of shoes for a week. The dull pain did not at any point between April 2016-December 2016 get any worse.

 I did however decide to go see a podiatrist in December to see what was going on. He put me on two different anti-inflammatories separate times and took x-rays (normal results). In January, after not having felt an improvement, he ordered an MRI. This is when we discovered that I have AVN of the fibular sesamoid. He put me in a post-op shoe for a few weeks, which did not help at all. In fact, it made the pain worse. I decided to get another opinion so I went to see another podiatrist who gave me a cam walker to wear for 6 weeks. She also suggested a bone stim. I wore the boot every day, but felt pain when I was walking in it.
Dr Blake's comment: Both the shoe and  walker typically stop you from bending the big toe joint but put extra pressure on the toe. So you need some form of dancer's padding to float the sesamoids even in these contraptions. Definitely if someone mentions AVN, because of the high risk of surgery if the bone stim not work, you have to use the bone stim for 9 months. 

 After 5 weeks, I realized that it was also aggravating the problem and starting hurting other parts of my foot (assuming this is because it forces you to walk in an unnatural way). I switched to sneakers with Hapad dancer’s pads and have been wearing them for the last two weeks. I found a third podiatrist who recommended orthotics. I just received my custom orthotics today and after putting them in, I feel a bit of pain when I walk in them (the same amount as when I wear the dancer’s pads). Not sure what to think of this...I also ordered an exogen bone stim, which will arrive tomorrow. Following the doctor’s suggestions, I will be using the stimulator once a day for 20 minutes for 3-5 months. 
Dr Blake's comment: This is a hard call. You have pain from 3 sources: mechanical (being off weighted by the hapad and/or orthotic, inflammatory (do the twice daily 10 minute ice pack, and once daily contrast bathes), and neurological hyper-sensitivity (try Neuro-Eze, pain free massage). Everything needs to be perfected. Look at each component since a littel change in anything can potentially make a big difference. Can you tolerate a bit more arch? How about a little more dancer's padding. If you are not immobilizing, perhaps a hike and bike shoes for several hours per day to rest the area better. Sometimes just go anti-inflammatory program, or consistently wearing spica taping. 

I am very worried that the pain is only going to get worse with the orthotics. If I feel pain when I walk in the orthotics, does this mean that it will not subside? My last hope is the exogen. I really am trying to avoid surgery at all cost because I have heard awful stories. Unless the pain gets unbearable, I do not even want to consider it. 
Dr Blake's comment: The real reason not to do sesamoid surgery initially is that in the long run it can effect the joint, and the lower leg biomechanics. We try to leave in what was originally there. But, it is a very successful surgery, and not too difficult to heal from. So, when a few of my patients need it from time to time, I do feel I let them down alittle, but I am happy they can gain relief. Whatever they have learned before surgery, in trying to prevent surgery, they can use post operatively to protect the joint. You would need to find a surgeon skilled at this surgery with good results, expectation to get back to full pre-injury activity, with a little sesamoid protection of the other one. 

Do you have any recommendations as to what I can do? Nothing seems to be working and it’s starting to put me down. I used to love running, but I haven’t been on a run in 2 months because I am worried I will worsen the situation.  Even before I started wearing all these shoe-alternatives, I would go on runs a few times a week and the pain was stable. I am so confused!!! I feel as though I should never have gone to see a podiatrist and ignored the problem because now the pain is worse. Are there any exercises I can do that will help?
Dr Blake's comment: You have to give this time. One year from now until you are feeling very fit is not uncommon. Avoiding the bend of the joint for the next 6 months is a start with the hike and bike shoes, spica taping, carbon graphite inserts, or just stiff shoes and orthotics. Just try to create a consistent 0-2 pain level in what you do. Bike, swim, and elliptical without lifting your heels are common exercises. Keep your foot strong with metatarsal doming, single leg balancing, inversion and eversion resistance bands, and FHL strengthening with theraband as long you only work the plantar flexion range. A physical therapist should be able to give you a good program, but protect the sesamoid also. Definitely this should include 9 months of the bone stimulation twice daily, and icing twice per day, and contrasts at least 5 evening a week for a deep flush of the stagnant blood flow trapped in the sesamoid. 

I live in NYC and am still trying to find the right podiatrist. Do you have anyone in mind?
Dr Blake's comment: Contact any of these 3 pods to get a name of someone good near you: David Davidson, Robert Connenello, and Karen Langone. 

I would appreciate any suggestions you can give me because I have been feeling hopeless.

Thank you for taking the time to read this.

Best,



Below is the report for my MRI that I got done in January:

Study Result

Narrative

History: 23-year-old female with left forefoot pain for 4 months. Evaluate for sesamoid injury.

MRI of the left foot

Technique: Routine multiplanar imaging of the left forefoot was performed on a 1.5T MR scanner according to standard protocol.

Comparison: None available.

Findings:

A skin marker has been placed along the plantar-medial aspect of the forefoot at the level of the tibial hallux sesamoid.

There is a homogeneous low signal of the fibular hallux sesamoid on T1-weighted and fluid-sensitive sequences, likely reflecting sclerosis, which can be seen in the setting of avascular necrosis. The tibial hallux sesamoid appears within normal limits.

There is no evidence of acute fracture. The joint spaces and alignment are maintained. The articular surfaces are intact. There is no significant joint effusion.

The visualized extensor/flexor tendons and ligaments are intact.

There is no Morton's neuroma. There is mild first webspace intermetatarsal bursitis.

There is no abnormal signal in the musculature to suggest atrophy or denervation.

The subcutaneous tissues are unremarkable.

Impression:

Findings compatible with avascular necrosis of the fibular hallux sesamoid.

Strengthening the Weak External Hip Rotators

I am very happy I found this video. It is beginning drills for activation of our important external hip rotators. As you strengthen a muscle or muscle group, isometric and active range of motion are important types of strengthening. Excessive internal knee rotation due to weak external hip rotators is so commonly seen, and so commonly a cause or factor in knee, hip and foot conditions. These 3 wonderful exercises are simple, but effective at getting them to work. You can add therabands for progressive resistance strengthening as the patient getting stronger. 


https://youtu.be/fMf4zuZ585I


One of my early videos on evaluating, and testing, for weak external hip rotators. These are huge muscles that can be very weak in even experienced marathoners. Why? Not sure in many cases, but shows how important these activation drills are. 


Saturday, April 15, 2017

Avascular Necrosis: Article supporting Bone Stim

Some of my patients get avascular necrosis (dead bone) after a sesamoid fracture. I have seen patients heal just fine with prolonged protection with orthotics and dancer's pads, improved bone circulation with contrast bathing daily, creating the 0-2 pain free environment for healing, and the Exogen bone stimulation. Attention should also be made to the overall bone health with healthy diets and Vitamin D deficiencies. Occasionally, it is apparent that a Bone Density screen is needed. Poor bone health overall will definitely slow us down. This review article on avascular necrosis, like all articles on this subject, are all weighted toward surgery, but does have many good points on conservative treatment and appropriate imaging. For the sesamoids in particular, get a CT scan if AVN is noted. The chance of healing is low if the bone has fragmented, which only the CT scan really shows well. 


https://curesearch.org/Avascular-Necrosis

Sesamoid Patient and Performer!!


People of all walks of life get sesamoid issues. This patient is many months from wearing her removable boot, but still has some symptoms. She also is the lead singer in a popular band, so this shoe should work. It is more of a flatform than traditional heel and she combines it with a 1/4 inch felt dancer's pad. This is why I can see 100 patients with the same injury and never be bored. The sesamoid are associated with interesting people!!!


Hi Dr. Blake and hope this email finds you doing well!

Thought you might get a kick out of seeing my latest "sesamoid friendly high heel shoe" for my singing on stage with my band:
*Note:  Only to be worn with 1/4" FELT Sesamoid Pad!    ;-)
    Is it helpful to use Exogen for as long as possible?  I recall reading 9-months treatment but am wondering if longer is helpful??    Thanks again!  


Friday, April 7, 2017

Setting Benchmarks for Recovery: An Important Skill


When patients come in for treatment, they can have a list of what they can not do. I try to get them to focus on what they can do comfortably right now in the 0-2 range. It is important for me to know and it is the first part of our important benchmarks. Therefore, it is important to know that a runner can run 5 minutes every other day, a basketball player can shoot 100 free throws a day, and a ballet dancer can work pain-free at the barre.

And also cross training should be part of this benchmark establishing. If they are a runner, can a bike somewhat and swim and even do elliptical to help with their overall conditioning. Staying in shape biking has proved invaluable for so many sports while we cross train.

And then he comes to the exercises, or the many treatment modalities. What can they do as part of the rehabilitation this month that can be helpful to know. Maybe they can balance on 1 foot for 1 minute. Maybe they can do 2 sets of Level One theraband or resistant cords for their tendinitis, but only 5 reps each. May be they can only go to 10° flexed when trying to fully extend their knee. The amount of total resistance, range of motion limitation, time of an exercise, and sets and reps that can be done can all begin to set our important benchmarks.

The patient comes in at the beginning of April, like today, you can begin to find out what they can and can't do at present. As you set your benchmarks, you can help them measure progress in the future. Some of my programs will take a good year like an Achilles rupture. You can set benchmarks much as attaining goals. It is definitely rewarding as you pass each benchmark.

One example I will use, is a common situation of an athlete coming in with crutches and a removable boot. As a get better, the benchmarks to be used will be first getting rid of the crutches, then weaning off the boot, then wearing normal shoes for 2 weeks, then starting to do sport specific drills (basketball player shooting free throws), then beginning a walk run program, then beginning sprinting or cutting, etc. etc.

I've attach one of my recent videos on posterior tibial strengthening. I was very precise in having the patient progressed through a comprehensive rehabilitation program. I set benchmarks by outlining the different exercises to be progressed through. Please watch the video to get the idea. I hope this is helpful for you. Even if another body part is injured, you should be able to get the right idea of bench marks and goal setting. Rich





Thursday, April 6, 2017

Big Toe Joint Injury: Possibly Turf Toe

Hi Dr. Blake,

I came across your blog on the Internet and it is one of the most valuable resources I have ever come across in terms of foot health. I understand you are super busy but I would be extremely grateful for any advice you could give me.
Dr Blake's comment: Thank you so kindly. I am trying, I love teaching and I love podiatry. So thank you!!

Approximately six months ago, I suffered an avulsion fracture on the metatarsal joint of my big toe. I wore a boot for six weeks, and pretty much was pain-free once I took it off. I did have a bone spur/swelling to the side the joint, and my range of motion was much more limited with my big toe, but I was nearly pain-free and able to walk.
Dr Blake's comment: If you injure the joint enough to get an avulsion fracture, then you had to technically develop a version of Turf Toe. or plantar plate tear. You will have to tell us later in the comment to this post how the original injury occurred. The ligament attaches into the bones, and when the ligament is pulled too hard, either the ligament tears or the bone avulses. Either way you are left with some instability in the joint. 

Unfortunately, around New Year's day I made a very dumb decision. I performed a deep lunge and pushed off this same big toe when I was in deep flexion.

I immediately felt the pain come back, but I was still able to walk normally without any sort of limp. Unfortunately, I stand and walk on my feet all day for my job, and As the month went on The pain either intensified or stayed the same, but did not get better. 
Dr Blake's comment: So you need MRI or at least comparsion AP feet x-rays. The x-rays are taken standing and you compare the sesamoid position right to left foot. Then, with the toe bent upwards (still standing) 30 degrees another set of xrays see if the sesamoids are still equal in there position from the joint. You are trying to get an idea if the joint is asymmetrical to the other joint in how it functions. 

By February, I decided to take off time from work so I could focus on resting and getting off of my feet. I also saw a podiatrist who thought I might've had a sesamoid injury. I got an MRI and bone scan done, but there was no signs of a fracture at the sesamoid and my ligaments were intact. This was on or around February 1, 2017. I attached the MRI report, were you able to read it? I did say I had a mild nonspecific edema and other things as well.
Dr Blake's comment: The nonspecific edema in the third met is probably a stress reaction from limping. As long as it does not hurt there, no big deal. The ligament structure of the first metatarsal phalangeal joint, including the intra-sesamoid ligament, was ignored in the report. Ask them to look at this further. I am also happy to take a look. Send the disc to Dr Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109. 

Now being that it is April 1, the last two months I have spent resting and healing the best I can. I am walking in normal shoes with inserts + dancer pads in them, but I still get occasional twinges of pain every so often.
Dr Blake's comment: I would definitely start taping the joint with Spica taping and see if it influences the pain. Also get flat Otto Bock carbon graphite plate to wear under the shoe insert and see if that helps. 

https://youtu.be/l_4HESXCG40

I just got back from the podiatrist today, and he noted that he thought it was a complicated injury. Between my avulsion fracture or of the metatarsal joint, re-injuring it when I performed a deep lunge, and standing on my feet nine hours a day at my job, I developed a chronic condition. He noted that there was probably a lot of information in there. And also that when I did my deep lunge, I probably aggravated it and resulted this with some turf toe. So: My ligaments and tendons were probably partially torn, completely torn, or definitely at least injured. He said this could take 6 to 12 months to heal, which I am accepting. At this point I just want the best situation possible and I will do whatever I need to.
Dr Blake's comment: Sound smart (because he agrees with me!!)

My main question is in regards to barefoot walking. The podiatrist says I should continue to hold off on barefoot walking as long as possible. I agree with him to an extent, however sometimes it just feels really good to barefoot walk. Honestly being barefoot is one of my favorite things in the world, probably one of the things I miss most since my injury.
Dr Blake's comment: Barefoot is fine, as long as you don't jerk the toe and have to start over. You have to create the 0-2 pain level consistency of a healing environment. Try spica taping during this time. 

I've noticed that when I do barefoot walk, my gait has definitely changed a little, I no longer push off of the big toe on my left foot anymore(because if I did, there would be pain and so my body automatically adjusted how I walk).
Dr Blake's comment: In my mind, that answers it. You have to not limp, or we will be talking of a more serious injury in the hip or knee or low back in several months. Test out barefoot walking monthly, and as the symptoms calm down, you may be able to walk barefoot more and more. 

He did say I could start doing strengthening exercises and also that I could start swimming again, which I am really excited to get back to some activity. However, I still really miss being able to run, jump and dance. And I am fearful that I will never be able to hike an inclined hill again. Hopefully six months or a year or two years or even five years from now I will have improved enough though, to where I can walk on at least gentle mountains again, anyway.
Dr Blake's comment: Really, if you developed Turf Toe, and you go on for awhile without improvement, then they need to find the ligament to fix and put some stitches in it. This is normally not a big surgery, and it has good results, but it can not be just an exploratory operation. The surgery starts a 1 year process towards complete healing and complete function. We expect complete function with some joint stiffness, but not pain. 

Anyway, what is your opinion on barefoot walking? How do I draw the line between "using my feet muscles/toes/connective tissues enough that they retain their function and gain strength and mobility", versus "using them too much that I slow down my healing or possibly re-injure them, because further inflammation/damage?"
Dr Blake's comment: No limping, and no pain over 2. 

He seemed really adamant that I should avoid barefoot walking as much as possible. Do you tend to agree with this?
Dr Blake's comment: See above. Plenty of my patients walk barefoot at least around the house with spica taping and 1/8th inch adhesive padding from www.mooremedical.com stuck to their foot and are fine with the above limitations. 

I noticed that you talk about having a 0 to 2 pain level, but I am able to walk pretty much pain-free barefoot as long as I use short strides and I'm careful not to push off from my injured big toe.
Dr Blake's comment: That sounds fine. The injury is one that you have to avoid bending the joint for a good period of time, but this has not even been documented, so I hope it is true. It is not the weight bearing, it is the bending. 

Any thoughts? Maybe I could still do a little bit of barefoot walking every day, and gradually build up overtime? Or do you tend to agree with him, that I should avoid it at all costs?

Just wanted to grab another opinion if possible, because I know there is the debate between wearing shoes/protection(which protects you more, but in theory could actually atrophy your feet/toe muscles more?) vs walking barefoot(which engages your feet/toe muscles and could potentially strengthen them and help them regain function, but also leaves them more vulnerable to further injury)
Dr Blake's comment: I am definitely in the middle, some of both because sometimes you need the protection (running a race hard downhills on irregular rocky roads). When you can get away safely barefoot, go for it. 

Additionally – – he said that I could see a chiropractor if I wanted to. I was planning on seeing one maybe three or four times total, for them to do a joint mobilization on my big toe and see if that might help me regain some motion. Since I cannot extend it downwards very far.
Dr Blake's comment: I love chiros, but you do not have an actual diagnosis, and if it is Turf Toe, you are trying to let it get stiff and scarred right now. It is all about timing, and I am not sure it is the stiffness that is giving you pain. 

To clarify – – I am not doing extreme amounts of barefoot walking. Just when I am walking around the house and relaxing. I will obviously wear shoes anytime that I go outside or go on a long walk. However, if you also have a strong opinion that barefoot walking should be sharply avoided, then perhaps I should be putting on my shoes even when I walk 15 steps over to go to the bathroom. I am willing to do whatever it takes to give myself the best chance of regaining activity.

Thank you again for any help that you can provide me with. This has been a really tough injury to deal with, but I am really thankful for the help I have an able to receive, and it's giving me a lot of time to focus on myself.

Thanks!!!

PS - I attached a picture of my feet, you can see that on my left foot there is a much bigger band/bone spur near my metatarsal joint where the injury has occurred. I also attached a picture of the MRI report.



Sorry these are on their sides!!







Wednesday, April 5, 2017

Ankle Pain and Instability: Patient Email Discussion


This is from a patient I saw several weeks ago. Since the email was so full of great information, I thought I would answer the best in the venue where I could give it the time it desires. She has had chronic ankle sprains with the last one in 2015 causing chronic soreness. She wants to be more active. Has had PRP injections to help tighten the ligaments, which still had some laxity. Her ankle was loose in the normal tests, including what I call translation of the subtalar joint. If I grabbed the heel, it would shift with pressure more than normal side to side. This can easily pinch the capsule (joint lining) when you move. I was not sure if the PRP addressed the ankle joint alone, or the subtalar joint also. I have seen cases of patients having surgery to tighten the ankle ligaments (most obvious) only to have the surgery fail since the problem was in the joint below (the subtalar joint). She walked with lateral instability (outward roll), and the arch of her orthotics (not really designed for supinators) made her worse. She looked slightly better without the orthotics. Her MRI was negative for surprises (no bony problems). I started her on taping to stop supination, contrast bathing for less swelling (this makes the joint more stable since fluid floats the joint surfaces on themselves making them more wobbly), an occasional use of an ankle brace when needed for stress situations (I would wear for basketball), and strengthening (you can always get your ankle 3 times stronger). I told her that each month for 24 months she should increase 3-4 ankle exercises by the amount of reps, sets, time, or level of difficulty guaranteeing that she is doing more and more. At followup, making some new orthotics may be done to control supination. I have placed a video after the email. 



Hi Dr. Blake,

Hope you’re doing well! I wanted to email my follow-up, and I also have some issues about which I would appreciate some advice. 

Insoles
I’ve stopped using my old orthotics in my running shoes as you suggested. It totally made sense to me that they were causing stress on my ankle. However, I didn’t realize how present my sesamoid problem still is. The sesamoid area on my right foot has started to get a little soar now that I am not wearing insoles - not nearly as bad as it has been in the past, but I can tell if I do not address it the pain in my sesamoid will return in full. In trying to find a solution I went to On the Run, and they suggested a pair of Sauconys (for the wide toe box) and an insole especially for sensitive sesamoids (made by On the Run). After walking in the shoes for 20 min the insoles started to bother other parts of my foot (there was extra padding on the outside of the ball of my foot that squeezed that part of my foot uncomfortably, and the insoles dropped off a little under the toes to take pressure off, but it wasn’t comfortable). I think I need a decent amount of arch support to take the pressure off of my sesamoid, but not as much as my old orthotics provided. Do you think that is correct? Do you suggest I go back to On the Run to see if they have a different insole recommendation? Or do you have a specific recommendation?
Dr Blake's comment: Since the old orthotics protected your sesamoid, I would go back to them in the new shoe. I will adjust them to stop some of the outward roll, and we can talk about another orthotic that both stabilizes the ankle, and protects the sesamoid. If you see my sesamoid videos, at least getting a dancer's pad on to the store's inserts. 



Shoes
My ankle was pretty irritated the first couple of days after I saw you when I stopped wearing my orthotics in my running shoes and changed my day-to-day shoes (since the street shoes I brought to our appointment were making my ankle roll out). I’ve been trying to find other shoes that work for both my ankle and my sesamoid and have had a bit of a hard time. Do you have any suggestions of brands? Is there any style of shoe you would particularly recommend (for example low top vs high top)?
Dr Blake's comment: The Altra is a soft cushion front with zero heel drop so not adding more pressure on the fore foot while keeping the shoe close to the ground. The Saucony Triumph was always a good shoe for supinators. I love that high tops boots are still in style. But, it is what we are putting in them that is at least half the battle. 

Tape
The tape has been noticeably helpful already. Even when my ankle has been a little soar, the tape alleviates at least some of the pain. I have been using it daily. 
Dr Blake's comment: Great!!! I use the opposite taping that is in the video below for pronators. It is a J strap for supinators. 




Contrast Baths
I have been doing contrast baths about every-other day. It is a little soothing. I don’t notice the same kind of relief as the tape provides.
Dr Blake's comment: That is okay. Still important to do. You have a mechanical problem so the tape, orthotics, shoes, brace, strengthening are the most important. Keep doing them for now. 

Ice
I haven’t been consistent with the 5-minute icing after exercise (often I forget). When I’ve done it I notice some immediate relief, but it doesn’t seem to last long after I remove the ice.
Dr Blake's comment: Okay, you can stop that for now. 

Physical Therapy
I am going to cut down to every other week with the physical therapist and focus on doing my exercises at home. Over the weekend I pushed my ankle a little too hard doing my exercises (jumping onto a pillow), so I’ve been laying off a little the past few days due to pain, but will go back to my regular routine once I feel up to it (today my ankle is feeling better than the last couple of days, so I think I can pick my regular program back up tomorrow). Also, the therapist said she faxed over a note to your office before our appointment on 3/24 - did you receive it? 
Dr Blake's comment: I will look for it. 

Thank you! I really appreciate having you on my team.
Dr Blake's comment: I am happy to be on your team!!


Best,





Monday, April 3, 2017

Achilles Tendon Pain: Where Do I Start?

Achilles Tendon Palpation

So, you begin to hurt in the achilles tendon. A Golden Rule of Foot: If you look at the achilles tendon the wrong way, it will hurt for 9 months. Is it all gloom and doom? Only a few unlucky ones. Are you about to tear it? Usually not, in fact most of my patients that tore their achilles did not have any symptoms beforehand. They are unlucky, probably a small defect in the tendon. Only rarely on both sides. But, this fear we have around the health of our achilles, typically when it begins to get sore, is not justified. However, we do not know if we are beginning to feel just the tip of the iceberg (with a bigger problem brewing). 
     When you first feel your achilles aching, try to play Sherlock Holmes and discover why. I like to always use a rule of three. Therefore, there is probably 3 causes of this injury, and each may have played a big or some role in the injury. Treatment of the possible causes can help in the prevention of its returning. The most common causes of achilles tendon pain are tightness, combined with some common overuse pattern (too much, too fast, too different), combined with some technical issue (switching from normal heeled shoes to zero drop, experimenting with lower heel drops in exercises, going to a shoe far too unstable). I have seen hundreds of combinations.
     The athlete needs to immediately cut their distance in half, as long as they have caught the problem early. If not, and they limp from normal activity, they may need a 2 week or more period in a removable boot. After finding the amount of exercise they can do without flaring up the pain, they need to stretch the achilles (even the plantar fascia), 3-5 times a day. I have included my video on achilles stretches and link for the general principles of stretching. Occasionally, I will find the patient on the opposite end of the spectrum that is overly loose, and stretching is a bad thing. Sorry if that is you. Start thinking about what either over-stretches the tendon, or torques the tendon with pronation or supination (rolling out) forces. Immediately try to remedy that aspect. Could be that you were doing too many negative heel stretches where your heel fell off the edge of a stair? Could be you changed into some lighter, perhaps less stable shoes? 



     So, you have created a pain free environment for healing by controlling the activity, begun to stretch 3-5 times a day, adjusted other possible causes (switched back to more normal shoes), and now you must ice. The achilles is the most powerful tendon in the body. It can lift 8-10 times your body weight under distress. But, it has relatively poor blood supply, and that is a bell shaped curve. The curve means you could be one of the lucky ones to get a lot of blood supply or not. There are so many beliefs in how to get blood supply that it is not the place for that discussion, but it is the place to tell you to control that initial soft tissue swelling from day one or day five, but quickly. Ice pack over the tendon is relatively easy and 10 minutes you are done. But do it 3 times a day. 
     So, smartly use activity modification, stretching, biomechanical awareness, and icing to help change that aching achilles into an achilles you want to bring home to mother.