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Sunday, May 15, 2022

Dr Ronald Valmassy Scholarship for Biomechanics


I have attached here the giving page for the California School of Podiatric Medicine. A scholarship fund to honor Dr Ronald Valmassy is being formed to foster the field of biomechanics for podiatry students. Please consider a gift and specify the location of your donation. 
     As many of you know, Dr Ronald Valmassy, was the head of the Biomechanics Department at the California College from 1974 to 1987. He trained thousands of podiatrists in the classrooms, clinic, lecturing and book writing. He has written the most extensive book on Podiatric Biomechanics in the last 30 years---Clinical Biomechanics of the Lower Extremities published by Mosby in 1996. 
     Biomechanics is the foundation of most of our treatment of patients. Your donation will help continue its emphasis in education. Dr Ron would be very proud of you. Thank you. Rich 

Friday, May 13, 2022

The Inverted Orthotic Technique is now also in eBook Form

https://store.bookbaby.com/book/the-inverted-orthotic-technique

Carlos Martínez Sebastian from Spain

Álvaro Gomez Carrión from Spain

     I am very proud of my accomplishments for sure, but humble enough (could be more!) and realistic enough, to know that your true worth is in how much you love (and not what you accomplish per say). This is why I love to teach, I love my students. They bring me great joy!! This is why I love to write and lecture, I love to help build up the collective we in the knowledge I know. It is another act of love. I have written articles, handouts, and of course, medical charts. My first attempt at some more serious writing was "Secrets to Keep Moving" published in 2016 following a small stroke. It was not welled planned, written okay, and never advertised. My next attempt was "The Inverted Orthotic Technique", a technique I have been working on developing for 40 years and which came out in English 2019, Spanish 2020, and Korean 2021. I am happy I could get this in electronic form in 2022. My next book came out this year in 2022 called "Practical Biomechanics for the Podiatrist: Book 1 of 4". This is an accumulation of all of the incredible teachers I have had over the years. These teachers have been Podiatrists,  Orthopedic Surgeons, Physical Therapists, but mainly my wonderful patients. Truly I have learned as much, if not more, from them as any other source of my medical knowledge. So, Practical Biomechanics is a blending of every aspect of my career, and I am so pleased with the love it shares. And, by the way, Carlos and Alvaro are now working hard on the Spanish translation along with writing a chapter themselves on Biomechanical Theories (Book 3). Thank you all for coming along on my journey with me, as you can see, I love to do things with others. Rich ﬞ


Monday, May 9, 2022

Right Achilles Pain: Initiate BRISS

I just saw a patient with Right Achilles pain for 6 months. She had no increase activity or change in medications. I initiated BRISS treatment for tendinitis and advised her to email me in one month about her progress. I found swelling, but no tightness in the achilles (to see if Occam's Law applied). BRISS is a simple acronym to remember to think about all the categories of tendon injury treatment. The acronym stands for:
  • B for biomechanical treatment
  • R for Rest or Activity Modification treatment
  • I for Inflammation Treatment
  • S for Stretching or Flexibility Treatment
  • S for Strengthening Treatment
How did it help start the treatment on our first visit?
B for 1/4 heel lifts in all her shoes, no barefoot next 6 weeks, heeled shoes as much as possible
R for day to day activities only, will consider cross training with bike, elliptical, swimming
I for ice twice daily and contrast bathing for swelling reduction each night
S for gastrocnemius stretching and no negative heel stretching now
S for two positional heel raises with the heels only on one inch book and no shoes each evening


This patient was given an RX for 8 PT visits and will email me in one month. We did talk about posterior sleeping splints, but since she is a poor sleeper, she was worried that it would bother her. So, the splint was not in our initial treatment. 

Wednesday, May 4, 2022

Wrestling with a Painful Foot: Thoughts on Treatment

I have many rules I use when attempting to help someone with a sore foot, and I also need their cooperation in the treatment. First of all, whereas they say periodic dieting is great for our overall metabolism, periodic levels of increased pain should be avoided. Therefore, after the onset of pain you want to reduce the pain to the 0-2 range (still smiling on the pain scale charts) as quickly as possible. This can be accomplished on one end of the spectrum with complete bed rest, and for some simply not running 5 miles. Get the pain down, and hold it down for 2 weeks for a start. 
     Hopefully, by this time you have a doctor or therapist appointment that can lead you further. But beware, all medical recommendations have to be tried by you, and if they increase your pain, stop doing them until this is reported. Some practitioners will have you continue if they deem the pain as "Good Pain". Good Pain is pain that does not linger for 2-3 days after starting, does not cause you to limp, does not come on during an exercise only after. 
     Now, what types of foot treatment should be done? These are general rules but will apply to most of you. The types of treatment, and I recommend one from each category at least, are Mechanical treatments, Inflammation treatments, and Neuropathic (nerve pain) treatments. Mechanical treatments can be walking casts, changing how fast you run, shoe selection, insert selection, padding, taping, braces, etc. There are so many things that can be tried and can vary from visit to visit. 
     Inflammatory treatments in my practice is typically ice in some form and contrast bathing. I try to avoid oral medications in general, but short periods are fine. If you have any swelling or sudden stiffness or sore muscles and tendons, you should be working on the inflammation daily.
     Neuropathic pain can be from local nerve injury, local nerve hyper-sensitivity, and referred from above the foot. Nerves love non-painful massage, warm, short ice no longer than 5 minutes, motion like walking, neural flossing, but not prolonged stretching. Any injury that still has significant pain after 3 months will develop nerve pain in the form of protective neural tension or just hyper-sensitivity. Nerve pain is more intense than inflammatory pain, but shorter in duration. Patients commonly describe level 10 pain bursts for a minute or less that shuts them down. There is a whole branch of PTs specializing in nerves. 
     Therefore, when you are treating a painful foot problem, think about what mechanical, inflammatory, and neuropathic treatments you are doing daily. If you are missing one, add it in. Or, make changes to each type of treatment if the treatment progress stalls. Good luck!!


Sunday, May 1, 2022

Wednesday, April 27, 2022

Lapidus Procedure for Bunions: Normal Results (what are your odds) for the Consumer

https://www.jfas.org/article/S1067-2516(22)00118-1/fulltext?rss=yes

Summary of Results:

Lapidus is a very common bunion surgery and the results of this study following patients for 2 years showed the odds. One of the differences from standard Lapidus procedures that this study tried to prove was that they could allow their patients to walk much quicker than standard 8-12 weeks of non-weight bearing, therefore walking in normal shoes on average 45 days post surgery!! This is huge!!
The results are pretty standard for operations at the foot:
1/117 early re-occurence of the bunion (typically want to get 15 years out of this procedure)
11/117 hardware was irritative (considered a complication)
5/117 other complication including 1 non-union
In total, 7/117 were re-operated on to fix issue within the first 2 years post Lapidus

If you match up the results I tell my patients before they get surgery, I think this study is slightly better.
I tell my patients, that 85% of them will be happy they had the bunion surgery (really good from our Podiatry perspective). Of that 85%, 50% of those patients will say excellent results and 35% will say good results from the surgery (good means that they are not perfect, but they are still happy that they went through it). The other 15% get fair to poor results (with this study around 10% which is close). 1-2% of patients are poor due to an infection, non-union, early bunion return, etc. 13% are fair due to some of the issues brought up (hardware irritation, pain more than they like, entrapped nerve, negative effect somewhere else, etc). Poor results tend to be re-operated on to fix what went wrong, and fair results about 50% have a re-operation (7% overall re-operation) and the same number just want to live with the issue. This 7% is almost exactly what the study showed for re-operartion 7/117 which is normal Podiatry surgery odds. So, in summary, I think this study showed that Lapidus patients (fusion across the metatarsal tarsal area) can walk earlier then the standard recommendation since the complication rate does not go above the standard 15% at all. 


Saturday, April 23, 2022

Our Personalities and its Effect on our Foot Care


     The doctor patient relationship is a very sacred thing. When there is a joining of spirits between these two individuals, healing has an easier route to go. A good relationship can be very challenging to find, and I hope both sides work at seeing the various problems that present from the patients' or the doctors' perspective. 
     The above image is merely one representation on how we view the world, and thus affects how we understand issues that involve us. Both the Patient and the Doctor can have the same or different lens that they view the world. This will affect any relationship that they engage in. I will limit this to the Patient's lens that they perceive the doctor patient relationship. There will always be both the good and bad of any perspective. 
     Patients can be very Body centered, which gets them into treatment earlier, but can have them too focused on their illness. But, this is why doctors, family, and friends can be so helpful to allow us (if we grant them permission) to see things differently at times. My body centered patients are probably my best patients at following instructions. They have an incredible drive to heal this body of theirs.
     Patients can be Mind centered. They can present with a problem, and already have read every available article on the topic. This can lead to both a cure, and a lot of confusion. They can both over-think issues, and come up with good conclusions. They have probably taught me the most, since they have tried from their research various gadgets or techniques. They can be so much in their head, that they forget the heart and soul of the matter (and undervalue other's opinions). They can also take the longest to see a doctor, as they typically ignore their bodies and the warning signals it produces. 
     Patients can be Spirit centered which can also detach them from their bodies. They can be over emotional, but also not attached to their problems. They have a hard time with body issues or problems. Since they are also not in their heads, they can be the most trustworthy of patients wanting to give their problem completely over to you. They can also have great perspectives on healing, at least in terms of the length of time it takes to heal.
     Finally, Patients can be Soul centered. How is this different from Spirit centered? Perhaps it is best explained but what it is and is not. The soul is who you are. The soul is not emotional, but greatly affected when the "who we are" is disturbed by injury. Soul centered patients can be the best patients when their injuries affect the very nature of who they are, but also not really care if they feel no threat to their being. 
     Let us take an example of these for approaches to the same injury. The patient sprained their right ankle and will miss 6 weeks of college basketball practice, games and perhaps playoffs. Here is how each of these personality types behave:
  • Body Centered---will follow the treatment plan to the fullest
  • Mind Centered---will read everything about the injury which may help immensely, but may get in trouble believing something other then prescribed, may go doctor shopping
  • Spirit Centered---could be an emotional roller coaster, since not connected to the body may have trouble doing what is prescribed, if they stay positive they can be the easiest patient to help
  • Soul Centered---in this case, this college athlete's being has been threatened, therefore, they will be early for each PT visit, and may ask you for an MRI now, even if you wanted to wait for a month

     

Thursday, April 21, 2022

Flip Flops for the Summer if you have heel pain: Blog from Dr Menn

http://www.coastalpodiatry.com/blog/best-flip-flops-for-heel-pain.cfm

Dr Menn emphasizes Oofos, Pure Stride, Birkenstock, and Vionic if you are suffering from Heel Pain. I am in agreement that these are great flip flops to try. 

Saturday, April 16, 2022

CorrectToes and their positive effect on Running

Female Athletes' Foot Changes from Wearing a Foot Orthosis: A Study of Hallux Deviation, Strength, Foot Pressure, and Pain


 This is a new article discussed the use of an insert called "Correct Toes" as being very helpful in patients running. CorrectToes to me are like Yoga Toes that you can run or walk with. Of course, who can be sure that if you have a bunion, and you use anything from a simple toe separator to the more elaborate CorrectToes, that you will not get the same response. Athletes have been telling me for years that toe separators can improve pain and function by aligning the big toe joint better. If you have a bunion, always wear something when you are in some, that attempts to straighten out the big toe joint. 


Keywords:
Bunions
Running
CorrectToes
Foot Pain
Toe Separators

Saturday, April 9, 2022

EvenUp Protects the Spine in Walking Boots and Casts

EvenUp on the left side to keep the spine level

     I am so impressed with this simple device for the opposite shoe that has the cast/boot. This helps the spine and prevents back pain overall. 

Problems with Lapidus Bunionectomy

Dear Dr. Blake,
     I had a Lapidus bunionectomy 2 years ago that is coming back. Will your conservative treatments help this? I have 2 pairs of new orthotics. One pair has a high dome in the mid arch to help with metatarsalgia, specifically 2nd toe pain. The other pair has a higher dome in the medial arch to correct over pronation and PTTD. I just started wearing these hoping to stop the bunion from coming back. Any advice on which pair is better? I have redness where the bunion is coming back and the big toe is starting to drift towards the 2nd toe. The hardware is painful and I would like it removed. Any advice would be appreciated. Thank you. 

Dr Blake's comment: First of all, it is really unusual for a Lapidus to cause a recurrence of a bunion this early post operative. If we share further emails, even a year from now, always remind me of this post on 4/9/22. As you walk, the forces of the ground will always push the big toe towards the second. This is more or less depends on other aspects of your foot biomechanics, shoe gear, activity level, and activities done. Did you have the Lapidus done to help with PTTD? Or were you just having bunion pain? How old are you may I ask? Why is the hardware painful, or when is it painful? Since I do not perform this surgery, you need to ask the surgeon, but most hardware can come out after 6 months post surgery for sure. You need to always wear toe separators to keep the big toe from drifting towards the 2nd toe. A Lapidus immobilizes a joint or two in the arch, so there is more stress at the bunion joint and the joint next in line closest to the ankle. The orthotic devices just have to make you stable, and you may find that the right and left sides feel the better with orthotic devices from different pairs. Are these full length orthotic devices, or ones that stop traditionally behind the metatarsal heads? There are pros and cons to each. Give me some feedback, and I will place any more information on this same post. Rich 

Practical Biomechanics for the Podiatrist: Book 1 Reviewed by Dr Kevin Kirby





Book Review: Practical Biomechanics for the Podiatrist, by Richard L. Blake, DPM, MS
Throughout my years as a podiatry student, podiatry resident and in podiatry practice, I have had the very good fortune to be a student of a number of very gifted podiatrists who were not only inspiring and innovative, but also demonstrated great clinical skill when treating patients. One of the most outstanding of these individuals was one of my biomechanics professors as a podiatry student, Dr. Richard Blake. I am happy to report that Dr. Blake has just published the first of four books on practical biomechanics for the podiatry student, podiatry resident and practicing podiatrist.
My first experience with Dr. Blake was during my podiatry student years in the early 1980s was when he was our Biomechanics Fellow at the California College of Podiatric Medicine. He was a gifted teacher, being able to bring complex biomechanics concepts, examination techniques and foot orthosis therapy concepts to us podiatry students in an easy-to-understand and enjoyable manner.
Furthermore, during that time, Dr. Blake had begun experimenting and developing his innovative custom foot orthosis technique, the Blake Inverted Orthosis Technique, which, to us podiatry students, seemed very impressive in its effectiveness at treating patients with abnormal amounts of foot pronation. Since that time, now four decades ago, I still marvel at the innovation and clinical acumen of my good friend and colleague, Dr. Richard Blake, and am very happy to announce his first book on biomechanics that he has dedicated to his podiatry students at the California School of Podiatry Medicine.
With his recently published book, "Practical Biomechanics for the Podiatrist", which is his first book in an eventual 4-book series on the subject, Dr. Blake covers an introduction to the general principles of podiatric biomechanics, how the podiatrist should approach and evaluate the patient with mechanically-related and non-mechanically-related symptoms, along with sections on gait evaluation and gait abnormalities and the basic components of the foot and lower extremity biomechanical exam.
This 175 page, hard-cover book has numerous color photos and illustrations that help explain the various topics that Dr. Blake discusses within its pages. In reading through the book, I was very impressed at how different this book is from any other previously published book on podiatric biomechanics. Dr. Blake approaches each subject with explanations that will make it easier for podiatry students to help comprehend the complexity of foot and lower extremity biomechanics and will also provide numerous clinical pearls that even the most seasoned podiatrist, who have spent their whole practice career treating foot and lower extremity biomechanical pathologies, will appreciate.
"Practical Biomechanics for the Podiatrist" covers each subject in a very practical manner with numerous case reports of patients from Dr. Blake’s 43 years of practice as a sports podiatrist and foot and lower extremity biomechanics specialist. There are even 138 “Practical Biomechanical Questions” included throughout the book, with answers at the end of the book, that allow the reader to self-test themselves about previously discussed topics.
Overall, I highly recommend Dr. Richard Blake’s first book on "Practical Biomechanics for the Podiatrist" to all podiatry students, podiatry residents and podiatrists who are seeking further knowledge on the evaluation and treatment of mechanically-related pathologies of the foot and lower extremity. The practical information in this book is outstanding and should be on the bookshelf of any foot-health specialist who is seeking to increase their expertise in the evaluation and biomechanical treatment of foot and lower extremity disorders.

Saturday, March 12, 2022

Pronation Syndrome: The use of varus wedges for treatment and diagnosis

1/4 inch varus wedges applied to several OTC insert

A closer look at the varus wedge applied along the medial aspect of the insert

     Pronation is a normal function of the foot (with a similar motion described for the wrist). The foot pronates as you hit the ground creating good motion to absorb shock, and loosening the foot to adapt to the ground. Therefore, pronation is a normal and necessary function for the body.
     I just ran a workshop to 6 students at the California School of Podiatric Medicine at Samuel Merritt University. Two of these students were what you call excessive pronation where the motion of pronation lead to significant arch collapse and knee instability. One of these had the instability limited to the lower extremities. But, the other student also had trouble with his hips and back where the foot pronation destabilized the entire body. 
     Therefore, if the pronation motion is too much, too prolonged in gait, or too rapid to decelerate, symptoms can occur from the foot up. Since there are over 20 symptoms tied to the pronation syndrome, patients tend to pick on their individual weak spots. One excessive pronator can present with posterior tibial tendonitis, another plantar fasciitis, another knee or hip pain, up to the spine and upper extremities. 
     What does this have to do with varus wedges? A 1/4 inch varus wedge makes a typical 4 degree change in the pronation for a patient. The varus wedge can be just a heel wedge, but will not help as much for a runner when they go up on the ball of their feet. 
     Athletes in general are in my office complaining about their knee, ankle or foot. But, I like to talk to them about other problems they have to either a lesser degree, or significant past problems. They may have had serious bouts of plantar fasciitis, shin splints, achilles, etc, but just not now. 
     One of my patients presented with posterior tibial problems and was very pronated. OTC arch supports and one pair of custom orthotic devices in the past were either painful to wear or did not fit into her shoes well. We spent some time over the next year designing comfortable but stabilizing orthotic devices. Over the next year I remember her counting over 10 areas in her body, mainly lower extremity, that did not hurt anymore (they were all part of this pronation syndrome). 
     Therefore, if you have some symptoms, or if your patients have symptoms, that you think could be tied to this syndrome of over pronation, applied a varus wedge as small as a varus wedge to one pair of shoes and see if the symptoms improve. It could be as vital as an MRI. 
     In the next few days, I will do a video to show how you can use an old shoe insert, cut the medial one inch off, apply it to another full insert to create a varus wedge. I sure hope this helps. Rich 

Friday, March 11, 2022

Beware of Subtle Xray Signs in the Foot


This image is of the 2nd toe (right) and 3rd toe (left).

     If you look at the major joint demonstrated (called the proximal interphalangeal joint), you can tell that there is a subtle cloudiness of the 3rd toe joint that is not in the 2nd toe joint. Since it was the 3rd toe that was the most sore and swollen from a run in with a furniture leg at midnight, and since the xray report was negative, I decided to get a lateral view of the toe involved. This is technically difficult as you have to get all the other toes out of the way so that there is no overlap. 







Here the lateral 3rd toe x-ray demonstrated a chip fracture off the base of the middle phalanx of that 3rd toe. I still remember our xray professor, Dr David Coulter, pointing out these subtleties, and I thank him at least once a week. 

Thursday, March 10, 2022

Hallux Rigidus: Surgery, No Surgery, or In Between

Here is the right big toe joint of someone whom has some minor DJD
(Degenerative Joint Disease AKA Wear and Tear)

Here is the left big toe joint of the same person with significant DJD

     Hallux Rigidus for many is a painful arthritic big toe joint. Patients can present with pain for many years or recent. Typically, like any sore joint, you can use common sense and get the joint comfortable. You may be just holding off the inevitable, the surgical knife, but who says that this is not worthwhile. 
Surgery is not without its problems. Most surgeries last 10-15 years and then have to be redone. If you fuse the big toe joint, you may not have big toe joint pain again, but you have totally messed up the normal pattern of movement. Our body must compensate for limping in pain, and it must compensate when a major joint is locked up permanently. 
     There are so many thoughts that run through my mind with this patient. One concerns why is the left side more broken down. We could discuss this for hours. Commonly, the left foot in our predominately right handed society gets beat up more. It is our support foot or support side that always takes more load in some way or another. Yet, podiatrists love to look for the nuisances to a pain syndrome like this. What also may put more pressure on the left big toe joint? Asymmetrical pronation is one, where the pronation or arch collapse places incredible stress on the big toe joint. Tight achilles and hamstrings, long leg syndrome, bone structural differences between the two sides, etc, all can place more force on the big toe joint which slowly and gradually collapses under this pressure. 
     Having been in a sports medicine and biomechanics practice my whole life, I have come to appreciate a non-rush attitude into surgery. Get more than one surgical opinion, and do not tell one surgeon what the other said. Find out if anyone can treat your problem conservatively. It is great to find out if there are mechanics that aggravate the stress at the injury that can be reversed. It is also great just to calm down the inflammation and relax any irritable nerves. 
     The last point today: treat the patient, not the xray. 

     

Sunday, January 30, 2022

Adding Stiffness to the front of a Shoe: Help for Many Problems in the Front of Our Feet


     My retired partner, Dr Jane Denton, known world wide of the Denton Modification for over supination, continuously used this metatarsal stiffener. It is a 1/16 to 1/8 inch thickness of out sole material. All chronic pain in the area may be helped with this shoe modification. When patients tell you that they feel better as the shoe stiffness increases, this may be something that a shoe cobbler can add to a more flexible shoe. It should be done on both sides (even if the pain is on one side). It can always be removed if not helpful, or after the need for stiffness passes. 

1/8 inch Stiff Out Sole Material Applied to Add Stiffness for Painful Metatarsals



The Stiffness has to be created with 1/16 to 1/8 inch Material only. This increases someone's falling odds due to separating the ground from the foot, so has to be broken in to gradually. The patients that it works for are really pleased that they can wear some normal looking shoes. 

Monday, January 24, 2022

Chemotherapy Can Destroy Nails and Hair: Ice to the Rescue

https://myhealth.alberta.ca/health/AfterCareInformation/pages/conditions.aspx?hwid=acj1006

Many of my patients have had to have chemotherapy and their nails have never been the same. Using an ice bath, head cap, etc, while having the chemotherapy infusion, can greatly help some patients. The theory is that you freeze the hair or nail cells while the chemo is working, thus preventing damage. Thank you Susan for bring this up to me. 



Squeaking Orthotics: JSuede helps

My small lab at Saint Francis Memorial Hospital has a roll of JSuede, from JMS Plastics, for the patients complaining of squeaking from the orthotic rubbing against the synthetics of the shoes


Here, both the bottom of the orthoses and the top of the JSuede is glued and stuck together.
This very thin material can help without increasing bulk too much

Sunday, January 23, 2022

Virtual Walks are really fun!!!

Totals after the first 5 days (out of 9) in this Virtual Walk

     The last 9 days I have been virtually walking from Canterbury England to Rome, Italy. 34 people from mainly England are participating. We made it the 1200 miles to Rome and are starting to head back. All of our miles count towards the total walked, but they also tell us our ranking among the other walkers. I have moved from 3rd to 6th place over the week. I am a competitor by nature, and this has been fun and motivating to walk daily more than 10,000 steps over 5 miles. I have one more walk today and it is over. We will not make it back to Canterbury as a group, but I will not have to fly from anywhere either. 
     The website I am using for this virtual walk is UltraBritain.com. It is a charity event to raise money for the maintenance of this historical walk. Canterbury to Rome has been a well travelled route since 500 AD. It goes by boat across the English Channel and then through France and the lowest part of the Swiss Alps. 

Friday, January 21, 2022

Adding Stiffness to the Front of an Orthotic Device

https://jmsplastics.com/product/j-suede/


     The image above was taken after I applied a very thin piece of suede leather. This is stretched before tacking down to stiffen the bend across the metatarsal heads. This is a very useful technique when trying to treat metatarsalgia symptoms, Morton's neuroma symptoms, hallux limitus and rigidus symptoms, and all without adding alot of bulk in that painful area. 




Wednesday, January 19, 2022

Good Rx: A Good Way to Get Some Prescriptions at a fraction of the cost


https://www.goodrx.com/how-goodrx-works

     This company has saved hundreds of my patients a lot of money while buying prescriptions. Please be aware of it. 

Monday, January 17, 2022

Sunday Night Musings of a Personal Nature

A View of Sunset in San Francisco from my walk tonight!

     I am working on a book for the last five years. Months will pass and not a word is placed on a page, and then I get really productive. I am writing this podiatry book for my students at the California School of Podiatric Medicine in Oakland, California. The Podiatry school is part of the incredible medical graduate programs run through Samuel Merritt University. 
     The book title is Practical Biomechanics for the Podiatrist and really focus' equally on both basic treatments and more sophisticated. In medical school, the emphasis is on teaching high tech, so I plan on cornering the market with KISS techniques (Keep It Simple Stupid). 
      I am basically trying to teach the thought process of helping patients throughout the whole injury. My book, however, has gotten too big, and too time consuming, that I have now broken it down to 4 books with book 1 coming out this year. Wish me luck!
     RETIREMENT!! Well, I was going to retire at 65, and now I just turned 68. So, from today on, I am sticking to my #70 birthday on 1/9/24. At my age, you worry about illness' that will suddenly bring you down at any age. I started working at Saint Francis Memorial Hospital when I was 27 years old!! Long time in one place, but I have loved it. 
     Unfortunately, Saint Francis is not finding a replacement for me. Most of my present patients will have to find someone over the next 2 years. It will be a great 2 years!!


     

Sunday, January 16, 2022

Lecturing: A Way of Giving Back

     Of course, I am the handsome guy to the left as you look at the photo!!LOL
Why am I showing you this? I am at the end of my career, and giving back as much as I can is very very important to me. This photo is for some online presentations in Spain. I will talk to almost anyone, in fact any one, who will listen. I believe in my careful blend of biomechanics and sports medicine. Patients get better, or get a better understanding of their problem. Patients and I are partners in healing. 
     This year I am lecturing at the California School of Podiatric Medicine through April, and then again in October and November. I am also lecturing at our state's meeting in Los Angeles in June. I may give an online lecture in Oman in March or April, and I hope to be invited back to New York next year. 
     What sticks in my side always was that one of my mentors, Dr John Weed, died at 54 while working at a busy office. I watched him work for over 13 years, a truly gifted and loving individual. He was excited about retiring some day so he could write of all his discoveries. Podiatry truly missed out. He died 30 years ago, and I still miss him a lot. As I try to give back to my profession, I wish he had been given the opportunity. 


Thursday, January 13, 2022

Common Foot Pads used to Off Weight Sore Areas




Adhesive Felt used to off weight ball of foot
Typically the padding is placed on the undersurface of the shoe insert

Adhesive Felt used to off weight the 2nd and 3rd metatarsals where they bear weight


Wednesday, January 12, 2022

MRIs: Their Usefulness in Patient Care of the Foot


     Those of you whom regularly read my blog know that I love MRIs and even serial MRIs when I am following an injury. Unfortunately, the quality of the MRIs is getting poorer, and the amount of the foot that is imaged is becoming less and less. That does not mean you can not get great MRIs but you may have to ask for the highest Tesla (magnetic strength) in your area. 
     Why is a negative MRI just as important in general as a positive MRI? Negative MRIs rule out bone injuries, ligament injuries, and cartilage injuries. Negative MRIs suggest that a patient may have nerve pain if all other causes of the problem have been ruled out. 
     In the MRI above, even though you are given only one of the 144 slices, the 2nd metatarsal phalangeal joint had a lot of inflammation. That is the white you see under the 2nd and 3rd metatarsal heads. Other slices confirmed no plantar plate injury (the ligaments under the metatarsal heads at the ball of the foot area). 
      When you see inflammation, you have to think that this area is being stressed. The inflammation is the bodies' way of healing itself. Inflammation brings in nutrients for healing, therefore very important for healing. Inflammation though is always an all or nothing response. The body feels like it is under attack, and it will send in the calvary, armed forces, and Knights Templar (even Luke Skywalker). All or nothing!! Fight or flight phenomenon. The guist is that the inflammation can be more than it needs. Chronic inflammation, still sitting around from a relatively minor injury, still hurts alot. The patient then wonders why they have not healed, even when they have. I see this phenomenon over and over.
     Inflammation also means something may be happening internally, like micro-tearing in the ligaments. I can not see it in the MRI, but the patient can not get rid of the inflammation by any means (PT, contrast bathing, ice massage, acupuncture). 
     In this individual, negative MRI except some inflammation (radiologists call this edema). Initial treatment to address the inflammation alone was nonproductive. Treatment switched to restricting joint motion with Budin Splints, and the pain got better real quickly from there. 
     I tell my patients that positive or negative MRIs are data points in their treatment plan. We have to react to the information, make changes when they are not improving, and follow the progress month by month. 
     

Sunday, January 9, 2022

Happy Birthday Me!!

     Yes, it is my birthday today. If I was born yesterday, I could of shared Elvis Presley's big day. But no, I got Richard Nixon. It was a cool birthday until the world found out he was a crook (along with other things). But, I digress!
     Thank you all for reading this blog. I can not believe the blog is also celebrating its birthday in March. 13 years for the blog, and 68 for me!! 



Saturday, January 8, 2022

Customizing an OTC Insert: The list is endless and limited by our Imaginations!!

Sole is one of the common OTC arch supports I recommend in my office

In this case, the front was just too hard for the patient so I removed it for softer material

The cut or transition was just behind the metatarsal heads (ball of the foot)

Here the Arch only part with be glued onto a full leather top cover. 

Using the original front, the leather can be trimmed to be an exact replica of the original


Now a soft material like 1/8 inch poron is applied as the new front






Thursday, January 6, 2022

Bunion Protection in Tight Shoes

Here is 1/4 inch adhesive felt (which can be used for 3-4 days) is placed behind the bunion prominence (never over) while wearing shoes

Wednesday, January 5, 2022

Metatarsal Pads: Proper Placement

Hapad Longitudinal Small Metatarsal Arch Pads are my preferred Pad.
These pads spread the weight over a large area and can be thinned by peeling layers off.
Hapad Metatarsal Pads can be used in 2 directions just before the sore area on the foot. This is the common direction.

This is a common modification of the small Hapad metatarsal pads with the thickest part under the 2nd metatarsal head. These adhesive felt pads also can be easily adjusted.