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Sunday, May 24, 2020

Chronic Big Toe Joint Pain: Turf Toe?

Dr. Blake,

I have been reading your blog for several weeks now and have watched many of your videos. I am emailing you on behalf of my daughter who is a 16-year-old soccer player (who will be a junior this fall) with the potential to play soccer in college. She has been suffering from an injury and is desperate to feel better and hopefully be able to continue playing the sport she loves. I am hoping that if you have some time you could give me your thoughts. I completely understand if you are unable to do so. 

She suffered an ankle injury in September 2018 while playing soccer. The orthopedic surgeon at the time said she most likely had torn the ATFL. She was put in a cast, then a boot and then went through PT for several months. She was cleared to play soccer in January 2019. However, after a few games, she continued to have pain and swelling in the ankle. She stopped playing, went back to PT and then was released to play again in April. Right at that time, she started to develop pain in the ball of her foot. She continued to have pain for several months until an MRI in June 2019 diagnosed turf toe. She was put back in a boot for several weeks and then went through PT for a few months. She returned to play in August but by October she started to develop pain in the same area after playing back to back games of 90 minutes each. All this time she continued to have pain and swelling in her ankle as well as the pain in her foot. She continued to play soccer until the date of her surgery on November 22, 2019.

After a year post injury, it was decided she would need ankle surgery. In November 2019, she underwent a modified Brostrom procedure and the doctor found that she had 3 torn ligaments in her ankle. I believe two were repaired with anchors and the third was reconstructed. (Note: this orthopedic surgeon was not the original doctor we saw when she suffered her injury in 2018) Once she was allowed to take her first weight-bearing steps weeks after surgery, she had immediate pain in the ball of the foot. The orthopedic surgeon had hoped that the rest after surgery would help and prescribed PT for both the ankle and the foot Jan-Feb 2020. We took her to a podiatrist in March of 2020 after continued pain in the foot. X-rays in the office were negative for any fractures or abnormalities of the sesamoids. He diagnosed her with sesamoiditis. He made her orthotics and shortly after she received them, the Corona virus hit and we were unable to see him for several weeks. During that time, we sought another opinion by an orthopedic surgeon specializing in the foot and ankle. He performed x-rays as well and found them to be negative also. An MRI was performed with the following results:

----There is very subtle bone marrow edema of the head of the second metatarsal. There is
no other bone marrow edema, marrow replacing process, or acute fracture. The
sesamoid bones of the first digit have a normal appearance with no signal or
morphological abnormality. The flexor digitorum tendons, flexor hallucis longus, and flexor hallucis brevis tendons are intact without edema or tenosynovitis. The extensor tendons are intact without edema or TR synovitis. The plantar fascia has a normal appearance without
inflammatory change. The muscle volume and signal is normal.
There is soft tissue edema in the interspace of the first and second metatarsal heads
tracking around the lateral sesamoid bone of the first digit.
1. Mild bone marrow edema of the head of the second metatarsal with surrounding soft
tissue edema extending into the first interspace and around the lateral sesamoid bone.
Findings likely relate to chronic stresses/ superficial repetitive trauma.
2. No evidence of fracture or osteomyelitis. No soft tissue fluid collection.

Dr. Blake's comment: Many patients have irregular sesamoids on xray, never get an MRI like your daughter, and due to the chronic pain have the sesamoid out sadly. So, I am so glad you did get an MRI. Swelling around the lateral sesamoid from turf toe (grade 2 or 3 tearing of the lateral collateral ligament) can appear like a sesamoid fracture. I am confused that the MRI did not document turf toe, but maybe it was a severe stage 1 or mild stage 2. If we treat the MRI only, this should be all healed by now. 

He put her on a Medrol pack, showed her how to tape her toe (like the videos on your blog) and told her to wear a boot for a few weeks to relieve some of the pain. She did not feel any benefit from the Medrol pack. He did not recommend a cortisone shot or surgery. Shortly after, the podiatrist called us back to the office. He modified her orthotics. He took her out of the boot because he felt her muscles would atrophy and would require more PT to rehab her back.  He found her hamstring and calves to be very tight so he instructed her to stretch 3 times a day and ice afterwards for 20-25 minutes. She is to do this for several months. She just started PT this week. The therapist said she is strong in both the ankle and foot but is still weak from her surgery as she was never able to start conditioning due to the pain in her foot. She is wearing Merrell hiking shoes for more support. I put a J-pad under her foot and she did feel a little bit of relief. However, the podiatrist does not want us to use this...maybe because he wants the orthotics to start working to redistribute her weight naturally? She is continuing to tape her toe as well. Per your blog, we will file down the cleat right beneath the ball of the foot and will also purchase turf shoes for training and play when her outdoor cleats aren't needed. 

Dr. Blake's comment: This is wonderful. Dancer's padding (J Pad) are a must, and I will use on the orthotic and also on the foot. You typically need 1/4 inch sesamoid float to take pressure off, so you can see how much the orthotic does. It is time for her to get at least 5 things that are working for her: taping, orthotics, J Pads, cluffy wedges, icing, contrasts, stable shoes. Can you get a pair of Hoka One One to try to see if the rocker eliminates some stress? 

The podiatrist would like to see her back in a few weeks to determine her pain level. If she isn't getting much relief, he said he would consider giving a Cortisone shot. He also indicated that if she continues with conservative treatment for a few months without much relief, and the fact that she's had this pain for over a year, he would consider surgery. While he said this is the last option, he did say she could recover well from it because it's the lateral sesamoid that would be removed. He felt that she would be able to return to playing soccer about 4 months after surgery. My concern is the health of the remaining sesamoid and keeping it healthy for the remainder of her life. I have read what can happen if both sesamoids are removed.

Dr. Blake's comment: Whoa!!!! There is no problem documented in the lateral sesamoid, and cortisone into a chronic turf toe may be okay, but may be not. Turf toe, which I think is our working diagnosis, is a tear or stretch of the ligaments. It can make the joint unstable, and I do not know if she is already naturally loose. She may consider an arthrogram of the joint where dye is injected into the joint to see if it leaks out, although have not seen that test for years. If a lachman test for turf toe has been done, find out what it was. She made need a couple of sutures placed into the big toe lateral collateral ligament if that is the case. Convince me that this is not ligament instability due to turf toe. Sorry, I know this is hard. I sure hope this helps your daughter some what.

I am reaching out to you because my daughter is starting to feel hopeless that she will ever recover. She had to stop playing basketball a year ago because it was all too much for her ankle. She will be devastated to have to give up on her dream to play soccer in college. 

If you are able to provide any thoughts or advice, I would greatly appreciate it. I feel that the orthopedic surgeon and the podiatrist have conflicting ideas and a third opinion (hopefully yours) would possibly help us with our next steps.  I have been doing a lot of research and stumbled across your blog. By far, your site provides more information about this condition than anything else I have found. Thank you for all you do for the health of others.


Saturday, May 16, 2020

Application of Temporary Kirby to Achieve more Pronation Support

Typical Patient with Custom Orthotic Device giving less than optimal Correction
The Green Wedge has been skived prior to application to lessen the abruptness of the Transition
This is also a great way off adding more support without placing it in the Medial Arch
The surfaces of the wedge and orthotic device are glued

Since this is the left foot, this wedge is on the medial side, called a Medial Kirby Skive or Medial Heel Skive

The final trimming has been done

Friday, May 15, 2020

Cluffy Wedge and Dancer's Padding for Sesamoid Injuries

The famous Cluffy Wedge for sesamoid help, named after Dr, James Clough from Oregon, is typically a 1/8 to 1/4 inch square of adhesive felt worn directly on the foot

Foot Bone Schematic seen from above the foot looking down on the right foot

Here the same schematic shows a dancer's pad to off weight the sesamoids with 1/8 to 1/4 inch adhesive felt or other soft material glue to the shoe insert or orthotic device

Here the same schematic with a cluffy wedge also used for the sesamoid protection

Tuesday, May 12, 2020

Utilizing Inverted Orthotic Devices for Knock Knees (Genu Valgum)

Here is the patient with knock knees or Genu Valgum and Rear Foot Valgus deformities. In an ideal world, the subtalar joint could stay in neutral where the foot and ankle lined up although everted.

If we were to measure this patient, the heels would be everted to the ground the same degrees of genu or tibial valgum. 

However, reality sets in, and one of two things happens. The subtalar joint supinates to bring the heel vertical or close to that position (as shown on the right side), or the foot collapses more medially with subtalar joint pronation getting more everted than the tibial valgus position as seen on the left side. The right foot needs an orthotic that allows for contact phase pronation and I set it to typically pronate from 6 everted to 10 everted by using the inverted orthotic device of 20 degrees or a 4 degree change and then grinding 4 degrees of motion into the rear foot post.  The left foot needs to get them close to their everted neutral position of 10 degrees everted typically with a 25 degrees inverted orthotic device. 

Would you rather run on Asphalt on a normal summer day or the concrete sidewalks?

International Podiatry Greeting (that I was part of) for Return of Crucial Podiatric Care: Very Well Done!!

Monday, May 11, 2020

Podiatry Question #1: What 3 common orthotic RX would help the foot below?

This patient presents to the office with a sudden arch collapse on the right side. Their symptoms are consistent with posterior tibial tendonitis, but really could be any of the symptoms related to pronation. The Rule of 3 of injury teaches us that there are probably 3 or more causes of a weak spot developing in one area. As you evaluate this injury, you find 3 possible causes. These are: 
  1. Unilateral pronation placing a strain on the posterior tibial tendon
  2. Some inherent weakness in the tendon 
  3. A Habit of wearing poor quality non supportive shoes
When we measure the heel bisection at a resting position, the left heel is vertical, but the right is 10 degrees everted. What are six immediate ways, besides placing this patient in a cast for 3 months, or brace them with an AFO, to begin to take the stress off the Tissue combining the Root and Tissue Stress Theories? 
  1. An Orthotic Device with some inversion
  2. A varus foot wedge external or internal to the shoe
  3. A gradual strengthening program of the posterior tibial tendon (may take us 6 months)
  4. Stable shoes, stability or motion control, with some heel elevation 
  5. Aircast Airlift PTTD brace
  6. Posterior Tibial J Strap for Inversion Support

It is also important to remember to strengthen the surrounding muscles and other leg muscles which can really help with the functioning of the posterior tibial tendon. These include: 
  1. Anterior Tibial Tendon
  2. Intrinsic Musculature
  3. Peroneus Longus
  4. Gastrocnemius and Soleus
  5. Sartorius
  6. Lateral Hamstrings
  7. External Hip Rotators
And now to our question about the type of orthotic device on the market for that right foot. What 4 orthotic devices routinely on the market will help this amount of severe pronation? 
  1. Mueller TPD orthotic device
  2. Inverted Technique with Kirby Skive
  3. Modified Root with Kirby Skive
  4. DC Wedge

This is an example that the left side was just stabilized, but the right needed a significant force to balance the pronation. The Inverted Technique gives you 1 degree of heel inversion per 5 degrees of cast modification. So, 35 degrees of inversion within the mold is equivalent to 7 degrees of inversion force, and the 2 mm Kirby Skive (medial heel skive) and a slightly higher medial arch gave me the extra 3 degrees of correction.

What is the modified Root device that should do the same thing? Here is pour the positive cast 6 degrees inverted and apply at 4 mm Kirby medial heel skive. This should work at times. The reasons that I see it have problems are: 
  1. Too much correction in the heel fat pad for the body to tolerate
  2. Since you are inverting the foot, you could end up with too much correction under the distal medial border of the orthotic device thus blocking first ray function of plantarflexion
  3. You modify the Kirby skive, or the medial arch, for comfort losing support in the long run
The Inverted Technique when augmented with the 2 mm Kirby Skive is designed intentionally not to block first ray plantarflexion, should not irritate the medial heel (the skive is carefully molded to remain the shape of the foot), and the support all the way up under the navicular first cuneiform joint gives incredible arch support. 

Saturday, May 9, 2020

Sesamoid Fracture: Email Advice

Dr. Richard Blake,

I recently broke my sesamoid bone walking in a new pair of work shoes. As you can see in the xrays the fracture gap seems wide to me. How does one bridge the gap? And should removal surgery be on my mind. I am three weeks into the boot and just ordered a stimulator. I am hoping a couple months on the 0-2 level promotes healing. What are your thoughts? Is full recovery possible after therapy? Thank you for your videos and time.

Very Respectfully,

Dr. Blake's comment: Thank you so very much for the email. I am glad you are in the boot, and should stay that way for 3 months. The bone stimulator should be a 9 month ordeal, even if you are back running by then. Here is some advice that holds true from another post. 

  1. Put your foot on an ice pack 3 times daily for 10 minutes to reduce inflammation. You want to have all some symptoms from the break and none from the surrounding inflammation. Avoid anti-inflammatory meds since they can slow down bone healing.
  2. Talk to your podiatrist about getting a bone stimulator from Smith and Nephew called Exogen. You place on your foot 20 minutes twice daily. The bone stim company will work with you insurance company so you know what you have to pay beforehand. The bone stim will probably for the next 6 months.
  3. Discuss you Calcium and Vit D levels/intake with your internist to make sure they are not a problem. I would consider a bone density screen, and especially if you have any family history of osteoporosis. Get your Vit D 25 levels.
  4. Make sure you can make that removable boot into a painfree environment. All podiatrists know that one well.
  5. Learn how to do spica taping as shown on the video above.
  6. Get a baseline MRI. Plan on another one 3 or 4 months later.
  7. Have a PT show you some simple strengthening exercises to start doing now. Everyday you are losing strength, and it will take longer to get better the weaker your foot is, but you can not produce pain. My blog has ample exercises that you can review with the physical therapist including playing the piano, metatarsal doming, flat footed balancing, and inversion/eversion resistance band exercises.
Surgery is needed in 10% of the population, for many reasons. From 6-12 weeks in the boot, you will need to find someone to make good orthotic devices to protect you as you wean from boot to shoe. Some will use the rocker on the Hoka One One shoe to help, others just find the traditional athletic shoe is fine. Try to get some Dr. Jill's dancer's padding to begin using. You will need some protection, even slight, for up to 2 years at times, so the Dr. Jills can be used in sandals, high heel shoes, etc. Xrays are a small help, but MRI is crucial I think, especially if it gets to the point of deciding on surgery. I hope this helps you. Good luck in your journey as the country gets back to some normalcy!! Rich 

Wednesday, April 29, 2020

Hintermann Test or First Metatarsal Raise Test for Recognition of Posterior Tibial Tendon Dysfunction

     Hintermann published a paper in 1996 about a clinical test to help him decide whether a patient needed surgery for posterior tibial tendon dysfunction. It was based on the fact that with the patient standing, when the heel is inverted (or the leg externally rotated), only in the 21 patients that had posterior tibial disease (not necessarily ruptures) was this test positive for leaving the first metatarsal off the ground. It is now known more as the First Metatarsal Raise Test. When I read the article many thoughts crossed my mind, and I need to do this test some, but I need other podiatrists to give me feedback on their successes and failures. So, what bothered me about this test? The things that bother me are:

  1. 100% of the patients were positive even though the surgical findings were all over the place (from tendinitis only to complete ruptures)
  2. 100% of the patients without post tibial tendon disease were negative, but they do not go into any of these patients (allow they implied the test was being done over 4 years)
  3. They made no reference to what type of orthotics were being used preop to avoid surgery and whether the tendon being strengthened thoroughly before (there was no mention about posterior tibial strength at all)
  4. They seem to have no knowledge of deformities like rearfoot varus, rear foot valgus, forefoot valgus and forefoot varus. Any of these common deformities would greatly affect this test. 
  5. In most of my patients with PTTD, with 10 degrees of heel eversion, and 10 degrees of positional forefoot supinates, when I put the patient into heel varus the first metatarsal is going to be way off of the ground. This does not mean I need to do anything but rehabilitate them. 

I am so hopeful that my esteemed colleagues around the world will help decipher the importance of this test. 

Saturday, April 18, 2020

Surgical Complications Post Bunionectomy and Pes Cavus Foot

Hello Dr. Blake,

I hope you are doing well and staying healthy during these crazy times! 
I have been thinking of writing you for quite a while, but my question is quite lengthy.
 I have attached some x-rays and photos to this email, but I also have a CT cat scan
 and an MRI of my foot if having those would be better.
Dr. Blake's comment: Yes, send those to Dr. Rich Blake, 90 Beachmont Drive, 
San Francisco, CA, 94132 to see if those are revealing. 

I have developed a hallux claw toe in my right foot after I had a bunionectomy
 and tibial sesamoidectomy in 2014 and I am wondering
 if I should get surgery to prevent a joint fusion surgery in the future.
 My toe does not bother me terribly now. Every other day I can go on a 1 mile walk,
 with minimal discomfort. However, I have noticed that as time has gone on
 it has become progressively more sensitive 
(able to walk less and less mileage without the next day hurting)
 and I want to maintain a relatively active life as I am 33 and a mom.
 My right big toe does not really touch the ground, and my other four toes
 on the right foot are starting to develop hammertoes.
 My left foot also has hammertoes so I know I am prone to them,
 but they are still relatively mild on both feet.
 I have been recommended two different surgical techniques to prevent further problems 
down the line with my foot, and am wondering whether you think
 1) surgery is a good idea, and 2) if so, which surgery you think I should opt for.


Initial Breaking of Tibial Sesamoid with subsequent Surgery: I have high-arched feet, 
and have worn orthotics since age 13 or 14. 
I broke my tibial sesamoid after wearing heels to a party in 2013.
 It was described as a freak accident (as I guess most bone breaks are!) 
but people had always remarked at how high my arches were,
 so I guess the pressure was too much. 7 months later 
I was told there was no healing and it was recommended I have a tibial sesamoidectomy
 as well as a bunion surgery (chevron osteotomy), 
as I already had a bunion but the broken sesamoid was accelerating its progress.
 I wish I had found your blog back then, as it was described as a relatively easy surgery
 with minimal complications. After the surgery I went to physical therapy. 
It was always hard for the physical therapist to get my big toe to touch the ground even then.
 A year after the surgery I noticed my right big toe no longer touched the floor when barefoot.
 As long as I wore orthotics in shoes I was pain-free and comfortable
 and could go about my daily life. Walking barefoot was uncomfortable 
because the ball of foot was pushed into the floor without weight bearing from the big toe.
Dr. Blake's comment: This is a common problem with the tibial sesamoid removal 
which weakens the short flexor under the joint. This enables the tendon on the top
 of the toe to win, called the extensor.This dynamic imbalance pulls the toe up 
starting the hammertoe. With the pes cavus or high arched foot, you probably
 even before surgery had a tighter extensor ready to pull the toe up. With this being said, 
it does not explain why the PT could not get the toe down which let this get out of hand. 

Most Recent Setback: In May 2019 I wore a pair of heels on date night
 and walked about 10 minutes on the cement sidewalks. (No heels allowed in my closet again!) 
The next day my fourth toe and especially my big toe were very inflamed,
 and it took 5 months of me wearing a boot and daily icing in order for the symptoms
 to calm down. This is when I found your blog. During those 5 months
 I visited multiple podiatrists and two orthopedic surgeons to try and figure out
 why it was taking so long to heal. It was determined that I stretched the collateral ligaments
 in my stiff big toe. The second orthopedic surgeon had a nerve-conduction ordered
 to ensure I did not have charcot-marie-tooth disease, due to my high arches,
 raised toe, hammertoes and slight atrophy of right-side calf muscles. 
Luckily it was determined I do not have the condition, but both orthopedic surgeons 
commented on how raised my big toe was, and were concerned about how my foot
 would handle such biomechanical stresses for the duration of my lifetime. 
Both of them suggested some surgical techniques to prevent the further deterioration of my foot.
 I know you are not a proponent of “preventative surgery”, but I am wondering
 what you recommend in my case.
Dr. Blake's comment: All we know right now in this correspondence is that you 
have a very sensitive
big toe joint. I think everyone, except a few surgeons, would agree 
that an operated on joint, is and will
be forever a weaker joint. When you do hip surgery, and slightly less with knee surgery, 
you can 
establish great stability on the surgical site with the surrounding muscles. You
have great opportunity to really tone them up. The foot has some crucial
muscles to help, but as podiatrists we mainly have to rely on shoes, orthotics, 
accommodations, taping, 
etc, and physical therapy to breakdown scar tissue, remove inflammation, 
and stretch and 
strengthen the muscles up the leg to the hip. 

Current Pain and Issues:

1) My current symptoms are that my toe is quite stiff at the MTP joint, 
and semi-rigid at the IP joint. I have good range of motion with the toe going upwards
 but pretty limited motion when trying to force my toe down. 
 The bottom of my big toe is sore (scale of 2 out of 10) if I go on a 1 mile walk or more.
 If I go on these walks for more than a couple of days I have to take the next day off. 
Furthermore, the side of the top of my big toe gets sensitive too if I go on long walks
 or walk barefoot on hardwood floors. I have noticed this is because my big toe 
actually turns into the rest of my foot, in addition to the claw toe. 
It feels like the bone is pushing out? This varus has been increasing over time. 
Dr. Blake's comment: So, if you were in my office I would have you practice and get really good at
spica taping to hold the toe down for the next 8 weeks. Patients usually can advance 
from the easier KT 
or Rocktape to the 3M Nexcare Waterproof tape. You should have a PT over the next 
month to year 
(when corona quarantine is lifted) measure the amount of plantar flexion 
of the big toe joint which
we will compare to 3-6 months from now. 

Also begin to experiment with the dancer's padding idea to shift weight from the 1st metatarsal
 and toe 
onto all the other toes in whatever shoes you can.  

Surgical Options:

1) First Doctor (Scar Tissue Removal):

a. Concern: The first orthopedic surgeon was concerned that without the use of my big toe
 the ball of my foot would take too much pressure and I could therefore damage
 my remaining sesamoid or put too much weight on the other four toes, 
causing an acceleration in the hammertoes in this foot. He noted that the IP joint
 was still flexible, and thought I had developed a claw toe largely because of
 scar tissue buildup from the first surgery in the MTP joint. 
He thought my symptoms would be greatly improved if I could get
 another 20 degrees downward or so from the big toe.
Dr. Blake's comment: He has the right idea. We need the joint measured so we can 
document this 
improvement. We need the tape and dancer's padding to do what he wants his surgery to do
 at this time. 
3-5 times a daily you need to stretch down the big toe at the ball of the foot joint.
 Hold 30 seconds, relax
5 seconds, and hold another 30 seconds. You need to straighten the IPJ which is
 flexible by pulling the 
toe out again 30 seconds times 2. You need to strengthen the EHL by pulling 
the toe up at the IPJ only, 
you have to hold the proximal phalanx down. You need to strengthen the FHB
 you have left (same 
exercise as in my video on bunion). Do these once daily in evening and build from 
10 to start of each 
to 30 over next 6 weeks (adding 5 more every 10 days or so). 

b. Timing: No rush, whenever is convenient for me and my family life.

c. Surgery: He recommended a 1st MTP dorsal capsule release and EHC scar release. 
Since there would be no bone being cut during this surgery, recovery would be relatively simple.

d. Recovery: Two weeks in a short cam boot and two weeks in a surgical shoe, 
with physical therapy afterwards.
Dr. Blake's comment: I think from the 2 photos above people can get an idea 
of your downward 
restriction of that joint. The 2 surgeries suggested are on the top of the joint
 to release things, but what 
if the whole problem is coming from the tibial sesamoid removal and blockage 
there to bring the toe. 
That makes more sense, since the surgical done effected the bottom more than the top.
 When you try to 
push the toe down, as in the photo above, where do you feel you are restricted? 
Do you feel tightness on 
the top limiting the downward motion, or do you feel a block in that downward
 motion from the joint 
itself? I am going to have you do my self mob routine from several weeks and 
see if you can get the joint 
looser. Now, for sure, you can have all the restrictions on top, 
and you will sense the restrictions inside, 
so this is not perfect, but I would like to make as logical a guess. 

2) Second Doctor (More Extensive Toe Reconstructive Work):

a. Concern: The second doctor seems quite concerned about the structure of my foot and toe
 (he originally ordered the nerve-conduction test for CMT) and is concerned that if the structure
 of my foot is left the way it is I will have significant degenerative changes
 on my toe going forward. He seemed pretty confident that if I left the toe 
untouched in its current state I would have to have a joint-fusion surgery in the future,
 possibly in both the IP and MTP joint. He said I really want to avoid a joint-fusion surgery
 and thinks this surgery would have an 80% chance of success.

b. Timing: Recommend to do the surgery within a year as he is concerned that my toe 
will stiffen if left in the current state.

c. Surgery: More substantial surgery. I would have a 1st metatarsal crescentic osteotomy,
 toe lengthening, IP joint arthrotomy and possible FHL lengthening.
Dr. Blake's comment: Let me start with the last 2: The arthrotomy just means 
to free up the joint (which
hopefully you can do with stretching or pulling the joint straight 
twice daily, and FHL lengthening
means to weaken it so it does not pull downward on the end of the toe so much.
 Let's mobilize, stretch, tape,
strengthening and off load as we have discussed.
 The image you sent talks to the osteotomy and toe 

d. Recovery: 6 weeks in a boot with no driving during that time. This is daunting to me
 since I am a stay at home mom right now taking care of a toddler (and I don’t have a yard!),
 but I would do it in order to better my chances of long-term foot health. 
Full recovery would be 6 months. Physical therapy afterwards.

So that is a summary of my problem. What are your thoughts on whether I should opt for a surgery, 
and if so, which surgery would you opt for? I am cautious since the first surgery
 I had took almost 1.5 years to feel better, but I want to maintain mobility! 
Do you think I need to get surgery or I will end up with a joint fusion later in life? 
I would appreciate your thoughts and advice on my issue. 
Let me know if you need more information…ie videos or the CT scan or MRI I also have.

Thank you for your time!

Dr. Jill's Sesamoid pad can help

Dr. Blake's comment: The side view xray of your cocked up toe and 
high arch showed nothing amiss, nothing obvious to cause concern.
The view from the top of your foot showed that the first surgery left 
the first metatarsal too short, thus the tendons retracting and creating 
the hammertoe. Yes, you can go back and correct for that mistake, but 
the rest of the joint looks perfect. A small bunion is starting so when you 
the spica taping try to straighten the toe slightly at the same time. Start 
wearing large toe separators sold everywhere, and use yoga toes 4-5 times
a week as a 30 minute stretch. What I do not know if it is best to do the dancer's
padding or a Morton's extension. I think you should see what feels better with 
a week of each. I use adhesive felt from Alimed 1/8 inch to create my Morton's Extensions 
and dancer's padding.
The morton's extension could go from the ball of the foot with a cut out for the
 good fibular sesamoid 
to the end of the toe. This all makes the most sense for the next 3 months. 
Hope this helps. Rich 

Saturday, April 11, 2020

Negative Impression Casting for Functional Foot Orthoses: 3 Videos

Gait Evaluation Lecture 4-10-20 California School of Podiatric Medicine

Welcome to my Google Document that I shared with my Podiatry Students at the California School of Podiatric Medicine Samuel Merritt University Oakland, California. This was my first Zoom teaching, so I over prepared, and dropped everything else I was doing last week, but I think it went well. I will be putting the answers to questions on this on request of student doctor Diksha Mohapatra by April 17th, 2020. The videos are great to watch if you want to learn about gait evaluation. Rich

Biomechanics Workshop Outline (4/10/2020 1-3 pm)

  • Introduction of Students and Dr. Rich Blake
  •                     Allison Ma
  •                     Amy Lau
  •                     Andrew Rasiah
  •                     Diksha Mohapatra
  •                     Maksim Rukhalskiy
  •                     Shane Hall
  •                     Usman Khokhar
  •                     Yona Mizrahi

2 Classes from Dr. Rich Blake  Gait Evaluation 4/10/2020
                                                     Orthotic Devices on 4/24/2020

(we will start next session with the discussion of the assignment below on Golden Rules)  

I hope to teach you that Gait Evaluation is much more than pronation or supination of the foot. Look at the whole body. We use gait evaluation as a clue to find out what is wrong with a patient, and how to help them. 

Right Foot
Some of your patients will like this video, so you should know how to treat them and we will go over orthotic devices next session.

I want to introduce my blog which will have a lot of info. My YouTube channel is also entitled drblakeshealingsole 

Maksim: What are the 5 common mechanical problems picked up in gait?
Shane: Give me an example of a problem related to a tight muscle?
Usman: Give me an example of pain related to a short leg syndrome?
Yona: What would be the general treatment categories of these 5 mechanical problems?

Allison: What are the 2 separate parts of gait called?
Amy: What are the 5 components of stance phase?
Andrew: What are the 3 components of the swing phase?
Diksha:  With what you know of the contact phase as the ankle is plantar flexing, what is the heel doing in the frontal plane and the knee doing in the transverse plane?
Maksim: How does the patient prevent foot slap gait with drop foot?

The common findings in gait that you as a podiatrist will see in regular practice is less pathological and more subtle, but still very important. Looking to see how to help each patient mechanically.
  • Ability or Inability to Walk (First and Foremost)
  • Structural deformities like pes planus, pes cavus, bow legs, knock knees, genu valgum, etc.
  • Signs of Asymmetry
  • Signs of Pronation
  • Signs of Supination
  • Signs of Limb Length Discrepancy
  • Signs of Tight Muscles/Tendons
  • Signs of Weak Muscles
  • Signs of Poor Shock Absorption
These are all problems that we can make mechanical changes to help

Maksim: What would be a sign of pronation?
Shane: What would be a sign of supination?
Usman: What would be a sign of short leg syndrome?
Yona: What would be a sign of tight muscles?
Allison: What would be a sign of weak external hip rotators?
Amy: What would be a sign of weak achilles tendons?
Andrew: What would be a sign of weak peroneal tendons?
Diksha: What would be a sign or weak posterior tibial tendon?
Maksim: What would sign of poor shock absorption?

Below is a video with a more podiatric approach with less emphasis on the aspects of gait, and more on what can cause injury that we can help. 

Maksim: What does good arm swing correlate to in the lower extremity?
Shane: If excessive supination was found in the left foot, and it correlated to some symptom like peroneal strain, what could be done about it? 
Usman: What is significant about knee internal rotation at heel contact?
Yona: If you saw excessive internal knee rotation at heel contact, what muscle group could be weak?

Here is a video on over pronation?

Amy: What are 3 foot problems caused by overpronation?
Allison: What are 2 knee problems caused by overpronation?
Andrew: What muscles would you have a PT strength with overpronation syndrome?
Diksha: Which types of shoes help with overpronation?

Here is a video on over supination?

Maksim: What are 4 problems caused by over supination at the foot?
Shane: What are 2 knee problems caused by over supination at the knee?
Usman: How does over supination cause joint pain and stress fractures?
Yona: What are 2 muscles/tendons to strengthen with over supination?

Here is a video on limb dominance?

Shane: What are the 4 main gait findings that may suggest short leg syndrome?

Where does gait fit into our General Approach to Injuries and Pain Syndromes?

14 Step Approach to a Injury or Pain in Office Visit
These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:
  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? 

Since I can never get enough on gait evaluation, here is another video. 

Amy: How many steps equals a stride?
Allison: What happens first, heel lift of the right or heel contact of the left? 
Andrew: Why is it important to watch both sides?
Diksha: Did the patient have tibial varum or valgum?

  • Common Gait Findings (Summary)

                              Gait Evaluation Checklist (circle findings)
  1. Head Tilt (Straight, Lean Right, Lean Left)
  2. Shoulder Drop
  3. Asymmetrical Arm Swing
  4. Dominance to One Side
  5. Trunk Mobility (Limited, Normal, Excessive)
  6. Hip Hike (Right or Left)
  7. Belt Line (Higher Right or Left)
  8. Hip Rotation (limited, normal, excessive)
  9. Excessive Shock (Right or Left or Both)
  10. Limited Knee Rotation(Right—straight vs external, Left—straight vs external)
  11. Excessive Internal Knee Rotation (Right or Left or Both)
  12. Heel Motion at Heel Contact (Right—eversion, none, inversion, Left—eversion, none, inversion)
  13. Symmetry of Arch Collapse (Right more vs Left more)
  14. Digital Clawing (Right or Left or Both)
  15. Angle of Gait (Right—internal, straight, external, Left—internal, straight, external)
  16. Other Structural Variations: Pes Cavus, Pes Planus, Tibial Varum, Genu Valgum, etc
  17. Correlation to Symptoms: _____________________________________________________________________________________________________________________________________________________________________________________________
  18.  Other Observations: ______________________________________________________________________________________________________________________________________________

Allison Question #1: In assessing gait in an adult, the finding of a head tilt to the right suggests which leg is possibly longer?
Amy Question #2: When you observe a patient walk, and you note that their right shoulder is lower, what should you ask them and where should you next observe?
Andrew Question #3: Asymmetrical shoulder motion is typically reflected in asymmetrical arm motion. If a patient has a sore right knee, what is the normal arm swing variance seen, and how can that cause neck pain? 
Diksha Question #4: As we continue to evaluate gait, what are the signs now that the patient has a possible treatable limb length discrepancy?
Maksim Question #5: How does the correction of 12 degrees of forefoot valgus deformity help with back pain from muscular tension? 
Shane Question #6: What does it mean for you to observe Hip Hike?
Usman Question #7: Watching the beltline of a patient as they watch back and forth in your clinic typically gives you 3 observations that you may be able to treat. These observations are:
Yona Question #8: The normal knee motion is a reflection of hip motion. What would it mean if the knee started central or straight, and externally rotated to an external position during the contact phase? 
Allison Question #9: How can a patient maximally pronated in gait due to genu valgum and weak posterior tibial tendons be a poor shock absorber and present with knee pain?
Amy Question #10: A patient complains of lateral foot pain recently. They have observed that their foot was out toed more in the last several years. They have some back pain also. What is the possible diagnosis? 
Andrew Question #11: Excessive internal rotation of the knee is a common gait finding. What 3 areas of treatment should be addressed? 
Diksha Question #12: As we learn to watch gait, what motions are found with the motion of heel eversion and heel inversion?
Maksim Question #13: When a patient with pes cavus walks towards you, you do not observe any flattening of the medial arch on the right foot, but marked arch collapse on the left side. We understand that there are pronatory forces occurring on the left, but what could be happening on the right?     
Shane Question #14: In gait we may observe that the toes tend to claw. This can be bilateral or occasionally unilateral. What are 2 common reasons that weak achilles tendons can cause this? What is the acid test for achilles strength? 
Usman Question #15: As we watch a patient walk, one of the last observations will be the angle of gait. It is really important for children to know what the reasons are for the internal or external angles because of our abilities to cast or brace young children to improve this transverse plane issue. If you observed in gait that the knee was straight, but the foot 30-40 degrees externally rotated, what are several common causes? 
Yona Question #16: The general rule used in shoe stores is that pes cavus feet supinate or underpronate. What percentage of pes cavus feet supinate?

Here is a video from the running shoe Company

Shane: What are the 2 types of overpronators they described?
Yona: What does the term Underpronation mean?

So, here is a summary of the gait findings I find daily in my patients associated with the common mechanical syndromes that I can make correlations to their symptoms and then treat mechanically. 

Common Signs of Short Leg Syndrome
  1. Limb Dominance where the patient spends more of their time over one side
  2. Asymmetrical arm swing (long leg can have the arm closer to the body)
  3. Shoulder drop is usually to the long side (when compensated with the spine)
  4. Head tilt is usually to the short side (also when compensated with the spine)
  5. More pronation or more supination on one side
  6. Belt height is angled up towards one side 

Amy: Which statements are false in leg length discrepancies?
  1. The typical limb dominance is to the long leg
  2. A true shoulder drop finding has lower fingers on that side
  3. The more pronated side is the shorter side
  4. The Standing AP Pelvis x-ray without lifts is the most important x-ray

Common Signs of Excessive Pronation
  1. Internal rotation at the knees is excessive
  2. The medial prominence of the ankle
  3. Digital clawing in midstance
  4. Abductory twist seen in propulsion
  5. Heel eversion is sometimes seen
  6. Arch collapse is noticeable as the patient walks toward you

Allison: What would not be considered abnormal pronation?
  1. Pronation after heel contact too rapid
  2. Pronation after heel contact too prolonged
  3. Pronation after heel contact excessively internally rotating the knee
  4. Pronation to heel vertical in 10 degrees of tibial varum
  5. Pronation to a 2 degree everted position before the midstance phase

Common Signs of Excessive Supination
  1. Lateral shift of the body weight following heel contact
  2. Heel Inversion at heel contact is sometimes seen
  3. No patellar internal rotation at heel contact
  4. Gait sometimes appears very rigid 
  5. Sometimes shock wave up calf and thigh seen
  6. Lack of arch collapse at contact

Andrew: Which of these problems is not related to overuse of the peroneal tendons trying to decelerate abnormal heel contact supination?
  1. Peroneal Tendonitis
  2. Fibular Stress Fractures
  3. Inversion Ankle Sprains
  4. Tibial Stress Fractures

Common Signs of Poor Shock Absorption
  1. A loud sound of heel strike 
  2. Shuttering of the muscles (especially calf and thigh) following heel contact 
  3. The rigid appearance of lower extremity
  4. Excessive subtalar joint supination at heel contact
  5. No Subtalar Joint Motion Observed

Diksha: A patient with lower back pain and limb dominance noted on gait evaluation may be caused by what problem?
  1. Limb Length Discrepancy
  2. Excessive Unilateral Pronation
  3. Excessive Unilateral Supination
  4. Poor Shock Absorption
  5. More than one cause

Common Signs of Equinus
  1. Early Heel Off 
  2. Bouncy Gait with heels barely touching
  3. Genu Recurvatum with excessive straightening of the knee
  4. Excessive pronation typically with out-toeing gait
  5. The collapse of the midfoot after heel off

Maksim: Severe equinus forces can cause severe pronatory forces on the foot needing to adapt. Discuss the concept of a “double heel lift” occasionally seen. 

Common Signs of Typical Severely Weak Muscles
  1. Medial arch collapse with weak posterior tibial tendon
  2. Lack of heel lift with weak achilles complex
  3. Excessive internal patellar rotation with weak external hip rotators 
  4. Lean to one side with weak hip abductors
  5. Contact Phase Lateral Instability with weak peroneal tendons

Yona: Posterior Tibial Tendon Dysfunction can be treated conservatively even in some Stage 3 patients. What are 3 major functions of the posterior tibial tendon that may need help in the rehabilitation, and the 2 functions helped with corrective custom made orthotic devices?

For next class, I am assigning this presentation on the 20 Golden Rules of Athletic Rehabilitation. Please be ready to discuss the ones assigned to you. 

Allison  1, 9, 17
Amy      2, 10, 18
Andrew  3, 11, 19
Diksha  4,  12, 20
Maksim  5, 13
Shane   6, 14
Usman  7, 15 
Yona   8, 16

This is the assignment for the next 2 weeks. You need to email Dr. Blake your answers and please do not all wait until before the next class!! LOL 

Examples of Gait Findings and Treatment Options

                                                 Example #1
     A runner presents after developing left knee pain on a long training run preparing for the San Francisco Marathon that was to be two months later. Gait evaluation walking revealed a dominance (or body shift) to the left side suggesting at least more weight bearing on the injured left side and perhaps a short leg syndrome. This dominance to the injured side is also significant due to the fact it is opposite of mere favoring to take the load off the injury. The left knee had more internal rotation at heel contact on the side of the runner’s knee complaint. The heel was actually inverting at heel contact (opposite direction of the knee internal rotation). The patient was then asked to run up and down a long hallway with the running shoes that they brought into the office. It was a brand new pair, as they had purchased in hopes it would clear the knee problem. I asked the patient to bring in the pair she was wearing when she hurt the knee. 
     Remember the Rule of 3 in evaluating these overuse injuries (from Chapters 1 and 2). Any injury, where the tissue is so overstressed that it begins to complain, typically has at least 3 causes (yes, you do not need to stop at three). This is why one patient with overuse, or overpronation, or wears inadequate shoes, can develop knee pain, another shin splints, another foot pain, and so on. It is a fun investigation and of course, should be started on the first visit on the new problem or new injury. In this case, the left knee pain was being stressed by:
  1. An inadequate training program (she was up to 15 miles only two months after starting running)
  2. A dominance to the left probably placing 20% or more weight on the left side (later found that the left side was the long leg of a ¼ inch)
  3. Excessive internal patellar rotation caused by very hip external rotators (yet, quickly improved with an appropriate strengthening program)
  4. Unstable athletic shoes with poor support and cushion (discovered at the second visit)
  5. I also think that when the knee is going in one direction (internal) and the foot going in the opposite direction (external) there must be terrible unnatural twisting motions whose stress must be taken up somewhere
  6. Other components discovered were weak quadriceps, tight hamstrings, and low Vitamin D (not sure if there was a relationship here). 
  7. Also, she lived on the bottom of a huge hill in San Francisco, and her running loop always had her run the last mile down hills when her legs were the most tired.
     So, gait evaluation pointed the way to several key components that were easy to correct in the long run. This particular patient would go on to run several marathons over the next few years with strong external hip rotators and quads, a good training problem, and Brooks Glycerin Shoes for her supination. She knows she has one leg longer, and someday that may be addressed. She reversed the Vitamin D deficiency, and if she breaks anything a bone density will be ordered. Her primary care physician thought at 32 years old, and no history of fractures, a bone density scan was not called for in this case. It took 6 months to get the external hip rotators strong, and initially, the therapist was not isolating the external hip rotators enough and not stretching the tight upper part of the medial hamstrings. When you imagine that the average runner quits running within a year, runners really appreciate this type of approach towards wellness and long-term prevention. This example also points to the fact that you do not need to always correct everything at first, but I love my patients to definitely know what is going on. 

All Students: Utilizing the Rule of 3 for gradual sesamoid pain developing in a hiker, what are some common causes in an overuse situation? Email me answer at

                                                     Example #2
     This 76 year old noticed pain in the lateral side of her left foot 6 months before the initial office visit. The problem has been getting worse and more limiting. She also noted some flattening of her left foot in the last few months. Gait evaluation showed markedly more pronation on the left foot compared to the uninvolved right foot, with heel valgus only seen on the left side. She noted swelling medially, but the pain was only lateral. We are obviously dealing with posterior tibial tendon dysfunction but it is not the usual location of pain. By again using our Rule of 3, the examination found (more than 3 or sure):
  1. Very weak posterior tibial tendon
  2. Very weak Achilles’ tendon with overstretched length 
  3. 12-degree heel valgus resting position measured, and 3 degrees valgus or everted on the right side
  4. The tendency to wear heels or flats with no support
  5. 30-year-old left ankle sprain with questionable rehabilitation 
  6. Not an ounce of athletic sense or body awareness when discussing rehabilitation with her
  7. Overweight 
  8. Inactive her whole life (busy professional until retirement)
     Gait evaluation pointed to the pronation problem left greater than right. The significant heel valgus would have been missed without gait analysis with the asymmetry very important. She had been dealing with weak muscles for a long time, but the heel valgus was causing lateral ankle impingement (between the calcaneus and the fibula). MRI showed some irregularities in the tendon but no tear. She really had pronation pain, not posterior tibial tendon dysfunction pain. She knew she had neglected her health, but fought diligently to take stress off the lateral ankle and was quite simple to treat in some ways. The 6 things that turned her symptoms around:
  1. Stable shoes and ⅜ inch varus wedge (¼ inch for the uninvolved right side)
  2. Joined Weight Watchers and lost 22 in 3 months
  3. Began a one year program of posterior tibial, Achilles, single leg balancing, external hip rotator strengthening (probably had doubled her initial strength in the first 2 months)
  4. Icing 3 times daily for anti-inflammatory
  5. Leukotape with coverlet to prevent heel eversion (helped the varus wedge)
  6. Several dressier flats, that could not hold the varus wedge internally, had ¼ inch varus outsole wedging applied full length by a local cobbler on the left and ⅛ inch on the right side.
     I am not mentioning the functional orthotics she received in the modalities that turned her around because she was so much better months before they were dispensed, and I actually never saw her wear them except at the orthotic dispense visit 4 months into our journey together. She was given highly corrective orthotics for the left (35 degrees, and 20 degrees for the lesser pronated right foot). Both athletic and dress versions were made, and because Medicare does not pay for them, she self-paid for this and only this part of the treatments. Chapter 13 on custom orthotic devices will go into the rationale of how many degrees of correction to order. She said they will be used in some hiking boots, but she always came into the visits in dress shoes with the outer sole with the varus wedge.
     I said that she was easy to treat in some ways because the real reason I remember her is that the first podiatrist she saw immediately used the “S” word. This podiatrist did watch her walk, and saw the pronation. She was immediately placed into the adult acquired flat foot reconstruction category, and without MRI or a lot of thought, had scheduled her for flat foot reconstruction with the breaking of the heel bone, fusion of some joint, and repairing tendons (patient’s description to me). She only saw me because a friend had seen me and told her to at least get another opinion. I only saw her five times, about one month apart. The first visit was for an hour and we talked about the surgery for 45 minutes of the visit, the next visits were 30 minutes each and each visit we talked about the surgery a little less and less. The last visit, she was completely out of pain, walking 30 minutes daily, no discussion of surgery until as she left the office she turned around and said: “how will I know when I need surgery?” The power of a word. I saw her one year later for follow up and an ingrown toenail, she looked 20 years younger, 37 lb weight loss overall, exercising regularly and did not say the “S” word. 

All Students: Research to find out how much inversion I would put into this foot using the Inverted Orthotic Device initially. Email answer