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Friday, December 6, 2019

Movement: One of the Secrets of Life

Movement: One of the Secrets of Life

For over 35 years I have watched a wonderful group of patients dedicate themselves to motion of some sort or other. They are not the athletes you read about in the papers; some would not consider themselves athletes at all. But they deeply understand that movement is crucial to their lives. I have helped them occasionally through life’s ups and downs, but mainly observed them and been inspired by them. This motion may start physically with some activity, but it is part of a larger pattern of involvement in life. They are engaged in life, inspired by some passion, or just very, very grateful for their time here on this planet. Daily they open the package called “the present” and celebrate in their own unique ways. 
I have come to appreciate the movement or rhythms of their lives. I can only weakly imitate some, as I try myself to find my rhythm of having a successful life. It is a type of success in life that is taught through movement, respect of the body and of others. It includes a respect of the soul, that inner force that calls each of us. That movement is away from the couch, away from self-pity, away from inertia. It is one of the deepest secrets in life that I know. Most 80-year-olds know that if you stop moving, you might as well cash it in. They understand. I hope I understand at 65. Can most 20-year olds-understand? It probably depends on how reflective they are.
The struggles to keep going are sometimes the food of the soul. In injuries, or disabilities, great lessons are learned. But in appreciating movement, deep truths are experienced and learned. An athlete that is self-centered has not learned the truth. A true athlete will learn many truths (humility, patience, kindness, etc.) when the secret of movement is realized.
One example of a person in motion is from my early days at Saint Francis Hospital in San Francisco. There was this funny old doctor when I first started—Dr. Waldo Newberg. Funny because he ran everywhere; between the office to the hospital, his car to the office, the elevator to the lunch room. When I first met him, I didn’t know what to think. I hadn’t learned the secret lessons of motion, even though I was an athlete. Dr. Newberg had seven children, donated time and money to the missionaries in Africa, ran the San Francisco Marathon when he was 80, and he was never rushed to say hello, or to answer any question.
My mother-in-law, Marilyn, was another wonderful example of a person in motion, even though she would say she is allergic to exercise. Her day is one of beautiful movement. A mother of five, with all her children and grandchildren in her daily conversations and concerns, she was always helping out. Always driving where she was needed, always bringing the family closer, always a beacon of love for those fortunate enough to know her. You never knew what city Marilyn will spend her day in, but everyone always felt her loving force, moving the conversation along, moving the grand kids to another event, moving the inertia personally from this world in a fully centered way.
So this movement is with the body, but it must come from the heart. It must come from deep within us. When it comes from this depth, a force is noted by all those around. It becomes an inspiration for how to live our lives. I felt that with my basketball, and my recent training and walking the Camino de Santiago in Spain. I feel a deep connection to my well being in my struggles and successes to move my body as I did as a 20-year-old. My job would tie me to a desk, dragging me into stillness, dragging me into 40 more pounds. I need movement to pull me out of my inertia and awaken my soul. I am a better person because of it. Now that I have finished my 500 mile journey across Spain, I pray I can find another way to keep moving, keep being engaged, keep caring, keep loving today for the present it is.

The preceding is from my book: Secrets to Keep Moving

Sesamoid Fracture Email Advice

Hi Dr. Blake,

I wanted to thank you so much for recommending hiking shoes to me a while back in August of this year. I was able to do some light hikes and felt comfortable for the most part.

However, I’d like your opinion on my sesamoid and if you think I have a fighting chance of it ever healing. I’d be happy to pay you for this opinion, so please let me know how I can. I’m worried that I may need surgery and I’d love to send you my xrays and mri if possible. Let me know if you accept them via drop box or if you want me to send to you.
Dr. Blake's comment: Yes, please send. You can give a donation on the blog, but none is required. They are sent to Dr. Richard Blake, 900 Hyde Street, San Francisco, Ca, 94109. Email at when you put in the mail to be on the lookout for. 

Here’s my story: Late September 2018, I was experiencing severe foot pain and decided to wait a week until I would visit a doctor. On October 2nd, I went to a podiatrist and he diagnosed my right foot with a medial sesamoid stress fracture. I was in the air cast for about 8 weeks and then he recommended I use a u shaped pad for offloading in my tennis shoe for two months. After walking about a week in the tennis shoe I experienced a horrible relapse in pain and was unable to walk comfortable. Any weight placed on my foot was painful. I visited them again and they recommended a cortisone steroid injection. He injected it right into my fat pad on the ball of my foot and it did absolutely nothing except cause my foot to swell and increase in pain. After 2 weeks of feeling worse pain, post injection, I decided to get a second option and visited and orthopedic surgeon.
Dr. Blake's comment: Yes, no cortisone injections around bones you are trying to heal. Hopefully they gave you short acting cortisone which is safe for the bones, but really not that effective. 

The orthopedic surgeon said I had lots of edema and that my fracture was still not healed. He recommended me to be completely non-weight bearing for 2 months. I used either a knee roller and crutches for that time. Once the 2 months was up, my pain decreased from a 9 to about a 4 and it has remained a 3-4 since early February this year.
Dr. Blake's comment: Even though non weight bearing is almost never necessary, your case it is was justified since you have to get the pain down to within 0-2 for healing to occur. 

I’ve visited this orthopedic surgeon and another one and received the same recommendation. Use a carbon foot plate and get custom orthotics with a cut out for my sesamoid. I’ve work these since March and though I am able to walk it has not improved. Walking for a long period of time or bending back the ball of my foot (for example, when trying to do a push-up or calf raise) still causes a sharp pain or dull ache in the bottom of my foot to the point I cannot do these activities.
Dr. Blake's comment: When you get an MRI, and I like them early in sesamoid injuries, it is a baseline. 6 months later you typically get the next one to compare. I like going to the same place for both if the quality is great. I like 3.0 Tesla if you can get that, but Saint Francis has 1.5 which is very good. You can ask the doctor reading if it is good quality. Doctors know. So many times at the 6 month interval MRI the sesamoid is clearly only 25-50% healed. At least I can help the patient with their expectations then. 

I’ve told my doctors this and they say to wait it out or proceed forward without recommending any further treatment. I just would like to know if my sesamoid has a chance or if I need to proceed with surgery. Based on my mri please let me know if you think a bone stimulator, contrast bath or if you have any other recommendation would help me to avoid surgery! 
Dr. Blake's comment: Will do!! Rich

Thanks again for your help. Your help is greatly appreciated. 


Wednesday, December 4, 2019

Standard Sesamoid Fracture Treatment Orthopedic Viewpoint

     This is the standard sesamoid treatment in the podiatry/orthopedic world. It is standard of care, but there are so many other options available. Unfortunately, surgery is the norm for many treating physicians, and I know this is only a superficial article by a brilliant doctor. I read any and all articles on sesamoid injuries, because I am always trying to have one more trick in my ability to heal sesamoid fractures. This week I have had 3 patients come in that I successfully treated for sesamoid fractures over the last 20 years, going back to full activity, and without the need for surgery. They were not in the office for the sesamoids but for another problem. If you have a sesamoid fracture, please read through this blog for the 30 common aspects of treating sesamoids. Perhaps you can send me a tip that you have found vital to your healing or the healing of your patients. The basic message with ball of the foot pain is to get to a diagnosis early, create a 0-2 pain level quickly, and do not settle for providers telling you that if you are not better in a specific period, then surgery should be done. It definitely has taken me over one year in most cases to decide on surgery in the less than 5% of all sesamoid fractures I see.

Monday, December 2, 2019

Biomechanics Lecture at the New York College of Podiatric Medicine

To Ice or Not to Ice: That is the Question?

     Here is a nice article that proposes, and quite well, that health care providers ice their patients too much, and to the patient's detriment. I believe that there is a role for ice, but solid sports medicine principles are 1) non painful motion (movement) is always better than rest, and 2) ice is to control swelling, contrast bathing is to remove that swelling. Contrast bathing (going from hot to cold submersion) is the most powerful method of reducing swelling. I can always tell when a patient is not contrast bathing when they have more swelling at a followup visit. When this good article did not even mention contrast bathing, which should replace icing at day 4 or 5 of an injury, I realize that they have too much at state condemning icing.
     Each individual is so different and each body part is so different. For one patient, ice needs to be deep so 20-30 minutes is needed. For another patient, 5 minutes of icing will do the trick since the injury is very superficial. This is also why the article is correct since patients are told to ice, but sometimes left alone on how long, how many times per day, and for how many days. If it is a month between office visits, you can see how ice can get a bad name.
     Yes, we need inflammation to heal, but icing if done correctly will just control the inflammation and not let it get out of hand. I love my patients to ice right after they aggravated something, but do contrast bathing when the injury just needs swelling reduction. And yes, I could go on and on. One of our PTs never used ice, and his patients were the ones that had bad flareups after PT. All of our other PTs used ice when appropriate and the patients had more comfort.