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Wednesday, October 30, 2019

Lifts for Short Leg help Hamstring and Low Back Pain

Here are two 1/8 inch lifts under the patient’s left foot. The reason I highlight this is that the patient presented for biomechanical assessment with chronic low back, hamstring, right jumper’s knee and foot pain. In my evaluation, he had mild pronation but significant limb dominance associated with short leg syndrome. Standing evaluation noted 3/8 inch short left. Our follow up today after 2 months reveal complete resolution of hamstring and low back symptoms, and no change in knee symptoms. 

Soccer and Sesamoids: Cleat Adjustment



It is soccer season, or for some schools coming in a month, and I get alot of sesamoid pain coming into the clinic. Typically, one of the cleats  is right under the sore sesamoid. I tried to shave down the exact spike at least in half, of course the athletes are terrified I am ruining the cleats. I usually works like a charm. 

Tuesday, October 29, 2019

Heel Pain: When the Plantar Fascia is Not Involved

Swollen Left Heel on MRI showing Good Robust Plantar Fascia that I thought may be torn

The cause of the pain is an infra calcaneal bursae or bursitis. See the Black lump under the plantar fascia and pushing the normal fat out of the way.

Treatment of this Subcalcaneal Bursitis with be ice massage, off weighting the heel for awhile, very soft cushioning around the heel while cooking and prolonged standing, soft Hannaford based orthotic devices, and PT to try to drive out the inflammation with ultrasound, soft tissue mob, and electric stim and ice.

Monday, October 28, 2019

Over The Counter Insert Recommendation

Greetings Dr. Blake,

I’ve recently come across your blog, thankfully, and have been attempting to utilize techniques you’ve already suggested. I’ve had nagging type injuries most of my adult life, which have apparently caught up with me this year, as I’ve been to the doctor more than I can ever remember. Most of my issues are back pain, knee pain and toe pain, and I am sure they are all connected in some way. I recently began seeing an Orthopedic doctor after having major swelling in my right knee, which he has diagnosed as Patellofemoral arthritis, trochlear dysplasia and patella maltracking. I have similar symptoms in both knees, so although my right knee is the one that underwent the MRI, I believe I also have similar ailments in my left knee. 

While dealing with my knee issues, my left big toe became very swollen and painful. Initially my primary healthcare doctor believed it was Gout, which he began treatment for, but my blood work returned normal, leading him to say he believed I had turf toe. I spoke with the orthopedic doctor during a follow-up on my knee, and he believes I have hallux rigidus, although the testing was not very thorough, in my opinion, and there were no x-rays or MRIs completed. 

Regardless, I’ve been dealing with pain in my toe, which has lead to other pains in my foot, due to being unable to walk normally. The toe issues began about three weeks ago, and have thankfully begun to improve. I still feel pain, but it is not constant (weighted or unweighted on foot), and while my walk is still not normal, it is better than it was. I believe part of it is due to being prescribed a steroid dosepak early on, then continuing with ibuprofen, ice, heat baths, self massaging and stretching, and most recently, spica taping has helped a lot! 

I know one of your articles mentioned having correct shoes to eliminate pronating, but I am required to wear boots throughout my work day. I am in law enforcement and I have to wear black boots, thankfully, due to my role as a dog handler, they don’t have to be polished, so I’ve mainly utilized hiking boots. I recently bought a new pair, which are supposed to have a more rigid sole, but I was wondering if there were any OTC orthotic inserts you could recommend that would help improve my biomechanics when walking, and hopefully get me to the point of run easier at work. I’ve seen some claim to provide support and correct alignment within your body, but am hesitant to spend as much money some are asking for their products, without solid reviews from others with my issues. Thankfully, I’ve been fortunate to not be tested very much while attempting to deal with these newfound issues, but the day will surely come, and I’d like to be as close to my prior form as I can be. Any additional advice you may have would be greatly appreciate. 

I, and I’m sure many others, am grateful you are running your blog and giving out such great advice. The way my own doctors read these issues off made it seem similar to a sprained ankle, where just a brace and time would fix the issues, and not much in-depth information was given. 

Thank you for your time and generosity,

Dr. Blake’s comment:
Thank you for your email. And thank you for the kind words. I really like the Red Sole inserts with the black bottom. These are very stable. If the arch is alittle high you can fill it down some or a shoe repair store can take some out of the arch. Let me know how they help. Rich

Saturday, October 26, 2019

Sesamoid Pain that is Possibly Nerve Pain

     I had a wonderful chat today with a young lady from the East Coast. She has been treated for sesamoiditis for a long while, with many opinions, and recently a very smart PT said that it may be her nerves. The sesamoiditis is on both sides, and produced by going from orthotics to no orthotics over night. There has been no swelling, MRIs are negative except some swelling in the tissue around the sesamoiditis. She wore a pair of wedges that put more weight on the sesamoids but actually felt better than flats. She has an intolerance to shoes. She has a documented L4/L5 stenosis at 49 years old with minimal back issues, and disabling foot issues. She had a negative Nerve Conduction Test.
     All these findings point to nerve pain as a problem and I told her to seek a peripheral nerve doctor that understands the concept of Double Crush. I told her Nerve Conduction Tests were document nerve damage but not nerve hypersensitivity. She may need an epidural or something that is invasive, but she can start with topical nerve creams like Neuro Eze or Neuro One, neural flossing, warm soaks or contrasts, B complex supplements, TENS units, loose shoes (sorry for winter coming), and no prolonged stretches and learning how not to irritate the sciatic nerve. PTs can teach that.
     One of the golden rules I have learned about nerves is that all of the treatments to help can irritate when you first learn them. I have shown each of the above, and most of the time the patients feel great and that they help, and then another patient will say it irritated them immensely. I apologize, and try to modify with less intensity in general. If you treat pain, and what you commonly do irritates a patient, it probably documents you are dealing with nerve pain. 

Sesamoid Fracture: First 3 Months of Treatment

I forget how much I like my own video. Here is a discussion of the vital first 3 months of treating a sesamoid fracture. Of course, the first 3 months of treatment may not be the first 3 months you have  had the problem. It starts when the diagnosis is made.





https://youtu.be/8cwW2Bmcc0E

Treating Heel Pain: What Type of Orthotic To Start With

In the article below from my friends at La Trobe University in Australia, they discuss the use of custom or over the counter inserts for acute heel pain. I could not agree more, that if there is no other reason but heel pain to use the orthotic devices, it is best to start with over the counter inserts. I like over the counter inserts, like Sole and Powerstep (and there are others), that I can customize if needed. The typical modifications include softening the heel area, and adjusting the arch higher or lower based on patient tolerance.

http://semrc.blogs.latrobe.edu.au/customised-foot-orthoses-better-option-plantar-heel-pain/

Thursday, October 24, 2019

Metatarsal Pain: Consider Bike Shoes with Embedded Cleat

     Had a patient today with chronic bilateral metatarsal pain. As we work through the diagnosis, I suggested to get bike shoes with embedded cleats to wear at least 4 hours per day to decrease the motion across the sore areas. I find thinking about making changes in the biomechanics of the patient can usually make significant improvements. This is even true when you have the patient use those changes for parts of each day. 

Wednesday, October 23, 2019

Pain Level 8 in the Heel without Swelling

     I had a patient recently with left heel pain normally around 8 on a scale to 10 for several months. The examination showed no swelling. She was unsuccessful in PT treatment, so referred by her PT to see me for an opinion. She was diagnosed as plantar fasciitis, with morning pain, but was not responding to plantar fascial treatment. 
     My first thought, which became my tentative diagnosis, was nerve pain. She had morning pain, at 8 level, but it never loosened up better than 5-6. She had orthotic devices, and felt some much better when I removed the heel posts that can focus the pressure on the heel area.
     She had some sciatica on the same side, although negative straight leg test today. What I did find is very tight hamstrings which can be from neural tension. She felt better with support the foot taping for plantar fasciitis and did hurt only at the plantar fascia. 
     So, I was getting mixed signals from her. But over the next month, she will
  1. Wear the orthotic devices with no post
  2. Wear support the foot taping if it continues to work for her
  3. Use warm not ice
  4. Use neural flossing three times a day
  5. Do no prolonged calf or plantar fascial stretches
  6. Avoid positions of maximal ankle flex ion (most stretch on nerves)
  7. Buy Neuro Eze or Neuro One from Amazon and apply three times a day
  8. Refer to Dr. Irene or Robert Minkowsky for peripheral nerve evaluation 

Tuesday, October 22, 2019

Plantar Fascial Ruptures: A Video and A Comment

https://youtu.be/eZF0XxUkJIM

Please watch this video about plantar fascial ruptures. This is a good anatomical lesson, but there is so much more to treatment for the majority of patients. I find some patients do not respond well after their initial period of removable cast or bike shoes with embedded cleats and Quick tape from supporththefoot.com. At this time, you have to customize the arch support with functional orthotic devices, and probably add PT, shockwave therapy, and/or PRP injections. Different doctors in your area may be more skilled at any of these treatment components and you need to search them out. Surgery I believe is in the 1% of patients who tear the plantar fascia from partial to complete. 

Where do I go from Here?

     Thank you for reading this blog. I am in my 10th year, and I find writer’s block is my daily friend. 
My wife and I just got back from walking over 500 miles in Spain along an old, but very relevant in today’s world, pilgrimage trail called the Camino de Santiago. I helped many pilgrims along the way with my Podiatry knowledge. I experienced incredible peace and joy. I was blessed to do it with my wife Patty, the love of my life for 42 years.
     I just finished my second book “The Inverted Orthotic Technique” for Podiatrists, and I am working on my third. I hope those who read “Secrets to Keep Moving” were helped. I plan on teaching and writing more next year as I move into semi-retirement. I hope you will continue to bless me with your friendship. Rich

Thursday, October 17, 2019

Can Patients Fly After Foot and Ankle Surgery? Part 1: What’s the General Risk?



The following is a great discussion on flying risks after foot or ankle surgery. Rich



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Issue 108
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Oct 15, 2019

Practice Perfect 676
Can Patients Fly After Foot and Ankle Surgery? Part 1: What's the General Risk?

  Jarrod Shapiro, DPM

PRACTICE PERFECT   October 15, 2019


Recently, I travelled to a conference via airplane, and while sitting in the airport lounge, I noted a person across from me wearing a CAM boot. It caused me to think back to a recent patient in my office who had sustained a fracture and decided not to fly to her vacation due to concerns of getting a deep venous thrombosis (DVT). I'd also had a similar patient who wanted to travel a few weeks after a surgery. I prescribed the patient enoxaparin as a prophylactic, which she accepted but didn't use when she was traveling.
This confluence of patient situations highlights how common this situation is. I also realized that I really didn't know the evidence, and therefore, didn't know whether there is significant risk for patients to do long plane flights after their foot and ankle injuries that required immobilization. The advice I've given over the years was based on wisdom that I received from my teachers and attendings and wasn't based on the evidence. As such, let's explore long air travel after foot and ankle surgery and immobilization. What is the actual risk of DVT when traveling by air? Should we allow our patients to travel by plane?
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The Basic Science
There is, of course, a logical scientific basis for the clot concern: Virchow's triangle. You'll recall this physiologic mechanism leading to increased coagulation risk is made up of blood vessel intimal injury, venous stasis, and hypercoagulability. Surgery of the lower extremity leads to all of these components, and one must wonder why we don't have more clotting episodes than we do? There are clearly balancing mechanisms to offset the clotting cascade, and it is for this reason that it's not a black and white "no, you can't fly after surgery" answer.
What's the DVT Travel Risk in General?
To gain some perspective on our question let's take a look at blood clot risks in general.
Arya and colleagues reviewed 568 passengers who went on long haul flights (defined as greater than three-hour trips in the preceding four weeks) who had suspected DVT1. They found an odds ratio (OR) of 1.3 when comparing DVT versus airline travel alone (no relationship of airline travel with DVT). However, when other factors were considered (surgery and previous DVT), the odds ratio increased to an average of 3.0.
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Similarly, Cannegeiter et al performed a subgroup analysis of a larger study, the MEGA study, that examined risk factors for venous thrombotic events (VTE) in a large cohort2 . This was a case control cohort study that compared patients with a DVT episode with their spouses (the control group). Two hundred-thirty-three patients from the original study were identified to have travelled greater than four hours in the eight weeks preceding the DVT event. They found the risk of a VTE due to any kind of travel to have an odds ratio of 2.1 (a two-fold increased risk), and travel by plane, car, train, or bus had the same overall risk. Other factors significantly increased the risk: Factor V Leiden (OR 8.1), BMI kg/m2 > 30 (OR 9.1), height > 6'2" (OR 4.7), and use of oral contraceptives (OR > 20).
Ferrari, et al, by the same token, found an odds ratio of 3.98 for VTE in people who had undergone recent travel by train, airplane, or car when compared to a control cohort3. The trips were on average 5.4 hours. The authors stated that travel alone was a risk factor for VTE.
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These research studies and others looked at the relationship between travel and DVT in groups more likely to have DVT in the first place (a higher prevalence), so we are more likely to see DVT in these groups - something to keep in mind.
Based on these and other studies the following factors are believed to increase the risk of VTE after travel4:
  1. Prolonged travel times > 4-6 hours (2x risk)
  2. Age over 40 years
  3. Use of oral contraceptives (up to 20x risk)
  4. BMI > 30 kg/m2 (up to 9x risk)
  5. History of thrombophilia
  6. Tall or short stature (up to 5x risk)
  7. Recent surgery (up to 3x risk)
Prolonged travel times of 4-6 hours doubles the risk of DVT.
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We can make two primary conclusions:
  1. There is an increased risk of venous thromboembolic events during any prolonged type of travel (somewhere in the range of 2-4 fold increased risk).
  2. Patient-specific factors significantly increase the risk of a VTE above the baseline risk.
FOR comparison, while LONG trips double the risk of DVT, Oral Contraceptives raise the risk 20x, BMI>30kg/m2 raises it by 9x, recent surgery by 3x, and strangely enough, tall or short stature by 5x.
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At this point, we can tell our patients with confidence that their clotting risk is elevated when they travel. What we haven't figured out yet is if recent foot and ankle surgery is one of those patient-specific factors that increase the risk of VTE while traveling. And that, my intrepid travel-concerned caregivers, is where I will leave you - a little cliffhanger to find out next week, when we'll discuss the clotting risks specifically associated with foot and ankle surgery and if there are suggestions we can make to patients to mitigate these possible risks. Until then...
Best wishes.

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
jarrod@podiatry.com

References
  1. Arya R, Barnes JA, Hossain U, Patel RK, Cohen AT. Long‐haul flights and deep vein thrombosis: a significant risk only when additional factors are also present. Br J Haematol. 2002 Mar;116(3):653-654.
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  2. Cannegieter SC, Doggen CJ, van Houwelingen HC, Rosendaal FR. Travel-related venous thrombosis: results from a large population-based case control study (MEGA study). PLoS Med. 2006 Aug;3(8):e307.
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  3. Ferrari E, Chevallier T, Chapelier A, Baudouy M. Travel as a risk factor for venous thromboembolic disease: a case-control study. Chest. 1999 Feb;115(2):440-444.
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  4. Gavish I, Brenner B. Air travel and the risk of thromboembolism. Intern Emerg Med. 2011 Apr;6(2):113-116
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