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Tuesday, November 28, 2017

Podiatry Question #2

I hope you enjoyed the first question several days ago. These are meant to educate, but also to test your knowledge. Sometimes there is more than one way to answer, but I need to give you my personal best answer from a podiatrist viewpoint. Hope you all survived Thanksgiving. It is the start of an energetic and blessed, but exhausting, month towards Christmas. I love the Holidays. 

Podiatry Question #2: When we help patients through a rehab process, what pain level do we try to keep them at? 

When rehabbing athletes and non-athletes, working them through the various landmarks of recovery from injury, you must keep them between the 0-2 pain levels which are considered a healing environment. Initially, that may mean needing crutches and a boot, then various forms of taping or braces or orthotics, then some limits on what shoes they can wear, etc. But, in the pursuit of keeping the pain within 0-2, the patient learns what is needed to help them fully recover. I see so many patients spend too much time waiting for a test to be done, with no attention being made to the amount of pain that they have. Every day with high pain levels causes more muscle compensations and weakness to develop, more possible nerve hypersensitivity, and more gait changes to avoid pain. It may be impractical for some reason to reduce the pain this much, but when you do not, you are always delaying the process of complete recovery. I just had a patient that needs her dislocated 2nd toe fixed surgically. This will be the only way to completely eliminate her pain, but I am trying various shoes, taping, Budin splints, icing, and activity modification while the long process of finding a surgeon and the right timing in her life comes along. We must have that as our mantra: Keep the pain down between 0-2. Compromise is needed at times, but we should look for ways to lessen the compromises when we can. 

Sunday, November 26, 2017

Podiatry Question #1

I created this blog to teach. I wanted to teach my patients first of all to be smarter in the rehab course, and perhaps to prevent injuries in the future. But, I also created this blog for podiatrists, podiatry students, and all in health care with an interest in feet and biomechanics and overall health. I am in my 6th year of teaching the podiatry students at Samuel Merritt University’s California School of Podiatric Medicine. They are wonderful, and I am blessed. I am starting this series of questions with the hope they will all know the answers by the time they graduate, or even as they begin their practices. Many of these questions will be for lay folks, sports store personnel, coaches, or just students of good health. I will ask the question, followed by a photo to gap the answer by some space, and then the answer. Shall we begin?

#1   When treating tendinitis in any form, what mnemonic is commonly used to think through the possible treatments?

Answer: The mnemonic B.R.I.S.S.  Biomechanics  Rest.  Ice.  Stretching.  Strengthening. These are the 5 key components to treating all types of tendinitis. Of course, there are so many other treatments of tendinitis out there that have helped, but BRISS gets the process started. The Biomechanics are concerned with the forces that caused the injury, and the forces that can be changed to help the injury. Rest is a four lettered word for everyone, especially top level athletes in competition, so we tend to shift the attention to Activity Modification. We need to rest the area, but we need to cross train. Ice is universal for Anti-inflammatory measures, but we are getting better at knowing when to ice, and when to heat, when to use contrast bathing. This also applies to anything that decreases the inflammation including oral medicines, injectables, topical, prescription or OTC, physical therapy, or acupuncture. Stretching is key to relaxing the tissue, and many tendinitis cases do not get better until you can find the way to stretch that makes the area feel better. And finally, Strengthening, is so crucial. We must assume that any tendinitis is caused by weakness of the tissue, or surrounding tissue. Start strengthening to some degree the day you hurt yourself. 

Tuesday, November 21, 2017

Post Bunion Surgery Suggestions from a Patient

Dr Blake,

Hi, things are really progressing for my toe! Pain is about 0.5 and it’s becoming more and more flexible. I’m in normal shoes with dancer pads—seems to be a good combo at this stage. In a few weeks, I’ll try some orthotics again. 

Anyway, if I had feedback for other patients it would be: 
  • Go to Defcon 4 of a healing program for yourself—it won’t get better unless you’re really doing the work. If you do the work, though, it will get better. 
  • Contrast baths are much more effective than just icing. Do it front of the TV at night. Easy.
  • Physical therapy to strengthen muscles and loosen up the joint. This really works.
  • Self-mobilization 3x per day works wonders. 
  • Elevate whenever possible.
  • Protect your toe from bumping into things with a toe guard or shoe.
  • Wear a post-op shoe when you sleep to protect it from injury at night. 
  • Take your time and remember that you’re injured—whenever I started feeling better I went too far with my movements and set myself back.
  • No pain meds—for me that would just mask injury and not give me feedback about progress and possibly further injure the toe without me knowing.
  • Lose weight to put less weight on your foot.

Wednesday, November 8, 2017

Ankle Pain with Email Advice

Hello again, dr Blake

I hope you are well. I am sorry to bother you once again. I am sure you are a very busy man. Since last I contacted you, I can report that I have gotten hold of the exogen stimulator, and taking Vitamin D and Calcium supplements (right foot sesamoid problems).

However, I am not writing about my right foot metatarsal problem now. Unfortunately, I have a more acute problem with my left foot. 

Originally, after my running injury 2 years + ago, I ended up with very bad pain in both feet. The pain got so bad that I ended up using a wheelchair for 4 months. About a year after I was diagnosed with sesamoiditis in the left foot after MRI (oedema in both sesamoids). I suspected that I actually had had a sesamoid stress fracture in the left foot too and that it was healing ok. But I also had strange aching pain in all of the left foot and continued difficulty wearing shoes and tight socks. This pain got better very slowly but seemed to get worse every time my right foot metatarsal pain flared up, and I focused on offloading that with more "flat walking". I mentioned it to several doctors, but it seemed to be written off as pain connected to my forefoot-issues. But all the time I had a feeling that while my pain level matched the diagnosis of my right foot, it was not so with the left one.

About a month ago, my left hind foot had gotten quite painful again, and then I felt a sudden stinging pain at the back of my ankle/over my heel. It then felt like I shouldn't place weight on my heel afterwards. In the following week, the pain got worse. After negative x-rays and being written off by my doctors once again, I decided to pay for an MRI myself. This was the description I got:

"Mild tenosynovitis in peroneus tendon sheaths with possible small longitudinal spilt of peroneus brevis tendon distally to the lateral malleolus. The tibial posterior tendon is a little thickened distally against the attachment to os peroneum. Very mild tenosynovitis in the flexor tendon sheath." I have excluded the rest of the description, which was of normal findings.

I have read a lot about these tendons afterwards, and today I was at a physiotherapist with diagnostic ultrasound expertise. He confirmed that it looks like a split right below the malleolus, although a very short one. I have a history of 2 ankle fractures and following sprains (with a major knee injury after 1 sprain) in the left foot since my childhood, so I am thinking there might be a connection there. 

My question to you now would be, what now? I feel that the pain gets very bad with any weight-bearing at the moment. I tried offloading with crutches for a week, but my right foot cannot handle the additional weight. I also have gotten some new pain in the ankle area of the right foot. It doesn´t feel nearly as serious as the in the left, but I suspect some inflammational tendon issues there too. I have used a wheelchair at home for 10 days now, and I feel a lot of pain reduction when offloading the feet.

I read that some use cortisone to get rid of the inflammation, but others say it can damage the tendon more. I see some statistics that look very bad for conservative treatment of tendon split, and that many end up with surgery. Others claim that conservative treatment could work well, after all. Do you have a position on this? Or any advice on how long to offload the foot, before attempting to walk again? 
Dr Blake's comment: I need you to send me the MRI for review, at least a copy. Your symptoms do not match the findings of the MRI. If the physio tests the tendons, do they hurt? You can try resting the ankle in an AFO custom made at a local brace shop. They are prescription items. I see these split tears in some, with absolutely no pain in the area, and no pain on the contraction of the tendon against some resistance when you are testing the strength. I think for some people they are normal variations of that tendon--to not present like a hold piece but to present as multiple strands. Yes, I do not like cortisone for tendon inflammation as there can be some weakening. The 9 classes of NSAIDs could be tried first to find one that works well. Ibuprofen in one class, diclofenac in another, Celebrex in another, and so on. It sounds almost nerve tension, so consider neural flossing, Neuro-eze gel massage, and neurological eval by a doc or neuro PT. Hope this helps some. Rich

Hope for a response from you, yet again.

Kind regards,

Friday, November 3, 2017

Calmare for severe nerve pain: More news

A Pilot Trial of Scrambler Therapy for Pain Associated With Pancreas Cancer - Full Text View.

Doctors seek new paths toward pain relief amid an epidemic of addiction and death.

Calmare Therapy
Four months after a botched podiatric surgery, Ridgewood resident Marilyn Green started to experience intense pain in her right foot. She was diagnosed with reflex sympathetic dystrophy (now largely known as complex regional pain syndrome type 1), a neurological disorder in which pain from damage to the soft tissues and/or peripheral nerves can spread to other parts of the body. Leery of narcotics, she self-prescribed a combination of B-complex vitamins and exercise that had proven beneficial to her mother after a case of shingles. The treatment offered some relief, but the gnawing pain persisted and began to spread. Green came across an article describing a rare procedure known as Calmare, designed to treat neuropathy, the nerve damage and concurrent chronic pain that can arise after chemotherapy, a shingles outbreak, or surgery. In cases like Green’s, says Michael Cooney, a chiropractor who is one of the few practitioners in the state to use the therapy, “we think there’s a hypersensitivity that’s developed within the pain center of the brain.” The Calmare device uses electrodes to move what Cooney calls “a no-pain signal” through the area of pain in order to “reboot” the brain, so that it’s no longer aware of the pain.
Cooney treated Green with 10 sessions of Calmare, and she is now pain free. “When I went in there, my pain level was at nine,” she says. “On day five of the treatments, it was down to zero.”
Calmare is effective only on true neuropathies; it appears to offer relief ranging from 6 to 18 months or longer.

Thursday, November 2, 2017

Fat Pad Atrophy: Email discussion

This patient has fat pad atrophy post cortisone shot one heel and sesamoid area other foot. Here is a discussion we recently had regarding a procedure to move the fat pad placement and inject stem cells to encourage fat regrowth. The doctors are up in Pittsburg, Pennsylvania. I have reviewed the MRI for her noting tremendous scarring of the fat pad at the heel called panniculitis. 

Hi Dr Blake,

I wanted to get your opinion on this procedure. I have lost fat on the lateral side of my left heel as well as under my big toe (same foot) due to a cortisone injection for plantar fasciitis and sesamoiditis. Unfortunately, I haven't found any shoes that help or inserts, taping, etc. I've been doing a lot of research and found 2 doctors performing the Foot Fat Grafting. They're married, the wife is a podiatrist and the husband is a plastic surgeon. It seems like they've had good results for far in their pilot and research study.

What are your thoughts, do you think it's worth trying? I'm only 28 years old and the pain is unbearable. I just want my freedom back.

Thank you!

Dr Blake's comment:
      I reviewed and found the articles interesting and hopeful. They would, of course, recommend it if you went there. You would need a doc near you to followup, and hopefully, someone independent to think your pain is from the fat pad atrophy also. But, it sure makes sense. Rich

Thanks, Dr Blake. I've had one doctor say it'd atrophy but then others haven't. It's hard because I hear so many opinions, a lot of "plantar fasciitis" but I have the scarring in my heel fat pad that is shown on the MRI. They will do ultrasound prior to the procedure to confirm the thickness 

Dr Blake's comment: 
     I read their reviews. Also, see if you can talk to one of their patients. 

I spoke to one of the patients yesterday and it sounded promising, she only had it done 3 months this ago so hard to say if the fat stays and if the stem cells from the fat help with new growth of the fat pad

Dr Blake's comment:
     I was thinking the same, but as long as we get good results probably does not matter!

They are doing a volunteer study for the heel which I'm going to apply for so it's free. Worth a shot. I'll keep you posted in case it might help others.