Total Pageviews


Dr Blake's Book


Saturday, March 17, 2018

Hallux Rigidus with Spurs: Role of Spica Taping

Dear Dr. Blake,

I am curious if you can see this Taping treatment as a way to restrict ROM for those with hallux rigidus + bone spurs in activities such as running (and other exercises that cause joint flexion)? I have been using a rigid foot plate for my hallux rigidus that was diagnosed about 6 months ago, but I believe it's throwing off my gait / causing further injury to my arch/heel/ankle. I am curious if you think taping could be an effective replacement treatment protocol for this condition... longterm! :) Thank you for this video, Dr. Blake! There isn't much info out there about using taping for hallux rigidus, so I would appreciate your thoughts!

Dr. Blake's comment: Yes, Spica taping is a very suitable alternative to carbon plates, without the dramatic effect on the whole body. That being said, there are many things you should do, and it is okay to rotate. I think using the flat carbon plates one out of workouts, maybe your easy workouts are great with or without the taping. You should develop with a local orthotic person an arch support that gets the weight centered on your foot with the arch part, and then uses a dancer's pad construction to take pressure off the big toe joint itself. Some shoes it will be good to skip the lace closest to the bone spur, and just design dancer's padding and use hapad longitudinal medial arch pads in shoes that cannot fit orthotics. If you have not tried the Hoka One One line, please do. The built-in rocker lessens the stress through the ball of the foot. Get some 1/4 inch adhesive felt from and apply on top of the foot just off the joint towards the arch. Usually, you use a one-inch square piece. For this problem, you can place another piece over the big toe itself (nothing over the spur) to help limit the bend of the joint.
But, I digress. Back to the taping. Once you are good with KT or RockTape, try to advance to 3M Nexcare Waterproof Tape and then Leukotape with Coverlet. These get stronger and stronger to do the job intended, but they are harder to work with so you better practice first with KT. The leukotape, the stronger tape I know, cannot actually touch the skin, thus you need the coverlet first placed on your skin. With 3M or Leuko start very loose to get used to it and the tension it gives. Good Luck. Rich
PS The key point, tape is good, but use other methods to take the pressure off the joint with it. If you are pronating, you must get a shoe that eliminates that problem, or the tape will not work in the long run.

Ankle Sprain: Email Advice

Hi Dr. Blake,

      I was googling Contrast Bathing for ankle sprains when I came across your website.  Thanks for the info!  I sprained my ankle on Jan 6 this year.  I knew it was really bad when it happened.  I've sprained this ankle now 4 times that I can remember and thought I could rehab with just home therapy after taking 2 days off work. 

     It's been up and down, aggravated by my overstretching and probably doing too much too soon.  Xray 5 weeks post-sprain was negative for anything acute and only showed an old avulsion injury.  Just had an MRI almost 10 weeks post-sprain which showed findings consistent with full-thickness ATFL tear.  I'm wondering if it's possible the complete tear can still heal this long post-injury.
Dr. Blake's comment: I have been around long enough to see the cycle go from surgery on these grade 3 sprains, to just rehabilitation, to some surgery. Truthfully, a lot of the success of rehabilitation has to do the expertise of the healthcare provider, or team, and the desire of the patient. I know too many patients who have had surgery, but probably could have rehabbed successfully, and I have rehabbed patients only having them need surgery down the line. It takes me a year of rehab on these sprains to decide on the few that need surgery, but of course, that is my bias from the start. 

  I've been off the foot as much as possible a good week now while waiting for the MRI auth and results during which the most stubborn area of the swelling has improved some.  But now that a peroneal tendon tear and OCD have been ruled out, I'm doing some weight-bearing and limited activity again. Any thoughts or advice you have would be greatly appreciated!
Dr. Blake's comment: A bad ankle sprain has on average 3.5 months of swelling which causes instability. You are right to do your contrast bathing daily, and twice on weekends. If you have functional instability, a feeling that you may sprain your ankle, you should wear an ankle brace during these stressful activities. Physical therapy is wonderful to progress you in terms of strengthening, especially the fast twitch muscles and proprioceptive nerve endings, and then return to activity. If you keep the 0-2 pain level healing environment as you decide what you can do now, each month for the next 3 months, you should be able to do more and more. One the best things if it is at all swollen is to wear a compressive wrap or sleeve when you sleep. Definitely start Single Leg Balancing now and progress each month making it harder and harder. If you have more specific questions, I will try to answer. 

Thank you so much,

PS: Here are some other videos that may help.

Friday, March 16, 2018

Short Leg Treatment: Email Advice

Dear Dr. Blake,

     I came across your blog online and am hoping that you will have a moment to read and respond to my question- I would REALLY appreciate it.  I am a 38-year-old woman.  When I was born apparently there was a glitch with the movement of my right leg that the doctor noticed and said might just go away on its own.  My parents never pursued it any further so I have no idea what was noticed when I was born or whether it is at all related to the current issue I'm trying to address.

     For many years I've noticed that my right hip and shoulder sit slightly higher than my left side.  I would typically walk with my right foot toes pointing out about 40 degrees.  My right knee has always turned in toward my left leg when I'm in a standing position.  A couple years ago I started wearing some Powerstep insoles on both sides, which helped turn my right knee out a bit straighter.  Growing up I was told I had slight scoliosis.
Dr. Blake's comment: You are describing a long right leg with more pronation or internal rotation on that side. When you stand is your right knee in and right foot out as mentioned above, or is it only in walking. You can turn your right foot due to the long leg and excessive pronation that collapses the arch and drives the right knee in with it in attempt to shorten that leg. 

     So, I've been to a couple chiropractors for adjustments and they said that my left leg was about 1/2" shorter and that my right hip was tilted forward, which they adjusted.  They didn't seem to really look at my legs or hips much but said that the leg length difference was because I needed regular adjustments. 
Dr. Blake's comment: The chiropractic world is to adjust out these imbalances that can start as leg length differences when you finish growing, and end up with pelvic tilts and scoliotic curves in the spine. Podiatrists, not skilled in these adjustments, tend to want to lift and support the short leg. It is an art though since there are many variables to consider and many ways patients adjust to lift therapy. 

     I felt that perhaps they didn't have much experience addressing these issues.  I think maybe I do have a structural leg length difference that has contributed to these other issues.  I tried a small heel lift on the left side but that seemed to make me feel more imbalanced on the right side.  Now I'm wondering if I should try a full length (as opposed to just heel lift) maybe 1/8" lift on the left side (in addition to the Powerstep insoles on both sides) and gradually work my way up to 1/2"?  If you think that's a good idea can you recommend a brand of full-length insole and over what period of time could I work up to 1/2"?
Dr. Blake's comment: I prefer full length lifts to balance the foot out throughout the gait from heel contact to push off. You can cut out the toes to give yourself room. You can go with simple Spenco Insoles without any arch, just flat. You can use the left as the first lever, if it feels okay in two weeks, try the right turned upside down as the second layer on the left side. The second layer you may or may not need to cut out the toe area, but keep the lift under the metatarsals or ball of the foot. For the third layer and possibly fourth layer, you will have to get another pair. You should feel better and more stable with lifts. If not, you should consider getting an AP Standing Pelvic Xray in normal stance barefoot to document the true structural leg length. 

Thank you very much!

Dr. Blake’s comment: Yes that sounds right. I tell my patients to get Spenco flat 1/8th inch insoles, you just flip the right one over to make a second left. If you are crowding the toes too much, you can stand on the insert, and mark between each toe. Cut out the area of the insert in the area of the toes. Typically you go 1/8th inch every 2 weeks.

My remaining questions after spending additional time on your blog-

Should I try switching from Powerstep to Sole insoles since those are what you recommend?  I have not tried the Sole brand before.
Dr. Blake's comment: Yes, you should try both to see what is more stable and fits you better. From my standpoint, they are both easy to adjust and customize for the patient. 

Just to make sure- would the full length lifts be placed under the Powerstep/Sole insole in the shoe?
Dr. Blake's comment: Yes, they go under the arch support. Hope this helps Rich

Thanks a million!

Here are some of my videos on short leg syndrome.

Wednesday, March 14, 2018

Scar Tissue Breakdown: Update from Patient

Hi Dr. Blake,

I've been trying to break down the scar tissue in my heel fat pad and so far the best success I've had is actually from an enzyme, Serrapeptase. The large bump I have has shrunk half in size so far. 

Dr. Blake's comment: I have seen the MRI showing this patient's scar tissue in the heel area. This enzyme is taken orally and can thin the blood, so if you take meds already for blood thinning, or that can thin the blood, you may have problems. Best to review with a pharmacist. I found it at Walgreens and they have pharmacists normally at all their stores to ask. 

Walgreen's carries it. Serrapeptase

Saturday, February 24, 2018

Hallux Limitus: Email Advice

Hi Dr. Blake,

I am a 34-year-old runner with Hallux Limitus and am hoping that you could help me. I have seen two podiatrists in my area (Lynchburg, VA) and they both have told me to just stop running. I run 20-25 miles per week (I did do a couple of 50k trail races last year but found that the steep up and down trails in the mountains irritated my toe). I am okay with not running these long races if it means that it will make my condition worse but I would love to be able to continue to run for many years.
Dr. Blake's comment: Hallux Limitus is either functional (which can be totally reversed with some arch support and dancer's padding to off weight), structural (meaning some degenerative process which will get worse and you still try to keep your pain between 0-2 and experiment with off-weighting and arch support), and structural and functional combined. If your big toe joints have some structural damage (typically diagnosed by x-ray or MRI), I would still run as long as you can in that 0-2 pain level. If long races increase pain, then you must avoid, but if 5-10 miles is fine, it is actually better for joints to have a pain-free high-level loading for cartilage nourishment.  

I do not want to ignore this and make it worse but rather run responsibly.
I have been running in Hoka Bondi's but I'm finding with the orthotics inserts a PT suggested I use (she has said I can continue to run), that the toe box is too small. I did try on Brooks Glycerin and Altra Paradigms and both shoes felt great but I'm not sure if they're great for this condition.
Dr. Blake's comment: There are some many factors that jam up the big toe joint, so it is experiment time for you. Definitely, find the wider Hoka One One shoes, they are out there. Hoka should be a great shoe for some of your running. Also, get a medium gel toe separator to see how holding the big toe in the center of its joint makes you feel while running. I love Brooks Addiction or Beast for the varus cant off the big toe, but of course, we do not want you to roll your ankle. Definitely, you want to see if those shoes, along with a 1/8th-inch dancer's pad to keep the weight in the center of your foot at push off. The zero drop shoes are good for metatarsal pain, but not good usually for hallux limitus. They put you back on your heels more, for pain reduction, but in most make it harder to push off. Some of my patients push off hard, and others hardly at all. 

Do you have any suggestions that will keep me running without irritating my toe or cause this condition to progress? Above If I take care of it and am cautious, does this condition always get worse? I would rather be proactive now than later.
Dr. Blake's comment: Have some weight bearing xrays taken of your feet, take photos of each frame, and send. Again, if it is primarily structural, you will have more work to do keeping in the 0-2 pain range. You would want to re-x-ray in 2 years and see what is happening. Arthritis is made worse faster by not using it, then if you can use in a pain-free environment. Look up the nutritional theory of cartilage development. Yes, if you have arthritis, and you push through pain, you will speed up the need to have joint replacement surgery. 

Also, do you know of anyone in the Central Virginia area that is up to date on this condition? 
Dr. Blake's comment: Call Richie and Company, an orthotic lab in Charlottesville, and ask who are the good biomechanics people in your area. They would know. Use my name. The owner is Brett Richey. 

Thanks so much. This whole thing has been frustrating and disheartening, to say the least. Also, I attached a picture of my most recent xray.
Dr. Blake's comment: The x-rays were poor quality and not sure if weight bearing. Have AP, Oblique, Lateral, and Plantar Axial xrays taken of both feet at some time and send me 8 individual photos. Please make sure they are weight bearing. Good Luck, Rich
Thanks again,

Monday, February 5, 2018

Considering Tackle Football for Your Youth: Please Read

This is a foot and ankle blog, but CTE, or Chronic Traumatic Encephalopathy, is bad and preventable. It is important as parents to at least discuss the subject when placing your child in a sport where CTE is a possibility. Is it Time to Ban Youth Football? When the Last Super Bowl be within the next 20 years? As a society, immune to change, unlikely. But, as an individual with a child you love, worth a few minutes of your time to ponder. Hate mail begin!!

Sunday, February 4, 2018

When Is 0-2 Pain to be Ignored?

This patient is recovering from a serious injury, and at some point had to ignore my advice to create that 0-2 Pain Level for healing, and Push Through The Pain. When do we Honor, and when do we push through pain? Email discussion

Dr. Blake

Reading that advice to maintain 0-2 pain level concerns me a bit.  If I hadn’t pushed through the 7-9 pain I’m not sure I ever would have come back from my problems.  I think the first period I had to try to offload it to heal but once that time had passed I kept trying to keep the pain low and that I think attributed to the rest of my body breaking down.  The one thing that changed for me was the area of the pain changed over time. At one point or another, I had serious pain in about every part of my foot as I got my strength back.

Dr. Blake's comment: 

Hey, Yes, you are right. The 0-2 applies to typical orthopedic musculoskeletal pain, not the nerve pain you had. With nerve pain, there is a time to Honor the Pain and a time to push through the pain. You had to learn when to do both. It is very hard to tell someone to push through pain because you are not sure if they are hurting themselves. Physios with nerve training, and docs also, can help people but it takes awhile to get a sense from each person. You have to then test the experiment, push the envelope of pain, and see how you respond. Thank you for this very honest discussion. I truly appreciate this. Rich

And the Patient Responses: 

Sounds like the guy needs to find a different doctor.  It really sounded like he's about to go down the path I did.  I went to 3 different Podiatrist and none of them knew what to do.  They all wanted to try to solve it with cortisone and I really think that is where my tears came from.  They didn't have those in the first MRI.   They would talk about surgery but I knew to go away at that point.   All Orthopedic surgeons I visited including Mayo, UAB, Andrews Sports Medicine and Birmingham Orthopedics said surgery was not a good idea for the situation I had.  The problem was they just didn't have a solution either!  

The more I think about it the more I think that shoes played a large role in my issues.  A Pedorthist told me that the New Balance shoes of all widths are now on the same footbed.  I believe that because I just can't wear them at all anymore.  If I put on shoes that put any pressure on the area I can immediately tell now that I need to stop wearing them.  Before I just thought it was "support".  Now I think it caused pressure on the area and caused at least part of the problem.  When the PT told me to get ASICS and I went with a larger size I could feel immediately there was not any pressure on the area.    I'm now getting into other shoes, boots etc and it takes quite a bit of time to find them wide enough but I know it when I find them. 

Wednesday, January 31, 2018

Insertional Achilles Tendinitis: Email Advice

Dr. Blake,

I have been diagnosed with insertional Achilles calcification in my left ankle. X-rays showed a pretty large buildup, which was actually the cause of a very visible bump on my ankle. I stopped all activity for 30 days and wore an elevated shoe, to avoid the boot. It helped but the pain is definitely less frequent but still there. I can’t get back to all of my regular activities I had enjoyed, like running or just horsing around with my son. Any period of activity of more than a couple minutes results in pain a couple hours later.

My ortho has suggested a boot for 30 days and if that doesn’t work, surgery. I read one of your earlier responses that icing down the area immediately after a workout is a good thing. Could I create more of an issue trying this and reincorporating activity or should I keep chasing a fix? My trainer saw the x-ray and agrees that it’s large enough to where it’s not going to go away.


Dr. Blake's Response: I have always taken the approach that pain from a bone spur is suspect since the bone spur has been there for a long time, so why is it just now hurting. I know that there is more to your story so I will add it on if you reply. When the "S" word is used, my deep-seated gut is looking for ways out.  You have to take out the bone spurs, and really just think of Achilles tendinitis at its insertion. How do we treat general tendinitis? The mnemonic is BRISS: Biomechanics, Rest, Ice, Stretch and Strengthen. The Achilles is now your weak spot that you have to make stronger. Maybe that will ultimately require surgery, but maybe not.
     The Biomechanics that help is a plantarflexed or pointed foot. This is why an elevated heel helped. Women have the advantage here by hanging out longer in wedges and heels and avoid flat foot. You must also take that rule and apply to stretching--only stretch to the ankle at a right angle, not negative heel, where the heel drops below the front of your foot. Strengthening you want to work the range first of your heel on a 1-inch lift and go up and down from there, not lower.
     The Rest is for Activity Modification. It normally takes 9 months to completely rehab an Achilles tendon. You are in month 2. The first few months are the Immobilization/Anti-Inflammatory to create a 0-2 pain level. The next Phase is Restrengthening. The final Phase is Return to Activity. You can not jump to Return to Activity now, that is reasonable. What we need in the good Physio approach to the restrengthening and gradual increase in activities.
     The Ice is anything that helps us reduce the inflammatory. Ice pack 2-3 times a day for 10 minutes is good. If there is a lot of swelling, then contrast bathing. You can use oral meds for 5-10 day bursts of the full dose, and then 2-4 days off to rest your system. Physical therapy and acupuncture are wonderful at reducing the inflammation, increasing blood flow, and PTs can give you exercise advise.
     The First "S" is Stretch. For any Achilles problem way down at the heel, the best stretch is the plantar fascial wall stretch. The second best is the soleus bent knee Achilles stretch. PTs have some heel. But, since stretching the Achilles in some cases is painful, you must consider only during deep calf massage to loosen its force on the heel. 
     The Second "S" is Strengthen. This is crucial for the achilles. Even relatively strong athletes can improve their strength 30-50% where it can help symptoms. Here is where range of motion comes in. You only want to strengthen the tendon from an ankle neutral to ankle plantar flexed position. Try to stay away from an ankle dorsiflexed position to start the strength work, like starting a heel raise from a deep squat or where the heel is dropped off the step. 
      These are some points I hope help. The more information you can share the better. Thanks and good luck. Rich

The Patient's Response:

I appreciate the response. This started early 2017, which had coincided with me picking up running after taking a break for several years. I was able to start doing 4-5 runs a week, typically on a treadmill, for 3-4 miles each time. I started noticing that my ankles would get very stiff several hours after running. I then started waking up with soreness but once I was moving around or running, the pain would wear off eventually, usually after pushing through. 

It early in 2017 though, it got to the point where the pain was constant and would last for days at a time. I am in Texas and a fan of cowboy boots and I noticed that wearing them seemed to help. After consulting with an orthopedic surgeon, it was determined that I had calcification at the Achilles. That is essentially where I currently am at. I will say that at this point, when I do have pain I can sometimes manipulate my ankle by twisting it around until it feels like it pops and that provides instant relief. I have avoided running but have replaced it with long walks and about 50% of the time I will have pain while other times it is totally fine. Basketball, tennis, anything with sudden side to side movement is out mainly due to the fear of pain from a couple of times I have tried it.

Dr. Blake's comment: This is extremely interesting, and it is good the pain is not constant. The fact that you can release pressure, means that the ankle joint is more involved. That sign of popping and feeling better is a joint symptom. I am hopeful you do not rush into surgery and give this proper time. Hopefully, some imaging can be sent here. See the blog post on WeTransfer. I would love to see a good MRI to look at the Achilles, spurs, and ankle joint. Good luck!


Saturday, January 27, 2018

Effect of Sequential Leg Compression Pumps

Dr. Blake attached are a set of photos showing my legs before and after using the pneumatic sleeve. The after is pretty much the way my legs after every use. However, there are times when my legs are quite a bit more swollen than is portrayed by this photo. If you would like additional photos. 
Dr. Blake's comment: I think this is hard to show, but the reduction of swelling is dramatic for this patient with the use of one hour a day Spectrum Sequential Compression Pump.

Thursday, January 25, 2018

Metatarsal Pain: Email Advice

Dr. Blake,

I hope this message finds you well. Thanks for the blog--it’s a great resource, I've been learning a lot from it, and I appreciate your therapeutic approach.

The short version: pain in the area of the right foot MTP joints on the underside of the foot, associated with activity, pretty well under control for now but worried about increasing activity levels in general and hills in particular.

The long version: healthy, active, 25yo male, lifted regularly, walked lots, went for backpacking trips with a heavy pack with no trouble for years, worked part-time in a commercial kitchen, etc. Tried to take up boxing in the summer of 2016, got some small but stubborn tibial stress fractures from skipping rope on concrete, took a lot of time off but gradually resumed activity (lifting, walking, dancing) with no trouble. Incurred some very small fractures in the left metatarsals in a motorcycle accident in March 2017, healed fully, resumed activity. A little pain in the left foot from time to time, but nothing that worried me.

After a couple of brisk hikes in late June/early July, I noticed some unusual pain in about the 3rd-5th MTP joints of the right foot, on the underside of the foot. Not tender to the touch, but a kind of dull throbbing on and off throughout the day. I thought it might be just part of the adaptation process--it had been a while since I had done any serious walking, what with coming back from the broken foot. And I had a short-term job that required a fair bit of loaded hiking (forestry), so I pretty much plowed ahead. The foot didn’t get any better, but it didn’t get dramatically worse, either; I was in stout, supportive boots (albeit possibly too narrow and with too high a heel, see below) during the day, and I noticed some pain when I took them off at night, but nothing crippling.

Still, I figured some time off would do me good, so after the job wrapped up in September I stayed away from running and hiking for a couple of months. The foot calmed down but wasn’t quite back to normal after six weeks off. Pain during everyday life was essentially zero, but eccentric calf raises with the forefoot on a block caused a lot more pain in the right forefoot than I would normally expect, so I saw a primary care doctor who ordered x-rays (attached--let me know if the attachment doesn't work) and referred me to a podiatrist.

The podiatrist diagnosed hallux limitus in the right foot--there was a lot of talk about “degenerative,” “never gets better”, “have you tried swimming, it’s great cardio,” etc. I didn’t care for the sound of this, not wanting to go back to working at a desk, and the podiatrist didn’t strike me as the most competent. So I sought a second opinion from a local AAPSM/ACFAS guy who had a fair bit of running experience (former D1 distance runner). I also began a walking/jogging progression, very conservatively, while avoiding anything I knew aggravated the foot. In particular, I noticed that time on the stairmill and on a steeply inclined treadmill seemed to cause pain out of proportion to impact, and forefoot striking when I ran also made things noticeably worse.

The second podiatrist said that hallux ROM was fine, he didn’t see any swelling, no tenderness to the touch, and encouraged me to experiment with shoes and over-the-counter orthotics and running surfaces and to stop walking around the house barefoot. He didn’t see anything unusual or alarming about my gait, and noted that my feet were a bit flat but not necessarily in need of an orthotic. His diagnosis was “metatarsalgia, like a bruise--not a stress fracture”. This was in about the first week of December.
Dr Blake's comment: This is why I love the AAPSM. Right or wrong, good overall approach. Sounds like nerve to me, and I am glad you had no Hallux limitus. Did he check your achilles for tightness? This is a big reason why patients get metatarsalgia. You work on the 3 causes of pain: mechanical, inflammatory and neuropathic. Mechanical is dropping the heel height, stretch the Achilles tendon, and Hapad longitudinal Metatarsal Arch Pad Small just behind the soreness. Inflammatory with icing or warm water soaks (have to see what feels better). Neuropathic with pain-free massage, Neuro-Eze gel, Neural Flossing three times a day. These at least for what we know now. 

I ended up in the Altra Olympus, very happy with them for walking and running, and somewhat happy with Altra’s desert boots for casual wear. (I tried Hokas, but even their wide sizes were a touch narrow in the forefoot for me.). A felt metatarsal pad on the stock insole (for both feet) also helped a good deal. I found that easy running on grass with a heel strike and a high cadence didn’t seem to make things any worse, and got a pair of cushioned flip-flops for walking around the house.
Dr. Blake's comment: You are doing everything right. For those that do not know Altra shoes, they are all zero drop, meaning no heel lift to put pressure on the front of your foot. I love the big Hapads to spread the force. You may have to thin out. The small size is usually perfect. 

Hapads on top of Orthotic Device with various pads under forefoot to accommodate or cushion

Since then, I’ve been titrating up the jogging, taking it easy and staying on grass, adding 5 minutes here and an extra session there, and I still seem to tolerate it pretty well, so that’s all to the good. I’m down about 5 pounds from 200 in December to 195 now and plan to drop another 5-10 in the coming months, which should also help. I’ve been supplementing D3 and K2 for years and have continued to do so, along with milk, yogurt, and a calcium/magnesium supplement. I've also been lifting and it doesn't seem to cause any pain. Two things have given me cause for concern.

The first was a hike I took on December 26 or 27. About 11 miles round trip with ~3000 feet of elevation gain, a big day out but the sort of thing I would have done without a thought before the motorcycle accident. I was in Asolo TPS 535 boots with Sole orthotics, a combination that had never given me any trouble on backpacking trips and big hikes before forefoot problems started. (Different pair of boots from the ones I had worn over the summer--I hadn’t really worn these for any major hiking since the forefoot problems had started.). By the time we got back to the car, my feet were in quite a lot of pain--both feet, dull throbbing pain pretty much all across the MTP joints, and also some “spiky” pain in the area of the right sesamoids. Outside of the 0-2 range, definitely not the normal soreness I would have expected after an unusually big hike. The pain was probably 90% back to normal and back to normal within a week, where “normal” means “maybe a little sensitive in the right 3rd-5th MTP joints with occasional fleeting mild soreness here and there, but essentially no pain and no discernable pain with everyday activity.”
Dr. Blake's comment: The problem was the new unbroken-into shoe, and a more then what you were used to hiking. It sounds reasonable it should have flared up with the shoe was not flexible enough at that moment allowing more stress to the tissue. Glad it calmed down. 

The second was a few days ago when I tried to stretch my calves by standing on a block with my heel hanging off and letting the heel drop. Felt fine at the time, but about three hours later, I noticed a dull throbbing pain from the right 3rd-5th MTP joints, which came and went periodically for the next 24 hours or so. I’ve been icing for 10 minutes 1-2x/day for the last few days as per your blog--too soon to tell whether it makes a long-term difference, but it sure seems to help acutely. I'm also going to start contrast therapy. Again, the pain was pretty much back to normal (so, a little “sensitive” or “tender” but essentially zero real, consistent pain with everyday activity and jogging on grass) within about three days.
Dr. Blake's comment: This is called placing your foot in a negative heel position and all the weight on the forefoot. Another unusual stress that irritated things. These are benchmarks for what you can and can not do this month. Typically they are not permanent in any way, but you are not ready for that for the next 3 months. Then you can test it again. Were you doing it single leg or double? Less stress with double. 

Anyway, what these two incidents (together with my earlier experiences with the stairmill and inclined treadmill) suggest to me is that even though I can run a bit on the flat, hills may be a problem. But I’d like to work in forestry again this summer, and walking up hills is a pretty central job requirement. And it’s been six months now, including two months more or less completely off--seems like a long time for this not to heal, given the circumstances.
Dr. Blake's comment: Please experiment when you are doing at risk things only either the double loop Budin splint (loops on the 2nd and 4th toes) and a carbon graphite plate under the insert you are wearing. These are only for the times you feel you should have the extra protection. 

So: any recommendations for reintroducing hills? Any suggestions for thinking about how much heel my work boots should have, other than trying various different things and seeing what’s comfortable? (For reference: high heel like what I wore last season, lower heel.). Anything I should be thinking about that I’m not? Anything I shouldn’t be thinking about that I am? Should I worry more, less, or exactly as much as I am that this is the first inkling of a degenerative condition that will lock me into a desk job forever, or at least for next season?
Dr. Blake's comment: Your thought process is wonderful, and we are dealing with some many variables: heel height, stiffness or lack of flexibility more like, tightness of shoe. The tissue is stressed by holding the stretch for a long time, like the negative heel stretch, making it too hard to bend through (like with the new shoe), explosive actions, high impact. Try several shoes and pick the one with some flexibility but some cushion (not weighted heavily on either side). Try to be mindful to reduce stress in your actions, whether that is slower, or gentler, or using your arms more to push you up. Do not favor or something else will go wrong. Ice daily whether you think you need to. Experiment with the plates and Budin splints or hapads, but try to change the environment. Work through times that get sore even if you thought you were getting it right. Healing should occur, even with these ups and downs. Good luck Rich

I think that’s about everything I wanted to ask, together with all the relevant information. If there’s anything else that would help you give an informed answer, feel free to ask. Thanks for reading, and thank you for your time.


Wednesday, January 24, 2018

Sesamoid Injury: Email Advice

I have been corresponding with this patient over injury to the sesamoids. Here are some of our recent conversations. 

     I reviewed the MRI which shows you have bone edema in both the tibial and fibular sesamoids, and also the joint, and also the soft tissue. It is one unhappy joint. For mineralization of the bones we need protected weight bearing with orthotics and dancer's pads. You need to be doing icing twice a day and contrasts once a day. You need to see if you can get the Exogen 4000 bone stim, like Harry Potter's broom!! You need some PT to de-inflame the joint, and help with the off-weighting. No surgery since more than one thing wrong and you can not be sure if it is the sesamoid and which one that is bothering you. A new MRI in 6 months to check progress is important. No NSAIDS or cortisone shots since they are bad for bone healing. No surgery should be needed, but it may take awhile for impact sports again. No guarantees, however. Have your overall bone health checked. Questions? Rich

The patient's response:  Wow, that is a lot of problems with my foot. Not good at all. Thank you so much for taking the time to review my MRI. As I suspected, my local doctor told me today that after reviewing my MRI, he wants to put me in a cast 4-6 weeks, preferably go on disability, he fears a possibility of Avascular Necrosis in the sesamoid bones. He even mentioned a steroid shot! Aggh. After the 6 weeks of casting, I should heal then begin retraining my foot to walk. If all fails he wants to remove the sesamoid bones. Aggh. What a way to start the new year. I wish you had a local office nearby. Lol. I asked if PT could help, he said it would just make inflammation worse. 

Dr. Blake's response:    Good luck my friend. See if you can push for a CT scan in 6 weeks to see the true shape of the bones. The MRI is vague sometimes when there is some much inflammation. The CT scan only shows the bones and many times shows things better then they seem. A CT scan is always good when the phrase "avascular necrosis" is being waved around. Please push also for Exogen bone stim. It is a commitment to 9 months of conservative care. Rich

     Hi Dr. Richard Blake, just an update. So today I got my cast put on. I took 2 months off work, and I'm doing my best to stay off my foot 100%. I'm using a knee scooter to get around the house and using crutches to move outside the house. I've been offloading all the weight of my right foot that now my left foot is aching near the same spot in the ball of the foot of my left foot what😥 a bummer. So I still want to get the device you recommend, Exogen 4000. But my doctor says it's to expensive and that it cost thousands of dollars and that my insurance won't cover it. He's right, my insurance won't cover it, so I'm still looking around. I found one on eBay used, does this look like the device? If it is I'm willing to buy it out of pocket. But my question is, could I use this with a cast on? Is this the one you recommend? 

     Doctor, from your personal and professional opinion, do you believe the 6 weeks of cast should fix my issues? I'm really scared of not being able to do any sport activities again like running and hiking. I just had my first daughter 6 months ago and I really want to be able to do sport activities with her. I'm afraid of the 50/50 possibilities my current doctor is giving me. He says there is a 50/50 chance the cast does not work and we need to do surgery. I asked him if he believes if this should work and he says according to all the literature, it's the best approach. I'm afraid he has no actual experience with this sesamoid issue. It's so hard to find a doctor that knows how to treat this. I feel like a guinea pig with my doctor. 

Sorry for my rant and for bothering you, but I'm at a lost right now. I truly do appreciate you taking your time to even read my emails.

Thank you,

Best regards,

Dr Blake's response: Any of the Exogen 4000 units should work. You are getting it to start a one year process of healing, with the 6 weeks of casting just the start. You should be at a 0-2 pain level and you then advance to a removable cast weight bearing for 2-4 more months still keeping the 0-2 levels. The bone stim should lay on the top of the big toe joint twice daily for 20 minutes so the cast would have to be opened up by the doc or you wait until the cast comes off. See all the advice in this blog on the treatment post-boot. Rich Good luck!!

OTC vs Custom Orthotic Devices: Dr Blake's Powerpoint Presentation

Monday, January 22, 2018

Several Modifications to Classic Plantar Fascial Stretches

I hope I am never too old to keep learning. This wonderful video on plantar fascia presents 4 stretches for plantar fasciitis sufferers. The first two for the gastrocnemius and soleus are common, but he discusses a variant of my plantar wall stretch and introduces the importance of stretching the anterior tibial tendon. I have included my video below James Dunn's video for your comparison. Thank you, James. I can not wait to try these versions and get my patients feedback. It is how we learn.

Sunday, January 21, 2018

Mechanical and Neuropathic Pain: Seeking a New Direction of Help

HI Dr. Blake:

My name is Francine (name changed due to witness protection) and I'm 45 years old.

 I came across to your youtube video of the talk you gave at the SF Main library, after going to see a podiatrist a few weeks ago. Coincidentally, the lady who arranges the library lectures is an acquaintance of mine who lives in the same complex as my mom, who later, after I mentioned of my chronic severe back and feet problems, recommended your office.

I was very excited to have seen your youtube video. I feel the compassion you have for your patients and ppl living with unnecessary pain. I thank you and whoever videotaped that video and to put it out there so many ppl can be helped.

Please excuse this little history:

I have had chronic back and feet problems probably for at least 20 years. Started with rounded shoulders (possibly bad posture and the heavy backpacks back in the day). I have seen probably a few massage therapists, PT, chiropractors (upon recommendation) to little relief. 

About 6-7 years ago I knew my feet hurt (the outer edge as I walk excessively on the outer heel and edge of my feet, as seen by the many pairs of excessive worn out heels from shoes. at the time (6-7 years ago I'm estimating the time frame) I saw a podiatrist at Cal Pacific (had to yelp for podiatrists in order to jolt my memory) and at the time he had made a custom-made orthotics for me. I was very persistent in using it for about a month but it was very uncomfortable so I stopped. I never went to follow up with him. I recall he boasted about working with celebrities and I vaguely recall he mentioned I have the typical Asian "flat feet". 
Dr. Blake's comment: You describe excessive supination or being on the outside of your feet. Do you think you know if these orthotic devices helped that? Do you remember what bothered you about them? If you still have them, putting back in your shoes for several days may help you remember the pros and cons. If you were to get new orthotic devices, you do not want to repeat the same, you want to improve on it. 

I started hiking/walking/swimming about 3-4 years ago (but was pretty much led a sedentary lifestyle growing up) as I gained 25 lbs over the past 6-8 years ago, suffering tremendously from some women's health issues that plagued me most of my adult life. After 2 major surgeries to deal with the issues (almost 8 & 3 years ago), I began to deal with the chronic back issues. I would get severe migraines due to the hard rock stiffness and tightness of my delts, rhomboids, shoulder/neck areas and since then began going to a chiro, PTs that were referred to me, of very little relief temporarily and nil permanently. and then finding my own massage therapist (who has tremendously helped me). A year ago I went to a podiatrist at Mills Hospital as an episode hiking in the park (moderate, not even strenuous by standards) left my foot debilitated. The outer edge of feet was in sooo much pain/ discomfort I had to YANK OFF MY BOOTS during our lunch break for the foot to breathe for 15-20m. After lunch was over, we had to return to the cars. Thankfully this was all DOWNHILL. I limped the rest of the 2 miles to the car, using my better foot (left foot was support) and right foot using just the bottom 1/2 of the foot. So, this podiatrist at mills spent about 5 minutes with me. I bought some shoes for him to examine. And he said he would send me to PT and sold me an OTC insert. I asked him before leaving, "Well aren't you going to do a gait analysis" and he said no, that the PT will do so. Went to Mills for probably 7 of the 10 sessions. The PT could not figure out what 's up with my foot /feet. He had me do some exercises. He had me go on a treadmill. He worked on my ankle with cupping. He had to give my ankle "stimuli"...when he instructed me to raise my ankle I couldn't do it in isolation. My whole body moves. He had to lift it up a few times, then my ankle was able to imitate it. In a different session, the "cupping" for a few minutes was the stimulus that allowed the ankle/foot to fire up. This PT felt disappointed he could not help me and didn't want to waste any more of my money with the remaining sessions, which he felt would not achieve much. Sent me back to the podiatrist and at the appt w/ the podiatrist, he shrugged and said: "find an osteopath or physiatrist". I asked if he could recommend one and he said "google it" after all these years, I haven't had luck with dealing with I shrugged and continued my life w/ my 2-4 x monthly massage therapist while continuing to put this feet issue on hold. 
Dr. Blake's comment: I am so sorry for such poor medicine. The therapist just needed direction, but no excuse from my profession. We are supposed to give the direction. The crucial point you made is not being able to do a heel raise. If you can not do that, you can not walk well. Having a physiatrist or neurologist do a nerve conduction study will tell you if it is neurological or if it can come back. Also, what have you found in shoe gear to help yourself? Any correlation to less pain with a slight heel versus flat shoes? 

Fast forward 1 year and the feet is just KILLING ME. I decided to try ONE MORE TIME. Bear in mind I have little energy and my chronic feet and back problems are killing me physically and more so, emotionally. Besides the massage therapy and Chinese chiro work I do, I am pretty busy running around to yoga classes, heat therapy (sauna & spa for my back as suggested by the massage therapist) so it's not like I'm sitting around whining and feeling sorry for me. I have gone to yoga for 2-3 years, then tried machine pilates after pilates was too unrealistic w/ the back and no core, classes @ the gym (which killed my feet---ANY type of movvement, whether dance, exercise based aerobics, even low impact step class was EXCRUCIATINGLY painful on my feet, whether I was barefoot or with good shoes running/walkign shoes, shoes with the OTC inserts (happy feet), inserts I bought in asia more to the "asian" foot, the original custom made insole from 6-7 years (?) ago. The massage therapist asked me to STOP ALL exercises and walk on sand. I cannot bear to think that for the rest of my life I will have a life sentence for physical activities. I am now looking into belly dance and hula dance (for the hip movements for the lower back).
Dr. Blake's comment: Even though this is a terrible situation, I just love your spirit!! We need you to focus on what has helped you somewhat. We need to put this together to help you. So, if you write back, list the 5 things besides massage therapy that has helped. There must be parts of Pilates you can do, parts of yoga, etc. There seems to be a mechanical source of some of your pain and can be addressed hopefully with a more thoughtful approach to orthotic devices, but what are we doing for the nerve pain. This takes an approach to the Neuropathic pain, not mechanical pain or inflammatory pain. What have you tried? 

So recently, I saw a podiatrist who insisted on XRAYS, full spine & right foot. 4 degenerative discs in the lower back (possibly from being rear ended 3 years ago . LAdy hit me so hard my car hit the person in front). From what the yoga instructors tell me, my pelvis is shifted. Didn't pursue the driver as I was naive and didn't see any mds and didn't realize it could have compounded cause more back issues since I already had pre-existing back issues and I was plain naive. When I realized I should have sought treatment right after the incident the time limit surpassed.

Anyway, she suggested doing two stretches and the diagnosis said :
foot contusion, peroneal tendonitis, and exterior tibial tendonitis.

My question to her at the 2nd appt to review xrays was: 

how do we know if the original custom-made orthotic made 7+ years (?) ago is correcting/fixing the problem she's diagnosing? my recollection isn't' 100% but the podiatrist who made it just mentioned I had flat feet, but current podiatrist and shoe sales guy said I don't. So how do I know by wearing the custom-made insoles will help me? Further, I wore them in an exercise class and it hurt like hell. 
Dr. Blake's comment: First of all, the reason I asked the above question on whether they made you feel more stable, is that is what custom orthotic devices are about. They increase stability by decreasing pronation, decreasing supination, giving you a broader base of support, etc. Just because you got orthotics does not mean that they were designed for the right function. It takes work to figure that out, and they have to be comfortable also. Typically I can always make old orthotics comfortable by some adjustment, but getting them functioning well in some ways depends on how they were initially made (what were they trying to do). 

I was able to raise many examples and give a lot of good history for this podiatrist in my 1st visit, b/c having taken all the yoga, pilates, and other exercises I've tried the past 3-4 years gave me very concrete examples of what my body was/wasn't doing in classes.

Please advise. Do you think you could help? Do you think getting a new set of orthotics (now that I'm 25-30 lbs heavier) would help? I wished I followed up after getting the first orthotics, but I didn't know what I do today.

Living in excruciating pain. Would be very grateful to live and manage my pain.
Dr. Blake's comment: Where we start in my mind is easy. You are very clear you have mechanical issues, and you have neuropathic pain. I believe there is a better orthotic device for stability, I believe every exercise you do is helping with the overall body stabilization from muscle strength. I believe that their is a whole other area dealing with neuropathic pain that you have not tapped into. Neuropathic pain is excruciating. Anti-inflammatory pain produces swelling, redness, black and blue, have not heard those words from anyone in your description. To heal, or at least not make yourself worse, you have to live in the 0-2 pain level environment. Could you do that? Can you find out who is the best in orthotics in your area and go to them? Can you see a pain specialist, not for opiods, but to work on neuropathic pain? Can you go back to the therapist and say I would like your advice on how to modifiy my workouts to live in that 0-2 level? I hope it helps some. Rich

Saturday, January 20, 2018

MLS Laser for Plantar Fascia

Here is testimony from a patient suffering from chronic plantar fasciitis treated with MLS Laser by Dr. Jenny Sanders here in San Francisco. This is another tool to treat this sometimes frustrating injury. I personally do not offer it, but I know it is fairly widespread in use. I trust that someone of Dr. Sanders expertise would know when to use it and when not to.