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Wednesday, July 29, 2020

Thank You Dr. Kevin Kirby!!

     This post is a thank you to a Rock Star, so to be noticed will probably never happen!! Dr. Kevin Kirby from the Sacramento area of California has greatly influenced my beloved profession and my beloved field of biomechanics. He has his beliefs, and stays true to those beliefs, a trait I completely admire. 
     So, let me explain why this overdue thank you in cyberspace is happening today. Today, I saw a typical patient needing my biomechanical help. At 17, and a runner, he had already had his left accessory navicular removed, and was trying to avoid the same surgery on the right side. This is a small extra bone that 10% of the population has, and only 3% have on both sides. Lucky him. It is both aggravated by pronation, and can cause pronation by weakening the arch. 
     One of my measures of a patients pronation is called the relaxed calcaneal stance position or RCSP for short. This measurement is ideally vertical (standing straight up) or a few degrees in varus. For my patient he stood 6 degrees everted RCSP, so very pronated, and this matched his pronatory gait and pronatory symptoms. 
     The technique I use for this is called the Inverted Orthotic Technique. It is a highly corrected orthotic device, which I felt important for the need to let the patient run and attempt to avoid right foot surgery. These are both moderate to severe implied needs for maximal correction on my part.
The technique is based on a 5 to 1 orthotic correction to foot change. Therefore if I correct the foot 5 degrees I get 1 degree of foot change. 
     So, what happened? I gave the patient with 6 degrees everted RCSP a 30 degree Inverted Orthotic Device and the feet changed to 4 degrees everted. I realized I was a little wide with the heel cup so I lost a degree or so, but this is common when you are initially trying to grab the foot that the foot does not respond how you want it. 
     So, at last visit with the patient, I gave him the 30 degrees of correction with a 2 degree foot change, and ordered a new orthotic at no cost to the patient. I was committed to helping. I added a 3 mm medial Kirby to the existing mold (which normally gives me 2-3 degrees of change when added to the Inverted Technique). I called the dad a week later just to see how he was doing and he said that the new orthotic (that I was unhappy with) was far superior to his previous orthotics and he was really enjoying running in them painfree. 
   Today, I dispensed the 30 degree Inverted with 3 mm Kirby and his heels stood straight up and down at vertical RCSP. This was then reflexed in his gait walking and running. At times it is the Kirby Skive that makes the most difference, and at times the Inverted Orthotic that makes the most change. So, we are inseparable (since I invented and the trustee of the Inverted Technique) and I thank you Dr. Kirby. This is how Dr. Kirby works in the shadows in my office daily, and why his technique has been vital now for over 30 years. 
Thank you Dr. Kirby for always being there for me!!



Tuesday, July 28, 2020

"How I Approach Problems": Heel Pain, Sudden Onset, Swelling


    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

With the description of heel pain, sudden onset (you can remember the day), and swelling, you are not dealing with plantar fasciitis, but either a heel bone stress fracture or plantar fascial tear. The post today will look at the calcaneal (heel) stress fracture and the thought process in treatment. 





In the 2 MRIs above, the patient's sudden heel pain with swelling was diagnosed as a calcaneal (heel bone) stress fracture. The xrays taken the week before were completely negative. This case completely resolved with the repeat MRI 6 months later.
     When you talk about any stress fracture, or gross fracture for that matter, you have to ask yourself if the patient deserved the fracture by how they treated their foot. By this I mean, did they seem to overdo or over stress the foot, and seemed to get what they deserved. If your answer is no, then you have to look for other reasons a bone would break like low Vitamin D, low bone density, eating disorders, celiac's disease, history of osteoporosis, etc. Even if they seem to deserve it, over 50 years old, I get a bone density, and ask about family history of osteoporosis, and a personal history of low Vitamin D or funny diets.
     I am going to attach the original video I did on heel pain so you can see the examination of someone pointing to a heel stress fracture. Heel stress fractures are treated very differently than plantar fasciitis as the patient was initially diagnosed due to heel pain. Heel stress fractures need soft cushions, perhaps custom Hannaford orthotic devices, bone density and Vitamin D blood levels, possible bone stimulator, and occasionally they break all the way through and need some surgical pinning. Making the correct diagnosis at the beginning of the process saves alot of time.

https://youtu.be/plbBvPASXwM






Dr Larry Huppin: Shockwave for Posterior Tibial Tendonosis and Tendon Dysfunction

If you have been suffering from chronic posterior tibial tendon issues, consider the non invasive shockwave therapy presented here from my friend and colleague, Dr. Larry Huppin.

https://youtu.be/lstR-Ls9M5g

Thursday, July 16, 2020

Gout Should be Re-Branded to Urate Crystal Arthritis

This abstract, sent to me by Dr. Craig Payne (Australia), really runs true. I make the diagnosis of gout, and maybe five year later their primary puts them on the appropriate drug. During this 5 year period, many joint destructive gout flareups may occur. Rich


https://link.springer.com/article/10.1007/s43441-020-00198-0?fbclid=IwAR18Jy-Q7dPtG5z3rS0qG7ZH6r-SybDrEMzde43WCKk8DlaaaobrXZ0cjZ0

Monday, July 13, 2020

How I Approach Problems: Plantar Fasciitis with Sudden Onset and No Obvious Swelling


    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

           Plantar Fasciitis: Acute in Nature and without Swelling

Most heel pain is diagnosed as plantar fasciitis, and everyone knows the ice, stretch, and support protocol. But what if it is not plantar fasciitis. One subset of patients that I see have a sudden onset of pain (not plantar fasciitis), and without swelling that I can note on exam, and therefore fall into one of these 2 diagnoses.

With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms)
Plantar fasciitis can morph into bursitis due to chronic low grade inflammation, but this is not the type we are discussing. The heel pain that is sudden with a plantar heel painful palpable mass, is called infra calcaneal (heel) bursitis.  There may or may not be a reason for the bursae to swell causing the pain that the patient will remember (like stepping on a rock barefoot at the beach). There is a bursal sac that is there when needed to protect bony prominences (like side of hip, front of knee, under the metatarsals), and only gets sore and swollen when irritated.



You can perhaps make the diagnosis with barefoot walking. Plantar fasciitis typically hurts the worse at push off, so walking on the toes may hurt. Heel bursitis hurts more when asked to walk on the heels alone (bursitis sufferers usually do not like this at all).

Heel neuritis can be local (Baxter's nerve entrapment) or referred pain from the tarsal tunnel or higher up (low back and even cervical issues). Like any peripheral nerve problem, you always have to think that it could be from higher up the chain (called Double Crush syndrome). In Double Crush, the nerve would be irritated at the heel (say a pes cavus foot with bony heel and no fat pad---the perfect storm), and is being irritated at the back, piriformis, behind the knee due to a baker's cyst, or in tight hamstrings or calves. What complicates this is that there is no test that confirms that the nerve is irritatable. Nerve tests like nerve conduction studies are looking for damaged nerves not excitable nerves.

 This photo may be alittle difficult, but it is of all the nerves on the bottom of your foot. Look at the nerves just under the heel bone. Any of these can get irritated locally or from a signal from higher.

So, when heel pain, initially diagnosed as plantar fasciitis is not getting better from plantar fascial treatment, you must start looking for another working diagnosis. When there is no obvious swelling, typically ruling out problems like plantar fascial tearing and heel stress fractures or bone bruises, you should look for heel bursitis and heel neuritis.

My next posts will go over the treatments for each separately.







Wednesday, July 8, 2020

"How I Approach Problems": Plantar Fasciitis with Heel Pain with Swelling

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

     Heel Pain with Swelling: This is Not Plantar Fasciitis

The “itis” from plantar fasciitis is deep swelling and inflammation that is really hard to feel. The patient does not appreciate any swelling or fullness to the tissues. So, when a patient presents with heel pain, with or without the previous diagnosis being plantar fasciitis, and there is obvious swelling in the tissues, the injury is not plantar fasciitis. From my last post, here is how I summarized Acute heel pain (pain that comes on quickly). 

With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:
  1. Plantar Fascial Tears
  2. Heel (Calcaneal) Stress Fractures
With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms
Therefore, an acute onset of heel pain, with the presence of swelling is either a Stage 2-3 plantar fascial injury or a boney injury to the heel (commonly a stress fracture). MRI is the image of choice, and even though the treatment is 3 months of immobilization for both, it is different thought process in treatment when the injury is fascial or bone. 

With fascial injuries, you made need to use plantar fascial treatments of taping, orthotic devices, and physical therapy after the period of immobilization.

With calcaneal heel bone injuries, you have to think about bone stimulators, overall bone health, bone density testing, Vit D, and the extent of the fracture up into the vulnerable subtalar joint. 

My next post I will discuss the protocol of plantar fascial stage 2 or 3 injuries, also known as partial or complete tears. 

Monday, July 6, 2020

“How I Approach Problems”: Plantar Fasciitis Not Responding to Treatment

    This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that prove to be more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.

                    Plantar Fasciitis Not Responding to Treatment 

Many heel and foot problems are called plantar fasciitis when they are not. Plantar fasciitis is a Grade or Stage I Ligament Sprain. It is inflammation from being pulled on too much in some manner typically in an overuse fashion. In the last blog post we talked about what is and what is not plantar fasciitis. And even though there are always exceptions to every rule, most of these are true. Plantar Fasciitis has the hallmarks of:

  • Gradual onset of pain
  • Worse in the morning
  • Pain after prolonged sitting
  • Minimal to no swelling
  • Typically at the heel 
  • Responds well to treatments of stretching, icing, and taping 
  • Responds well to some forms of arch support where the weight is transferred forward off the sore heel
Therefore, it is good if the patient or yourself has this pattern of symptoms, and you are probably correct at calling it Plantar Fasciitis. But what happens if your initial treatment of stretching, icing, and taping does not help. And one or two forms of arch support are not helpful or even seem to make it feel worse. I personally like to follow my patients monthly and I expect if I have made the correct diagnosis, the patient begins to improve. Each visit I have with the patient after the first will show steady and gradual improvement. It is hard to measure time to complete success, as some patients want to pin me down. But, progress is key month by month if your treatment and diagnosis are in sync.

Each diagnosis has very different treatments so it is important to make an exact diagnosis when you are not improving. What are some of the typical signs from the patient that the problem may be something other than plantar fascia?

  • The Onset of Pain Happened on one day
  • The worse may is not when you first get out of bed in the morning
  • The involved heel is more swollen than the other side
  • The pain radiates into the arch or toes
  • It hurts more when you walk on your heel then when you lift your heel
With an acute (sudden) onset of pain, and swelling in the heel, the 2 common diagnoses are:
  1. Plantar Fascial Tears
  2. Heel (Calcaneal) Stress Fractures
With the acute (sudden) onset of pain, without noticeable swelling in the heel, the 2 common diagnoses are:
  1. Heel Bursitis (only deep palpation away from the plantar fascia finds a painful bursal sac)
  2. Heel Neuritis (this can cause heel rim pain or radiating pain or other neuropathic symptoms

So, I have tried to show the myriad of patients who are not improving in their treatment of plantar fasciitis, typically because their heel pain was called  plantar fasciitis and it was something else. That something else, needing totally different treatments, was either:
  • Plantar Fascial Tearing or Fasciosis
  • Calcaneal Stress Fractures
  • Plantar Calcaneal Bursitis
  • Infra Calcaneal Neuritis
Each of these problems will be discussed separately in posts later. 

Friday, July 3, 2020

Sesamoid Fracture Advice

Dr. Blake's comment: The patient's mother kindly sent the MRI CD for me to review which I did not until 6/29/2020.

Hello again Dr. Blake,

Thank you for reviewing L's MRI.  Here is a recap of my initial email with updated/new questions.  We look forward to hearing from you and are very thankful for your time and expertise. 

History:
L is a competitive varsity cross country and track athlete with her high school.   In February of this year she sustained a left metatarsal stress reaction (diagnosed via MRI) during track and field training.  She was immobilized for 8 weeks in a CAM boot, sat out the track season, received PT and did aqua jogging and swimming to maintain cardio fitness.  She had a  full blood panel and everything was WNL. Vitamin D was WNL, but in the lower range (we  live in South Florida and she gets plenty of sun on a daily basis). She supplements now with Vit D.   She is a very healthy eater, healthy weight and has regular menses. After a slow progression to return to running over the course of months she has been pain free in the left foot and doing summer training with her cross country team.  She has always run in HOKA Cliftons, but does rotate with Mizuno Wave Rider and Brooks Adrenaline during cross training.  She currently uses the customizable NB2400 (by Aetrex) shoe inserts in her left shoe.  
Dr. Blake's comment: I love the routine change in shoes to vary the stresses.
On June 11th after a practice she complained of R foot pain in the big toe region.  Due to her previous injury, we did not waste time diagnosing and the next day visited her foot and ankle specialist and had an MRI of the right foot the same day . They placed L in a CAM boot to be worn at all times until her follow up July 22nd (approx 6-7weeks post injury).  She has started Exogen bone stimulator 1x day x 20 mins, has had 2 out of 6 scheduled ESWT treatments , and has begun 2x week acupuncture.    She does not complain of any pain. 
Dr. Blake's comment: I would have to see what the literature says about ESWT for acute fractures. Please ask the doctor if there is anything for us to read.

1. How long would you recommend she remain in the boot? 
Dr. Blake's comment: My general rule is 3 months, however at 2 months you can begin to gradually wean out of the boot into bike shoes with embedded cleats or Hoka's with the rocker sole. You have to maintain the 0-2 pain level. 

2. Do you allow patients to remove the boot for gentle ROM of the ankle (the boot is driving her crazy with c/o foot cramping) ?
Dr. Blake's comment: Yes, it is a removable boot for walking. She does not need to wear it when she is not walking. Many patients find that around the house they can walk flat footed in soft sandals and avoid the boot since they can avoid toe bend and still protect. 

3. When should foot strengthening be initiated?   and massage to desensitize?
Dr. Blake's comment: Foot Strengthening is now!! Massage is now!! The massage is best done by the patient since she can make sure that she is avoiding pain. Each massage should b 2 minutes with some massage oil or topical gel like mineral ice. The foot strengthening she should don is metatarsal doming, single leg balancing with a float for the big toe, double and single heel raises also with a float for the big toe joint. 

4. Do you recommend she incorporate a dancer pad (or similar sesamoid cut out)  in her CAM boot? should we add a cluffy wedge with this? 
Dr. Blake's comment: Depends on her pain level. You place pads in like dancer's or cluffy wedges if you need to get the pain to 0-2 within the boot.

5. She is wearing a Darco Toe alignment splint while in the boot.  Do you prefer spica taping over this?    Do you use spica tape and dancer pad at the same time?
Dr. Blake's comment: If the boot gives 0-2 pain, no need for anything else. If not, you have to see what works to drive the pain down. Typically, dancer's and spica taping are used in the next phase as she re-introduces her activities. She should be cross training with cycling, or swimming without pushing off, etc. Some patients can use the eliptical if they stay flat footed. 

6. When could she attempt pain free short bouts of WB for mineralization?  
Dr. Blake's comment: Typically, this is a weight bearing boot, even if you need to off weight with dancer's padding. Around the house, you typically need the boot off to do the contrast bathing and, as long as you do not bend the toe, and you have dancer's padding and overall cushioning in a slipper, you can meander around. Keep the pain low!! At 8 weeks, if the patient is doing great, symptoms are where they should be, you begin to spend more and more time in a Hoka shoe or other stable but cushioned shoe. You need your orthotics with dancer's padding made by then. 

7. At what week post injury do you recommend beginning Physical therapy?   Aqua jogging?   or Swimming?   (we would like her to get some kind of cardio exercise when safe to do so)
Dr. Blake's comment: Agua jogging in the deep end of the pool is now just not emphasizing the toe motion. Swimming also great without fins and without pushing off the wall. Cycling without cleats with the pedal on the arch, not ball of the foot. Eliptical with Hokas flatfooted is fine without using the arms. 

8. Do you have a preference regarding  HOKA Clifton's vs Bondi?
Dr. Blake's comment: No, but it seems that the Bondi is more stable. With Hokas, each shoe has a different rocker point. So, I would make the decision based on how she feels the bend protects the sesamoid. If they both feel the same, go with the one that feels like it has the most toe box area. You will need it for all the sesamoid protection. 

9. At what part of the recovery do you initiate getting fitted for custom orthotics?
Dr. Blake's comment: This should be done as soon as possible. You need to have a good supportive and protective orthotic device, which could take adjustments or re-dos, when she is trying to wean out of the boot at 8-12 weeks. 

10.Do you have any recommendations for a physician in the Sarasota/Bradenton Florida area?
Dr. Blake's comment: I trust Dr Brian Fullem (Clearwater) and Dr. Matthew Werd (Lakeland) and Gerald Cosentino (Tampa). You can call their offices for a closer referral. 

11. We have been advised to avoid any icing and/or contrast baths at this time while she receives the shock wave therapy. Would she still benefit from it 6 weeks from now? 
Dr. Blake's comment: Shockwave is meant to inflame, but help in the healing. I have no experience with it for sesamoids. Sorry. I assume that icing and contrasts are fine after that stops. 

12.  As this is her second fracture in less than one year, do you think we should request a bone density test for her?
Dr. Blake's comment: Our doctors have gotten bone densities at her age and use the same values as the 20 year olds for understanding of the bone density. It is a test if she has low Vitamin D levels repeatedly, if her eating habits are suspect, if her menses is irregular, or if she is slow at healing bone. Did everyone feel she healed the metatarsal fracture fine and in the normal time length? 

13. Are we missing anything?    The MRI report  references sesamoiditis, so does she have a double whammy or will the fracture treatment help with the sesamoiditis?
Dr. Blake's comment: Heal the fracture, heel the itis part with the icing and contrasts and protection. 


Running is a big part of L's life and we want the absolute best care for her. We would like to be aggressive with her treatment to prevent a more chronic problem, however I want it to be within safe guidelines.  Her team is her family and it is hard on her to be away from them for weeks as she heals. 
Thank you!  
Sincerely,

ps. on a side note, I should also mention that L was an idiopathic toe walker and as a toddler wore AFO's and spent years in PT.  She was a very difficult case to treat (we avoided surgery), and still has very tight calf muscles and poor dorsi flexion, which is more than likely pre-disposing her to her injuries.  Are you familiar with Aaaron Mattes and his stretching therapy?  He is in Sarasota and L was treated by him years ago for her toe walking.  His sessions are very costly, but if you are familiar with his techniques and feel it would benefit her, please let me know.  
Dr. Blake's comment: Tight achilles is a huge reason for athletic injuries to the front of the foot. You should do what you can to help stretch out the achilles and I will look at Aaron's work. On a ironical note, the tight achilles gives her power to do sports where you are up on your toes.