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Tuesday, December 31, 2019

Calcaneal Stress Fracture: Last Patient of 2019


     My last official patient of 2019 was the 95 year old mother of a wonderful patient of mine. He brought her into the treatment room in a wheelchair with acute one day pain in her right heel. There was no incident of trauma. She has been struggling with pain in her left knee for a long time and perhaps is favoring her right foot. I went right to an MRI which they were able to get within the hour at our hospital fearing broken bone with this age and history until proven otherwise. Xrays can take weeks show subtle signs of a stress fracture, but the MRI images below (both T1 and T2) dramatically show the stress fracture non-displaced. I will keep her off her foot for the next month and start an Exogen bone stimulator if I can get approval for. Interestingly, her son fractured his heel bone doing ball room dancing 10 years ago in the same place. Genetic do give us weak spots. You can tell by the MRIs that the stress fracture was not due to weight bearing compression forces, but to the pull of the achilles tendon similar to many cases of Severs. Look how strong the achilles looks and the overall bone density seen on T2 throughout the area looks fine and not demineralized like in disuse atrophy. 



On a side note: This is my 2000th Blog Post since my start of blogging in March 2010! No one cares but me, but that will not stop me from raising a glass of champagne or bubbly tonight! Happy New Years. 


Sunday, December 29, 2019

The Role of Second Opinions

Second Opinions

After over 40 years practicing the science and art of podiatry, I fully appreciate the role of second opinions for treatment of injuries. I am fortunate to work at an institution (Saint Francis Memorial Hospital in San Francisco) where second opinions are almost second nature. But, this is not the norm. I believe getting a second opinion for orthopedic/podiatric surgery is really a no-brainer, unless you are stuck in an emergency situation. But for most cases of elective foot and ankle surgery or difficult to treat non-surgical pain syndromes, getting at least two opinions can be helpful. It is ideal that a non-surgeon (podiatrist, therapist, primary care physician, sports medicine physician) helps you decipher the recommendations of two surgeons before you go under the knife. This is the ideal world, but hopefully, you can get this type of ideal treatment. For most patients and doctors, that is way too much work to do. But, you cannot go back and reverse a surgery. Even when the two surgical opinions are identical, you will develop a feel for which surgeon you want to do the surgery. Find out how their surgical approaches are different, and what differences there are in the postoperative treatment. Second opinions for complicated non-surgical problems are less commonly done. But, the approaches of physicians can be so different that they should be done when improvement is stymied. If a doctor/therapist ever implies that you will not get better because of your age, definitely get another opinion. Age can be a factor, but normally only a small part of a slow healing process. Take an active role in your own care; at least you and your family will have fewer surprises in the process. And, never tell one surgeon what the other one says. You want an independent opinion. I tell most of my patients that really we are getting a second opinion on what should be done next. I am surprised when orthopedists and podiatrists that I am using for second opinions recommend another direction in the conservative treatment that I had not thought about. These opinions are worth their weight in gold. 

Golden Rule of Foot: It is best to have a non-surgeon say, “You really need elective foot or ankle surgery,” since surgeons tend to be so selective on who they cut on.

This is an excerpt from my book: Secrets to Keep Moving

Flare Up Pain Post Examination: Nerve Related?

Dr. Blake,

I hope you're well. I have spent some time reading through you blog as well as various reviews. It seems you are a leading expert in sessamoid injuries. My story is I'm a 35 year old competitive runner. I never had sessamoid issues until recently. I went for a hike/run in the mountains and had the indicative stiff toe shortly thereafter. I was able to get around well and saw improvement through the week. I tested my foot 7 days later and had mild soreness after the run. Although I was able to walk without issue I was unable to run and wanted to rule out any sort of fracture. I went to see a sports medicine doctor three days after the light run. Before the doctor came in a resident physician on rotation examined me twisting my foot in various positions as well as pushing my big toe up to the highest point my body would allow. The pain was not immediately debilitating but on the way home from the hospital I began to feel pain on the top of my first metatarsal as well as pain in the ball of my foot for the first time. The pain got progressively worse over the next 24 hours.
Dr. Blake's comment: Sorry for that. I have inadvertently done that to a few patients over the years. Residents do not have experience yet, actually you are their experience. I was a resident once so I feel for you. It normally lasts a day or so. 

 I wasn't able to sleep that night and was unable to walk or weight bear the next day. It's been three weeks since that examination and I still cannot bear weight. I knew something was wrong and had an MRI done two days after my initial visit to the doctor. The MRI results did not show a sesamoid fracture just some metatarsal edema and "sesamoiditis". I have been taking prescription anti-inflammatory meds and limping around in a post op shoe putting my weight on the outside of the heal (i find the cam walker to be too uncomfortable). I use a scooter around the house. When I do limp in the post op shoe I try to put a ballet pad on my foot to offload some of the pressure from the sesamoid. I live in the Carolinas so literally across the country. Is it possible to schedule a remote consultation with you or do you only see patients in the office? I have been reading the horror stories and like most I have seen no improvement over the past month. I'd also like to have a second opinion since the doctor who initially diagnosed me as not having a fracture was the attending physician when I was injured by the resident.....which makes me question his familiarity with this injury. He recommended a graphite insert which I can't even imagine walking on anytime soon. 
Dr. Blake's comment: So sorry for your problem. I can review the xrays and MRI. You can have them mailed to Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. Look up my friend at the Barry University in Florida Dr. James Losito. He also may have a local recommendation. You need to get back in the removable boot with a cut out for the sesamoid. Some times I need 1/2 inch sesamoid accommodations to protect the sesamoid. Anti-inflammatories slow bone healing so try to change to ice and contrast bathing. With contrast bathing start with 1 minute hot and 1 minute cold for 10 minutes and see if it makes it feel better. I would rather you do that. This is very unusual to hurt like this after an examination, so if you forget about the diagnosis for awhile, the goal has to be weight bearing with 0-2 pain levels. Typically podiatrists are great at that, but if you have to also work with a pain specialist. The 3 sources of your pain are mechanical injury documented by the MRI, inflammation, and nerve hypersensitivity. So many patients with pain like this actually have nerve pain. If you float the sesamoid 1/2 inch off the ground and you still have major pain, then you have some nerve pain. And, nerve pain has to be treated differently than mechanical produced pain or inflammation produced pain. I hope this makes sense. Rich

http://www.aapsm.org/members-south.html I also love Pat Nunan in one of those Carolinas!!


Thanks

Saturday, December 28, 2019

Failed Neuroma Surgery: What Next?

Hi Dr. Blake,

I had stump neuroma surgery ( plantar approach) in November 2018.  For the first 6-7 months post surgery I was able to bike without pain, and hike and walk 5-6 miles with slight pain.  When I got to month 8 things started changing.  I could bike without pain, but with walking the pain increased.  I will also say in month 7 and 8 I was diagnosed with uterine cancer and doing some type of exercise was needed for my mental health.  It ended up they got the cancer through surgery and I did not need further treatments.  Yeah! 
Dr. Blake's comment: I am so happy for you!! 

During months 4-7, I did have some physical therapy and continued to check in with my doctor.  At month 8, I went to another doctor for a second opinion and he suggested that I need softer cushioning under my forefront.  I did this and what he prescribed did not work well with my orthotic. 

Fast forward to month 11, and I return to my foot doctor telling him I am in pain almost all the time and that I feel a lump to the right of the scar on the bottom of foot.  I suggest we do an MRI so he orders it.  Now I know it probably should have been done with contrast...  but it wasn’t.  It showed postoperative scarring within the third web space and within sub adjacent plantar subcutaneous fat and adjacent to the fourth flexor tendon related to the neuroma excision.  They also found a small ovoid T2 hyper intense mass along the plantar margin of the second MTP joint consistent with a small ganglion cyst. 3 by 7 by 3mm.
Dr. Blake's comment: Is this where you hurt? They probably need some diagnostic injections with local anesthesia only. Does it feel like the same pain as before? Hyper-sensitive nerves from double crush (like coming from your back) can involve neuromas, but removing the neuromas does not help always. 

Both doctors did not think anything of the cyst.  And they said the best way to break up scar tissue was with steroids.  My doctor would only give me 1 shot because of my history of steroids in that foot.  I am 5 weeks out from that shot, and have noticed no improvement.
Dr. Blake's comment: I am assuming that you never respond to steroids. Are you some one who scars alot? Do they think you kept entrapping the nerve in more scar tissue. That makes sense from the timing of feeling good for awhile which normally happens in scar entrapment but not double crush. These of course are general rules with exceptions. What happened with the first surgery? Same symptom development months after the surgery?

At this point, my doctor has given me my records and said there is nothing more he can do.  Wow... I was not ready for that.  The other doctor I am seeing  is pretty non responsive.   So in one weeks time, I am discharged from a doctor and then learn they found some more cancer cells on my check up.  It’s been quite a week.... but I am strong and I will tackle this!  My CT scan showed it was contained... so I think a few zaps of radiation will kill those nasty demons....
Dr. Blake's comment: You are inspirational to me!! Go Girl!! You got this!! I have had a patient once similar where the pain was double crush and coming from Stage 4 prostate cancer pressing on the L5 nerve roots in his back. The foot pain made the diagnosis since it made us look at his back that did not hurt. 
     What about alcohol shots to de-sensitize the nerves? This is a very successful treatment. I have a recent post on my protocol. 

So now I am back to foot searching for the answer.  Before having stump neuroma surgery, I had done RFA and PRP with some success.  I reached out to them and they said most likely there are some nerves caught up in that scar tissue that are causing me the pain.  At this point, I can’t do PRP because of active cancer.

I am doing some massage and stretching exercises. I have also ordered a new orthotic with metatarsal support.   Can you think of anything else?  Should I get more tests done.... mri with contrast...ultrasound?  No one seems concerned about the cyst... I guess that is ok?  I am just discouraged about the level of care I have received.  I would have never thought I would be worse off post surgery...
Dr. Blake's comment: 

  1. Make sure no feels this is double crush from the uterine cancer or low back issues
  2. Yes, get an MRI with contrasts which is standard of care for this issue
  3. Be considered for alcohol injections (typically one or two series of 5 injections which each injection one week apart). 
  4. Do the typical nerve treatments which I have not heard you mention: Lidoderm patches, TENS home use 2-3 times daily, neuro-eze or neuro-one topical gel massaged in, other ketamine based compounding medicines, and neural flossing.
  5. Find the local PT member of the Neurology Academy. They look at PT from nerve standpoint. You need to be at least on a Sciatic Nerve protocol as you can be tweaking the nerve by sleeping, sitting, standing, lifting all day long. http://www.neuropt.org/about-us
  6. There are other treatments I have some experience with like Quell for pain control. 
  7. There are tons of oral medications like Lyrica and Gabapentin. These are to drive the nerve sensitivity down, and then maintained with whatever dose achieves that, and then we attempt to wean off.
  8. The goal with all these treatments is to get you fully functional at level 2 pain and hold you there for a year.
  9. New orthotics with perfect metatarsal support is crucial. That task alone can take awhile to do with a good orthotic person who wants to experiment.     


Any advice is welcome.

Injured or Treating Someone Injured: Fight Inertia and Get Going

Golden Rule of Foot: When injured in one sport, find another one or two to keep healthy. 

     These Golden Rules which are all over this blog are rules never to be broken. However, this article speaks of how we become so addicted to one method of exercise, that when we can not do that exercise, we also have the inability to do something else. Inertia wins (and in this case it is psychological inertia). As health care providers, it is a good reminder as we talk to our athletes, that we help them understand the significance of cross training. Do not say "I think you should do something else for awhile". Say "we really need you to spend 30 minutes every other day on a bike and 30 minutes on the elliptical. Also, on your off days start hitting the weight room for your core, upper extremity and stretching." Be more proactice!! Your athletes will rehab better.

Golden Rule of Foot: When injured in one sport, start cross training the next day. 

https://journals.lww.com/acsm-msse/Abstract/publishahead/Injured_Runners_Do_Not_Replace_Lost_Running_Time.96421.aspx

Arch Adjustments on Custom Orthotic Devices

Arch Adjustments are Necessary for Good Orthotic Devices

     My patient yesterday needed several arch adjustments to her custom orthotic devices which took me 30 minutes (between adjustments, gait evaluation, and patient's feedback), and another patient needed adjustments to her arch for the third visit in a row. Why is this needed after I took the appropriate impression cast and wrote a great prescription (in my humble estimation)? I will focus on the medial arch in this post. It is by far the most talked about aspect of any orthotic device, yet sometimes the least important in terms of what an orthotic device is supposed to do. 
     I always tell my patients when they receive their new orthosis that there is a period of breaking in as the body gets used to the new positioning. Even if a patient has been a long time orthotic wearer, a new orthotic device should always be treated with this respect. It will make changes, hopefully all positive, but those changes may pull and push and compress and stretch tissues that complain some.
That being said, the breaking in process should never be painful. The 0-2 range of mild ache or discomfort is fine. If there is pain, the patient is advised not to wear the device until I have time to analyze why.
     The 4 typical reasons that patients need their medial arch adjusted are:
  1. Nerve sensitivity from low back, tarsal tunnel, or another cause. These patients do not want any orthotic pressure on the sensitive arch structures. They need nerve treatment much more than the mechanical treatment of arch support.
  2. Plantar fascial bow stringing at heel lift. A small groove needs to be placed along the plantar prominent medial slip of the plantar fascia.
  3. When the pronation is still excessive with the orthotic devices, so the medial column collapses into the medial arch causing pain. This is not related to fit as the orthotic device can seem like a perfect fit onto the relaxed foot. When the patient walks or runs, you can see that the foot still pronates excessively on the device. Temporarily you must lower the arch, unless it is simply that they need more stable shoes. Permanently, if the powerful pronation force needs more control, a higher arch with or without an inversion force at the heel is needed. I know, to the patient, it is counter intuitive.
  4. The arch fill makes it too rigid. Many labs make orthotic devices where the medial arch is filled from the ground up with material. It can be rather soft material but this fill removes the flex of the arch. This flex can be crucial for comfort. When this seems to be the case, I remove half of the arch fill at first telling the patient that I can always put it back. 

     
     

Friday, December 27, 2019

Alcohol Shots for Morton's Neuromas Instead of Surgery

     This article documents the positive results for 20% alcohol injections to help Morton's Neuroma Pain. My present protocol is one series of 5 weekly injections starting at 10% and ending at 18%. I then wait one to two months, and if there has been a positive help, and less then 80% success, I then do a second series at 20% only. If patients have a bad reaction, it is one in five patients on the first shot at 10%. They will have more pain for 4 days to 2 weeks. I do not give them another shot until this has calmed down. They do not experience more pain with any other injection even with the higher doses. Rich

https://www.ajronline.org/doi/10.2214/AJR.06.1463

Sesamoid Injury: Surgery in a Few Days Scheduled

Hello Dr. Richard Blake,

     I stumbled across your blog and am hoping to get your opinion on some sesamoid issues I’ve been having over the past 12 months. Your input and advice would be greatly appreciated as it seems you are very well versed with these injuries. Here is my story

     I’m a 24-year-old male and I have a sesamoidectomy scheduled one week from today (at the time of this blog post). My issues first began in January 2019 after skateboarding on a concrete boardwalk for about an hour and the next day my left foot was very sore. Within about a week the big toe joint became very inflamed and I could hardly put any weight on the foot. I went in to get an x ray and suspected I may have fractured my sesamoid bone but the x ray came back negative only showing bone marrow edema in the MTP joint. I was already aware of these sesamoid bones because I fractured my right one when I was 17 and after over a year of failed treatments I ended up having my medial sesamoid bone removed in that foot. I’m relatively pain free in that foot now but I definitely can’t do the things I used to athletically speaking.

     I spent about a month wearing a boot on this new injury and was eventually able to transition to a running shoe with a steel plate in it about two months after it first flared up. I was later on given some plastic orthotics which restricted the motion of the MTP joint. Fast forward to August 2019 and I was still having pain and could not walk long distances and my gait was still altered. I ended up getting an MRI and the diagnosis was bone marrow edema within both partitions of medial bipartite sesamoid. They knew I had a bipartite sesamoid because they had x rays from years ago. I saw an orthopedic surgeon shortly after and he recommended surgery. He showed me the MRI and how there was a jagged edge on the medial sesamoid and fluid in the bone which apparently indicated degenerative changes. At that point I schedule surgery and decided I was going to try to attempt to transition out of orthotics and would cancel if my foot felt better by surgery time.

My foot has definitely improved but the pain is still there. I can walk alright but I am not living the very active lifestyle I desire. Some days are worse than others but there always seems to be at least some pain and redness in the injured foot. I avoid impact activities and I believe I am definitely walking with an altered gait to compensate for the pain. I feel like this is negatively affecting the health of the rest of my body including knee, hip, and low back.

My question is do you think I should just continue to wait this out and hope the pain in my foot eventually goes away? Or has it been so long that its unlikely to completely get better at this point? Is there anything else I should try before getting the surgery? I’ve diligently iced and avoided activities that cause pain over the past 12 months and I’m getting so emotionally drained dealing with this. At the same time I am so worried that I’m jumping to the surgery too soon when it there’s still a chance the foot could get better on its own. However, my surgeon doesn’t think that’s very likely at this point and is a proponent of the surgery.
Dr. Blake's comment: Thanks for the email. After 6 months of dealing with sesamoid fractures, the standard of care is to remove the sesamoid. But, as you said with the sesamoid removal in the past, you have had some permanent changes. There is no sign of bone fragmentation or sclerosis of avascular necrosis, so there is hope you can heal. I feel the sesamoids break by accident, as in your case of overloading against cement (where the cement won), but do not heal in young healing individuals like you when something is missed. That can be your biomechanics that put too much weight on the sesamoids. It can be Vit D deficiencies, which I am always dealing with in the winter months with my athletes. It can be that you have not been treating it correctly, so I will list the top things you need to do for the next 6 months. They are:

  1. Exogen Bone Stimulator twice daily
  2. Contrast Bathing for 5-7 days per week for a deep flush
  3. Vit D Blood Test and correct if low
  4. Biomechanical treatment to off weight the sesamoid 24/7
  5. Keeping the Pain levels between 0-2 (must stay here while being physically active)
  6. Avoid Cortisone shots and the use of NSAIDs
  7. If swelling persists, get PT
  8. Cross Train with cycling, swimming, and the elliptical flatfooted
  9. Massage painlessly twice daily for 2 minutes to desensitize.
  10. See a sports doctor who is not a surgeon for an opinion, or, without telling someone about this list find a doc who mentions at least 6 of the above.
  11. Go to the AAPSM to find a local sports podiatrist
Then get another MRI at the same location and see what the comparison. No healing, surgery is your best option. No regrets. Some healing, keep going for another 6 months. A strong sesamoid will help you for years and years be active, but with your history, I would always protect it. Good luck! Rich


I greatly appreciate your input.

Kind regards,

Thursday, December 26, 2019

Always Have Plan B

 Always Have Plan B

When treating athletic injuries, it is always important to know various ways to help people with their problems. I was lucky to have great instruction in podiatry school that taught me to have a Plan B when Plan A did not work for a patient. Patients also had to be educated that if Plan A did not help them, come back, and we will see if Plan B works better.
In 1981, I joined Dr. James Garrick, orthopedic surgeon, and an orthopedic rebel if there ever was one. Dr. Garrick wanted many skilled docs and physical therapists surrounding him, helping his patients, so that he could spend his time in research, writing books, and doing surgery on patients who really needed it. He was the first doctor I ever heard say that you don't need to fix every torn ankle ligament, every achilles tendon complete rupture, and every knee meniscal tear. These injuries  could be treated conservatively, and that many foot and ankle fractures would heal fine with the right rehabilitation without surgery. What a mentor for my first days in practice! For most sports medicine injuries, Dr. Garrick had a Plan B different from what podiatrists and orthopedists were taught. Needless to say, he helped me develop many Plan Bs for my injured athletes over the 33 years we worked together.
As our practice grew, we hired more physical therapists, dance medicine specialists, athletic trainers, sports medicine MDs, other podiatrists, physiatrists, adolescent medicine specialists, and they all were trained differently. The blacks and whites of training became the grays of the art of medicine, which became the rainbows of a true sports medicine holistic approach. Plan A was carefully selected, and if not helping totally, Plan B, and C, and D could be called into play.
                                                                  In the last 30 years, this approach has been further molded by chiropractors, acupuncturists, body workers, personal trainers, nutritionists, and other healers. I clearly see that there are many ways to  help my patients get well. Any time I get tunnel vision on a problem, and the patient is not responding, a second opinion from a colleague can wake my creative side up, and a new Plan B can be developed. If I can impart anything on this topic it is that if you have a difficult problem that is not responding to treatment, see if a new Plan B can be found through the role for second opinions.

Golden Rule of Foot: When rehabilitating an injury, always have a Plan B.

The above is an excerpt from my book: Secrets to Keep Moving 




Tuesday, December 24, 2019

Going Alone is Never A Good Idea

Injury Rehabilitation Principle: Going it Alone is Never Good, and Self-Reflection is Crucial

I have spoken to some patients recently who I sense are feeling alone and scared with their injuries. They have significant disabilities with their injuries, and I am struggling to help them without much luck so far. They are always on my mind and I cannot help but feel alone, too, in helping them. I am lucky to be surrounded by gifted health care providers to help me, but sometimes they also say that nothing can be done. I have been around too long to believe it. I recognize my limitations, and I see so many gifted souls out there struggling. My intuition tells me "one step at a time." One step of progress, one change in direction, one lesson learned, and we may be able to take another step.

I wrote a poem once about this progress that I will retell now. It is entitled “On Death Experienced.” The death is the darkness we feel in our hopelessness at the loss of who we are, the loss of our identity as athletes, or as healthy individuals. It probably applies most to patients with nerve pain that they have to live with. The poem also implies that there is another side, a side of rebirth, of healing. Some of you will relate.

ON DEATH EXPERIENCED
by Rich Blake

The fist is hard
As it explodes so deep
The emotions so high
Talk seems so cheap

Death of self plays a sour note
A loss so deep that everything
Is affected and actions in remote
Continue the self while the soul begins

In that very death, flowers bloom
Priorities shift
As inward
we drift
The self being sifted

When death is experienced
The grief cycle will play
Inner strength must end it
With friends we can say

I'm ready to go on now
At least for another day
To work with you in the garden
And accept my stumbling along the way.

The above is an excerpt from my book: Secrets to Keep Moving

Plantar Fasciitis and Cortisone Shot: Email Advice

Hi Dr. Blake,

Love your blog.  Two questions:

(1) Is stretching still allowed and/or recommended for a patient that receives steroid shots for plantar fasciitis?  I have had bilateral heel pain/PF for a year?  I'm going to keep working at rehabbing, but I am often tempted to try the shots -- if only to give myself a break from the pain.  However, I would like to continue the stretches.  I assume the calf stretches are still safe, but what about the wall stretch that directly pulls on the plantar fascia?  Also, are strengthening exercises still allowed for someone who has received the steroid shot?
Dr. Blake's comments: If you get a steroid shot for plantar fasciitis, you temporarily weaken the tissue at the heel attachment, so stretching is not recommended for at least two weeks. Calf massage is okay and most strengthening like metatarsal doming and single leg balancing is fine. Please do no work at all with the heel not in contact with the ground, like heel raises, during this time. Remember long acting cortisone shots are the ones we worry about. Some doctors place their patients in removable boots during this two weeks, others just tell the patient to be careful. I have been burned with the plantar fascia tearing post injection that I want to see what an MRI shows first. If the fascia looks very degenerative, then I discourage a cortisone shot completely. Have you done an MRI? What about PT? Rich 

(2) I am going to try to start the contrast baths.  I see from your blog that it starts with warm water immersion.  Which bath should I finish with -- the warm or the cold?  I would like to end on the warm so that my feet are warmed up enough to do some stretching immediately afterward.

Also, for someone who doesn't have all the required tubs, can I use warm water in the bathtub and then just use frozen water bottles for the cold contrast?  The swelling/pain is specific to my heels, so I'm hoping this could work in lieu of cold immersion.
Dr. Blake's comment: No, you need at least 10 minutes to unthaw after the contrast bathing to do stretching. Submersion is the best, but if you have to roll on frozen sports bottle double the time to 2 minutes ice. Good Luck Rich
Thank you and happy holidays!

Best Christmas Songs!! Merry Christmas Rich

Friday, December 20, 2019

Varus Support for Forefoot Strike Running Pattern


     Biomechanics is all about experimentation. This runner is very fast and a forefoot striker. In designing support for runners, you have to control the motion at the point of strike: rear foot, mid foot, or fore foot in this case. We are between seasons: cross country and track. That is the perfect time to make biomechanical changes. After my first visit that analyzed the problem as a pronatory mechanical fault, and that he was a fore foot striker, I had him bring in 3 OTC inserts that I could experiment with at the 2nd visit. Today I placed different wedges of 2, 3, and 4 degrees of varus to the forefoot . I watched him run and none of the inserts caused more pronation or lateral instability. All three inserts controlled the pronation at strike in different amounts. Since one foot pronates more than the other side, I advised the patient that he may end up deciding that one side felt the best with a higher control amount. I however did not want to influence the situation my telling him my expectations of what may happen. He will run two weeks with 2 degree fore foot varus wedges, then two weeks with 3 degree fore foot varus wedges, and finally two weeks with 4 degrees fore foot varus wedges. This of course may change if he feels uncomfortable as he increases on both sides. I advised him that it is okay to increase only side for the two weeks. I plan to see him in 6 weeks to see where he is. His coach had wanted him to run one day a week in the off season, but I need 2-3 days per week so we will have at least 5 runs at each level. Rich


1/8 inch poron used for my varus wedging

3 Pairs of Inserts each with different corrections

Isolated view of 4 Degree Varus Wedging with beveling laterally, distally, and proximally

Closer View of the Beveling Needed for 4 Degree Varus Wedge

Achilles Tendon Ruptures: Excellent Article on Your Choices

Thursday, December 19, 2019

Stripline Posts: A Stable but Lower Volume Rear Foot Extrinsic Posting for Stability


     This form of rear foot extrinsic posting for an orthotic device is called Stripline posting. It is used in a young soccer player to maintain stability in very tight soccer cleat. 

This is called Stripline Posts for Improving Stability but keeping volume low. The image shows that a normal post is applied and then the back 1/2 is removed. 

This is the side view of the same image. The important frontal plane stability is maintained in stripline posting.

Safety Bar in Bathrooms for the Elderly

Monday, December 16, 2019

Simple Solution Hammertoe Pain

Sore at top of 2nd toe. 2 off weighting pads. The white is 1/4 inch adhesive felt and the pink is 1/8 inch adhesive felt. Simple solution for a 93 year old with dementia. 

Sunday, December 15, 2019

Best Foot Exercises and Stiffness Recommendations

Dear Dr. Blake:
     Hi, I love your blog posts. I just re-read the one about the golden rules for feet.  I have stiffness in my feet after undergoing 2 separate bunion surgeries 6 years ago with a third one to correct a bunch of scar tissue in one foot. What would you recommend as the three best exercises to do on a daily basis? 
Dr. Blake's comment: The three (four) best exercises to do each day are:

  1. Single leg balancing up to 2 minutes either barefoot and with shoes on
  2. 2 positional achilles stretches done once or twice a day to make sure the calf is loose
  3. Single leg heel lifts up to 25 (if one is difficult spend a month just doing 2 sided)
https://youtu.be/-4OB7wcYTJE

https://youtu.be/xjsYz_YFGyY

https://youtu.be/0eAqJ4-oKTM

https://youtu.be/GY-mJjXmeIc


I do so many exercises for different ailments in other body parts that I can’t or don’t have the time to do a lot of feet exercises but would like to narrow it down a bit. I find that I have a lot of stiffness/pain  in my right foot when I go to do a push-up or something like that when my foot is bent at that weird angle. I’m sure you’re too busy to write me individually but maybe you could send a letter out about post bunion surgery exercises to avoid the situation I’m in.
Dr. Blake's comment: Stiffness is an interesting thing. It can be related to stiffness, so rolling out the arches regularly on a tennis ball is good along with the plantar fascial wall stretch on one of the videos above. It can be related to foot weakness, so the four exercises above will be helpful. It can be related to scar tissue that really needs some PT work. It can be related to swelling stuck in the foot. Try doing contrast baths daily for a week experiment (sorry this is time consuming) and see if that loosens up you foot. It can also be related to nerve tension. Neural flossing can help that. Good luck. Rich

https://youtu.be/rRt5hC24Afg

https://youtu.be/g94F8g_jzGg

Thank you,

Partial Tear Plantar Plate: Email Advice

Hello Dr.Blake,

My name is Allison (name changed due to witness protection), I would really appreciate your time to answer me on my problem. I’ve been in a lot of pain and recently I had an MRI and was told I have a partial tear of the 2nd plantar plate. I’ve been advised to wear a boot for 2 months. Unfortunately I’m still in a lot of pain and don’t feel there’s any progress.
I found you online and I was hopping you might have any suggestions on what I should do to help heal and not be in so much pain. Doctors say there’s no successful surgery. Do you have any recommendation or suggestions?

I would really appreciate it, Thank You!

Dr. Blake's comment: First of all, thank you for placing this in the blogger contact area of the blog. It is nice to meet you. Secondly, surgery is a common treatment for this condition with great results, so that is important to know. The treatment conservatively, and even post surgery, is based on figuring out the mechanics to protect and off weight, controlling the inflammation, and calming down the very sensitive nerves. The removable boot is a go-to for 2-3 months, but only if the pain in the boot is 0-2 on a scale to 10. That way you know that you are calming down the tissue. Sometimes the boot only puts more weight on the metatarsals increasing the pain. If this is the case, the boot has to be modified to off weight the sore area, or abandoned for bike shoes with embedded cleats, or just really stiff shoes with no bend. 
     You have to work for several years with budin splints or taping of the joint while you ice daily. If there is any swelling, you want to do contrast bathing each evening and do more elevation than you are doing. Massaging the area initially painlessly with hand lotion for 2 minutes twice daily can desensitize the tissue relaxing the nerves. PTs and acupuncturists know how to relax the tissues. Here are some videos that may be helpful. Good luck! Rich



https://youtu.be/-v9IrSucQpE



https://youtu.be/928DwpwEaXE

Here is the concept of Budin Splint:
http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

Here is a summary of plantar plate injury treatments:
http://www.drblakeshealingsole.com/2015/01/capsulitisplantar-plate-injuries-of-2nd.html





Saturday, December 14, 2019

Philosophy of Treating Athletic Injuries (Part 2)

Philosophy of Treating Athletic Injuries (Part 2)
A patient should have already answered in their mind the following thoughts before coming to the initial visit (these can be sent to them in the initial email or fax of paperwork). These are:
1.     How serious do I think the problem really is?
2.     Do I want only home remedies or can I afford the time and expense of physical therapy done 2 or 3 times a week for 3 or 4 weeks?
3.     Could I totally rest from my sport if advised? Would that devastate me physically, financially, and/or emotionally?
4.     Do I need to know exactly what is wrong on the first visit, or can X-rays, bone scans, MRIs, etc., wait if initial treatment does not work?
5.     Do I want to take the necessary steps to prevent recurrences if lifts, shoe inserts, daily exercises, prolonged therapy is recommended, or do I think of this as a one-time occurrence?
6.     Is the cost of care a big issue? What does my insurance cover? What is my deductible?
Without knowing the answers to these questions, the doctor or therapist may make some wrong decisions with regard to your care.
So, you have an injury and want freedom from it. Some of the basic Golden Rules that everyone must follow are:
1.     No running, dancing, etc., if you cannot walk without pain.
2.     Never exercise with pain; if you have an injury, you cannot do anything that keeps producing the pain cycle.
3.     If there is swelling, you must work on that daily to reduce it as soon as possible with compression, massage, elevation, contrast.
4.     If there is stiffness, full return to activity is restricted until the stiffness is greatly improved.
5.     If the decision to start your activity has been made, and you are experiencing a return in symptoms, you must rest again for minimum of two weeks. You are just not ready.
6.     Alternative activities to cross-train are normally encouraged to maintain cardiovascular fitness.
With some injuries, the sequelae of scar tissue accumulation and muscle weakness, joint instability and stiffness, chronic swelling and nerve hypersensitivities, all can play a role in a slow return to normal activity. Rest alone may not help some injuries, and treatment may be prolonged in addressing these issues. Of course, no athlete wants to deal with that. If there has been permanent damage as a result of the injury, only partial rehabilitation may occur. It is so important to quickly produce a pain-free environment (0-2 pain levels maintained). How to get there normally dictates some of the early treatment.

For most injuries, reversal of the cause is often helpful, and even mandatory. Without finding the cause, the injury may chronically recur over and over. But for many injuries, that can be overdone or misused. For example, flat feet can cause knee pain, or prevent knee pain from getting better. So, should all patients with knee pain and flat feet get corrective inserts? If you realize that most patients with knee pain get better without correcting the flat feet, you can perhaps see that treating flat feet in all cases of knee pain would be improper. The clinician needs to select only those patients that really need a certain treatment. This is not always a simple task to accomplish. Temporary orthotic devices, like Power step or Sole, which can be modified for greater support if needed, have created a wonderful diagnostic test to see which patients may need permanent corrective devices. The patient's response to the insert will help make the decision on custom orthotic devices easier. But, this is just a small example of cause reversal. With every injury, there are a myriad of common causes, and some not-so-common causes, which may need to be treated as treatment goes along.
So the doctor and therapist must have free communication with the patient each step of the way in rehabilitating the injury. The patient must understand the doctor's or therapist's plan of attack, and help advise on the limitations of time, expense, and energy. The patient should be given clear guidelines on the present activity level allowed, the proposed treatment plan, and options for further treatment if needed. With this communication, injuries can become a learning process for the patient, and a guideline for further injury prevention.
The above is from my book: Secrets to Keep Moving.