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Tuesday, July 5, 2022

Highlight of Recent Interview by Podiatry Today on Running Shoes

<iframe src="https://player.vimeo.com/video/720006906?h=2d4d78605e&title=0&byline=0&portrait=0" width="640" height="360" frameborder="0" allow="autoplay; fullscreen; picture-in-picture" allowfullscreen></iframe>
<p><a href="https://vimeo.com/720006906">The Science Behind Walking and Running Shoes: Insights from the Western Foot and Ankle Conference</a> from <a href="https://vimeo.com/user35596045">HMP</a> on <a href="https://vimeo.com">Vimeo</a>.</p>



Monday, July 4, 2022

CRPS and Low Dose Naltrexone


     CRPS stands for Complex Regional Pain Syndrome. It is a sympathetic overload of the nervous system set off with fairly minor injuries. One of the key observations is a distinct change in color of the injured side, and pain out of proportion to the injury. Basically, if no one can explain why your foot looks like that or why your pain is so high, you may have CRPS. The treatments are many and successful, but must be done soon to relieve the tension in the nervous system. The article below talks about a medicine that can help in the long term treatment. 

Sunday, July 3, 2022

Correspondence Related to Left Neuroma, New Orthotic Devices custom made, and some Right Foot Symptoms

Hi Dr. Blake,

Very interesting wearing shoes for the first time since Aug. 2019, and wearing orthotics for the first time ever.

I delayed my “2 week report” because things were so different everyday, and I couldn’t figure out how to describe it in email.

Now that it has been 3 weeks, here’s a brief report. I’m hoping that we can talk on the phone, as a prelude for meeting up in person so that you can see my gait and consider tweaks.

I have pasted a table below my signature showing my 3 weeks of wearing time. I only counted standing/walking time, of course. I have managed to get up to slightly more than 7 hrs, but discovered on the way there that normally I am on my feet 5-6 hours per day. 

Overall things were surprisingly good until I got close to 7 hrs, then some bunion pain, and foreshadowing of corns arrived. 

I have gotten used to the new way my feet balance, and my usual tight IT band aches and pains have disappeared. My ankles, knees, and hips feel like they are much better aligned. I had shin splints for 4-5 days, but they went away.

I am wearing the orthotics with a pair of New Balance 860 running shoes, and with a pair of New Balance clodhopperish walking shoes. The clodhopper walking shoes are probably better. Both pairs of shoes were essentially new, and not broken in at all. (I bought them in my search for shoes that might work with my neuroma a good year before I first saw you.) I haven’t worn the Chaco sandals in at least 2 weeks. The orthotics don’t work in the other 2 pairs of shoes, due to neuroma pain.

I ice my feet at night, and use NeuroOne every morning, and often also at night. I also do nerve flossing.

Left Foot (the foot with the initial neuroma issues)

• Neuroma pain comes and goes, as it did with the Chaco sandals. It is never worse than the worst days with the Chacos, and is often more comfortable than the Chacos. Intermittent bristly or mildly burning pain, sometimes aching. Clicking in the first few minutes when  I first start out walking in the morning.

• Some of the pain might actually be from that callus that you have worked on in the middle of the ball of my foot.

• Today i began to feel the foreshadowing of a corn on my little toe. See Right Foot notes for more on corns.

• Something to talk about real time: I noticed that the neuroma pain has decreased as my orthotics wearing time has increased. Would tweaking the orthotic with the neuroma in mind help, and/or will wearing them longer without tweaking help more? (Part of the reason that I waited to report in was that the neuroma pain was coming and going so much.)

Right Foot (lesser neuroma issues, tailor’s bunion)

• Neuroma pain mostly gone.

• Initially, there was no bunion pain. Bunion started to hurt as my time on my feet passed 6 hrs. The little toe bunion sleeve you recommended definitely helps, but it still hurts some. Definitely hoping to nip this in the bud, so it doesn’t get worse. 

• Started to get whispers of a corn on my little toe. Many years ago I had some shoes that gave me corns on my little toes, and I still have some Dr. Scholl’s small corn cushions, which solved the problem back then.  Turns out that Dr. S no longer makes this kind of small corn cushion. Everything on their website is bigger, and a different shape. I only have 13 of the antique-style corn cushions left, so I could use your help with finding a solution. The corn “foreshadow” is hurting now, as I sit here typing.

• I have a touch of intermittent sciatica in my right hip that started with wearing the orthotics. 

• Something to talk about real time: I also get some pain along the “rim” of my right foot. Is it possible that the orthotic is tipping my foot a little to far over, so that the little toe, bunion, and “rim” of my foot hurt? 

There you have it. Email definitely does not seem like the best way to discuss this stuff, but I am hoping that this message will serve as a good outline for a real time discussion.

Many, many thanks. It is oddly thrilling to be wearing shoes again, I just wish it were a tiny bit more comfortable.

Best,


Date (June 8-29)

# of hrs/minutes standing/walking in orthotics

8

1 hr

9

10

1 hr 30 mins

11

2 hrs

12

2 hrs 40 mins

13

1 hr

14

2 hrs 55 mins

15

16

4 hrs

17

4 hrs 30 mins

18

19

5 hrs

20

3 hrs 45 mins

21

5 hrs 40 mins

22

23

2 hrs 35 mins

24

5 hrs  35 mins

25

6 hrs 40 mins

26

7 hrs  5 mins

27

1 hr 50 mins

28

6 hrs 25 mins

29

7 hrs


Dr Blake's comment: One of the ways you get to understand how the body works is by making a change and seeing the response. I sure wish all of my patients could be as great in looking at the pros and cons of my new orthotic devices. The left Morton's Neuroma has dictated that she wear wide shoes, which can be inherently unstable if too wide for the foot. Her symptoms are improving both footwise and up the leg. The right sciatica and rim pain are signs of slight over correction, so I will have to adjust that soon. Rich 



Saturday, July 2, 2022

Subtalar Joint Neutral

     I use subtalar joint neutral position daily as part of my practice. The video is a nice way of finding it when the patient stands. For some many injuries, this simple test will define treatment success or failure. You typically want to place the patient closer to this position in your treatment regimens. 
     The subtalar joint neutral is a point where there is equal stresses both on the inside of the ankle and outside of the ankle. If you are away from this position, one side of the joint is being compressed and one side stretched. Both of these positions can cause injury. 

https://youtu.be/Vf0FWDIO1_U

Sesamoid Evaluation Tip: Check First Ray ROM


     In the photo above, I am evaluating the motion and position (kinematics) of the first metatarsal (called first ray) crucial in sesamoid injuries. Of course, when there is significant pain and/or swelling in the big toe joint, this examination may not be accurate. With the patient lying on their stomach, or standing on the other leg with the examined side having the knee bent and the leg resting on a chair, you first stabilize the 2nd metatarsal head. Then, you grab the first metatarsal head with your thumbs parallel. Keeping the 2nd metatarsal still, you move the first metatarsal up and down (typical motion around 10 mm total or 1 cm). With sesamoid injuries, you are looking for reasons that the first metatarsal is overloaded. You may find either less than 10 mm of excursion (called hypomobile first ray), or all of the motion below the plane of the 2nd metatarsal (called plantar flexed first ray). Both these conditions can lead to the sesamoid pain in activities due to overload, and both these conditions can be treated. You treat hypomobility with physical therapy or massage therapy to increase overall first ray range of motion. You treat plantar flexed first rays with some form of dancer's padding to load the other metatarsals. 

Friday, July 1, 2022

Setting Benchmarks for Recovery: An Important Skill


When patients come in for treatment, they can have a list of what they can not do. I try to get them to focus on what they can do comfortably right now in the 0-2 range. It is important for me to know and it is the first part of our important benchmarks. Therefore, it is important to know that a runner can run 5 minutes every other day, a basketball player can shoot 100 free throws a day, and a ballet dancer can work pain-free at the barre.

And also cross training should be part of this benchmark establishing. If they are a runner, can a bike somewhat and swim and even do elliptical to help with their overall conditioning. Staying in shape biking has proved invaluable for so many sports while we cross train.

And then he comes to the exercises, or the many treatment modalities. What can they do as part of the rehabilitation this month that can be helpful to know. Maybe they can balance on 1 foot for 1 minute. Maybe they can do 2 sets of Level One theraband or resistant cords for their tendinitis, but only 5 reps each. Maybe they can only go to 10° flexed when trying to fully extend their knee. The amount of total resistance, range of motion limitation, time of an exercise, and sets and reps that can be done can all begin to set our important benchmarks.

The patient comes in at the beginning of July, like today, you can begin to find out what they can and can't do at present. As you set your benchmarks, you can help them measure progress in the future. Some of my programs will take a good year like when I treat an Achilles rupture. You can set benchmarks much like attaining goals. It is definitely rewarding as you pass each benchmark.

One example I will use, is a common situation of an athlete coming in with crutches and a removable boot. As a get better, the benchmarks to be used will be first getting rid of the crutches, then weaning off the boot, then wearing normal shoes for 2 weeks, then starting to do sport specific drills (basketball player shooting free throws), then beginning a walk run program, then beginning sprinting or cutting, etc. etc.

I've attach one of my videos on posterior tibial strengthening. I was very precise in having the patient progressed through a comprehensive rehabilitation program. I set benchmarks by outlining the different exercises to be progressed through. Please watch the video to get the idea. I hope this is helpful for you. Even if another body part is injured, you should be able to get the right idea of bench marks and goal setting. Rich






Bunions: Tips on Conservative Care







                                                         Tips on Bunion Care


     So you or someone you love is developing a bunion, what to do? Bunions are sometimes classified Stage I (you begin to see a bump), Stage II (the toe starts to drift towards the 2nd toe), Stage III (the 1st and 2nd toes come together), and Stage IV (the 1st toe moves under the 2nd toe with great instability to the entire foot as seen in the photo above). The goal of bunion care is to keep it in Stage II. During Stage II the bunion is not getting worse quickly since its alignment with the metatarsal is not too bad relatively. Stage IV is a surgical bunion and there are many great surgeries available. These surgical corrections, however, have a 6 month to 1 year recovery period depending on what is done.

     Stage III can persist for 3 weeks or 30 years, and in general is a stable place for your overall foot stability. Once the 2nd toe begins to drift dorsally (towards the top of your shoe), Stage III can quickly become Stage IV. In Stage III, with the 1st and 2nd toes abutting, as you push off the ground at heel lift, the poor angle of the 1st toe pushes back on the metatarsal gradually increasing the bunion deformity over time.

   
Sometimes a Budin Splint is used in Stage 4 to improve the overall stability. The success is based on the ability of the splint to keep the second toe at the same plane as the first. Here is a failure of the splint where the 2nd toe is too high off the ground.

     So the goal in treatment is to get the bunion back into Stage II---its Happy Place, and keep it there. The bunion will not go away, but you may stabilize the joint, eliminating or at least postponing surgery for a long time. Bunion surgeries have not changed dramatically in the last 30 years like knee replacements, yet, the post operative care has greatly improved. I believe that avoiding/postponing surgery now, with the chance of never needing it, is worth the possibility of better results in the future. You will see this is my bias against immediate surgical procedures.

     However, that being said, if you are disabled by anything like a bunion, try 6 months of aggressive conservative treatment first. If your condition has not improved after this time period, proceed with surgical advice. Your disability must match up with the risks and recovery period for the operation. Get 2 or 3 opinions, be a smart consumer, bring a friend or loved one to the appointments, make a logical decision, and go for it.

    Stage II in bunion development is where, when you stand on the ground, and look at your toes, there is still a gap or separation between the 1st and 2nd toes. Medium gel toe spreaders from Silipos® http://www.silipos.com/ or separators between those two toes instantly put the bunion in stage II. You wear them in any enclosed shoe. You can now buy socks, like Injinji ® http://www.injinji.com/ , and bedroom slippers, like Vibram ® Five Fingers http://www.vibramfivefingers.com/ , that have individual compartments for each toe to wear around the house. Several years ago, YogaPro® came out with YogaToes http://www.yogapro.com/ . The product has 5 individual compartments and patients stretch their toes for 30 minutes 2 to 7 days a week when they are sitting down. I usually start patients at 5 minutes a day several times a week and they can slowly build up time. Some patients, especially with small toes, can not wear the product at all, or it must be modified. If you are in pain, do not wear the device (Good rule of thumb for most things). YogaToes are designed only to be used while sitting. Bed, Bath, & Beyond has an effective, but not as aggressive product, called Pampered Toes®. There is another YogaToes knockoff called Healthy Toes®. Another great product is Correct Toes where you can walk around with the toes in better alignment https://correcttoes.com/

Free standing Medium Gel Toe Separators, but I also like the Zenn Toe product that fits completely over the 2nd toe

Toe separator that attaches firmly to the 2nd toe

Yoga Toes




    If your bunion is red, start massaging it. The red inflamed tissue adds to the discomfort and fragileness in shoes. Use circular motion to try to get rid of unwanted inflammation with soft tissue swelling. Gradually push harder during the massage. Massage for 5 minutes several times a day for 2 weeks longer than you think you need. What do you massage with? Ice cube is used if the bunion is sore. If not sore, use massage oil, or any hydrating, lubricating, lotion or cream. It is the massage that moves out the bad stuff.

    Padding with 1/4" adhesive felt just proximal to the bunion (called proximal padding) instantly takes pressure off of the bunion and allows you to wear many shoes that would normally irritate. The padding can be purchased in many locations including http://www.mooremedical.com/ item #09229. You normally cut out a 1 inch square and place not over the bunion, but just behind towards the arch, but as close to the bunion as possible. Best to place it on your foot directly. You can experiment with size and shapes so it does something without showing. You should never place under the foot or on the big toe itself—that will make the bunion worse. Sometimes, you may want to put on top of the 1st metatarsal and the side as just described. Each pad can be used multiple times, so 1 roll can last almost a lifetime or be shared with other bunion sufferers you know or see in the gym.

Proximal Padding is only when wearing shoes that irritates the bunion area



    Another vital aspect to bunion care is strengthening of the intrinsic foot muscles. These are tiny, yet powerful muscles within your foot that weaken over time due to life stresses (the aging process, pain, bad foot mechanics, reliance on shoes and orthotic devices, etc.) Normally, I would send a patient to a physical therapist to learn these exercises properly.

    If you can not wait, start doing the flatfooted balancing exercises now. All strengthening exercises should be done for a maximum of three days a week. Foot and ankle exercises fatigue the leg so much that they should be mainly done in the evenings when you are home for good. Stand on one foot in a doorway. Put your hands at your side so that you can grab the door frame if needed. Very slightly bend your knee that you are standing on. With your eyes open, try to balance on each foot for one minute until this is easy. Then, gradually build up to two minutes at a time. Then, begin to close your eyes during the two minutes off and on until you can keep your eyes shut the entire 2 minutes. This easy task can take 1 month to 1 year to complete. The longer it takes, the more important it is for you to accomplish this tremendous strengthening exercise. Very important: do not push through any pain whether it is in your foot, ankle, knee, hip or back. This is really where a physical therapist can help making sure you are safe at what you are doing. You can always have a doctor write a prescription and send you to therapy for 4 sessions to learn a HEP (Home Exercise Program).

     In summary, bunion care should be started as soon as possible after making the diagnosis. Elements of treatment should include toe separators/spreaders, YogaToes or a knockoff version, proximal padding, possible socks and slippers with individual compartments, foot strengthening and massage. . Hope this was helpful. Of course, most of this advice is also used post-operatively to stabilize the strengthen the foot if it ever gets to that point.

Key Word: Bunion

Saturday, June 18, 2022

Sesamoid Injuries: Consider Dr Jill's Dancer's Pads to Off Weight

Comment off of my YouTube Channel on Sesamoids:



Jill's Dancer's Pads were a life saver for me! They greatly reduced my pain and allowed me to continue to get around. They stick to your feet so they will stay in place and fit into shoes, and they're washable. Don't get the extra thickness. The regular thickness works best.

Monday, June 6, 2022

5 Common Orthotic Adjustments (Answers on Wednesday 6/10/22)

Match Orthotic Adjustment with Image
  1. Morton's Extension vs Dancer's Padding
  2. Denton Modification for Lateral Stability
  3. Metatarsal Accommodation with Met Support
  4. Temporary Kirbys
  5. Arch Pain Adjustments


Image 1
Image 2
Image 3
Image 4
Image 5

Answers: Image 1: Metatarsal Support with Accommodations
                Image 2: Temporary Medial Kirby Skive
                Image 3: Arch Pain Adjustments with Increased support
                Image 4: Denton Modification for Lateral Support
                Image 5: Dancer's Padding to Off Weight Big Toe Joint

14 Point Patient Assessment for Treatment Summary

  1. History of the injury and the patient’s reason why they were injured.

  2. Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches)

  3. Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic)

  4. Physical examination of possible biomechanics involved

  5. Is there biomechanical asymmetry

  6. Tentative working diagnosis made

  7. Common Differential Diagnosis: common not rare

  8. Occam’s Razor and the Rule of 3 for initial treatment help

  9. What Phase of Rehabilitation is the patient in at this visit?

  10. Should we do Imaging at this point?

  11. First Decision: What do I have to do to get the pain consistently between 0-2? This is the real reason that the patient has to be put into Phase 1 of Rehabilitation where PRICE rules. The 0-2 pain level realm is where injuries can heal.

  12. Second Decision: How Much Inflammation needs to be Addressed?

  13. Third Decision: Is there any neurological component that should be treated?

  14. Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal? 

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.