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Friday, December 13, 2019

Gout Sufferers: A Wearable to Help!!

Philosophy of Treating Athletic Injuries (Part 1)

Philosophy of Treating Athletic Injuries (Part 1)

The treatment of athletic injuries is based on many principles that must be applied to the individual with his/her injury. Of course, the same principles that are used on athletic injuries can be applied to non-athletic injuries and pain syndromes as well. The experience and knowledge base of the doctor and therapist become very important to the patient. The decisions of diagnosis, cause, when to cast, when to X-ray, when to inject, and when to stop all activity must be carefully thought out. This is why this is not a cookbook lesson plan to be easily followed by any doctor or therapist. Understanding the individuality among athletes is the key to understanding the complexity of treatment of athletic injuries. Each similar injury has a different set of circumstances associated with it. There may be differences in, among other things:

·       severity of injury
·       severity of the cause
·       length of time that the injury has been present
·       amount of residual weakness, swelling, scar tissue accumulation, or stiffness
·       suddenness of the injury
·       individual’s sport
·       individual’s physical, psychological, or emotional need to return to activity
·       previous treatment
·       speed of return to activity
·       pain tolerance
·       multiplicity of the problem(s)

Does this give you a hint of the complexity? The patient is a stranger to the doctor or therapist on the first visit. There is sometimes a limited amount of time to sense the patient’s problem, frustration, cause or causes, and possible treatment plans, etc. Many decisions are then made. The patient’s main goal is to rid himself or herself from the problem as soon as possible, with no recurrence. The health care provider’s main goal is to safely rid the patient of the problem with no recurrence. Should the patient rest a day, two days, two weeks, three months? Should the patient self-treat the problem at home to save expenses, or be seen in therapy daily, weekly? Should an elaborate work-up on the cause be pursued? Should every ache and pain be X-rayed, bone scanned, MRI’d, casted, or injected? Should every possible cause be treated, even if this would entail months of treatment and huge expense to the patient? The purpose of this conversation is to bring the patient closer to the doctor/therapist in making decisions on treatment care. It is a joint venture, and both must know what the other is thinking. This TEAM approach is unique to sports medicine, but slowly spreading to other disciplines as well.

There are a few common athletic injuries where the doctor or therapist must immediately realize that the patient’s problem is very serious. The crack or snap that is heard, the amount of sudden swelling, the severe intense pain, the total inability to walk without pain, the inability to bend a joint without severe pain, the history of years of pain without relief, can all signal the doctor/therapist to regard this injury as special and definitely serious. Complete investigation should be performed in all of these cases. Fortunately, these are the rare injuries. Definitely, five percent or less of all athletic injuries fall into this category. Most of the time, the injury was gradual, with no to minimal swelling, only moderate aches (level 5 pain at most), with no limping when walking, running, skating, dancing, etc. All body parts are freely movable. The symptoms have existed for three months maximum. Should be easy to treat, right? Sometimes that is the case; but there are so many variables that play a role in the difficulty or ease of treatment.
     The doctor or therapist must have basic rules that guide them in their treatment of  injuries or pain syndromes. A starting place for the treatment of most injuries develops from there. For each doctor or therapist, these basic rules are very different. Hence, the reason that some are successful at treating sports injuries, while others are not.
But even the best doctor/therapist cannot put all the pieces together all the time for every patient. And, of course, the patient feels let down, misdiagnosed, ripped off, etc. Can this be prevented? Sometimes it can. If the basic trust in the doctor and therapist is there, the patient will communicate his or her frustrations. This forces the health care provider to re-evaluate the course of action and accept failure, change direction, etc. Usually the doctor/therapist is busy actively treating many patients at any one time, all in different stages of healing, without the ability to individually check on the progress of each patient. The patient must follow up, inform if there is no change for the better, and positively help in the healing. There can be physical reasons a treatment regimen fails.
We must avoid failure from patient frustration and lack of communication and distrust in the doctor/therapist and patient relationship. Fortunately, 90 percent or more of patients get better when communication is free flowing.

Here are some basic principles in the treatment of athletic injuries. The first priority right at the initial visit is to decide on the severity of the problem. The two important categories are major and minor. A major injury needs no guesswork in treatment philosophy. The patient may develop permanent injury if not treated quickly, accurately, and intensely. This is the first type of injury we discussed, when there is the inability to walk, severe and intense pain are present, etc. Diagnosis is important. X-rays are taken, and MRIs or other tests are considered quickly. Physical therapy is initiated. Expense, time, and risk of radiation become minor concerns or no concern of all. These, in a way, are easier to initially treat. Cookbook teaching is present for most. Follow the book and success in treatment is usually obtained. It may take months or even years to rehabilitate, and the patient may never run or ski or dance again, but the doctor is the hero. He/She prevented it from getting worse, taking longer, etc. Hopefully, you are completely cured in the process and can resume all activities.

Fortunately, most athletic injuries do completely recover!!!
And, fortunately, few injuries are considered in this major category.
The patient's outlook on their injury varies according to:
·       outlook on severity: major or minor problem to them
·       expense of possible treatment
·       time and energy of possible treatment
·       speed of recovery desired
Therefore, with 95 percent of all injuries considered minor in consequences, the doctor/therapist must come to grips with the patient's perspective. The doctor or therapist then maps out a plan of attack after the initial evaluation. Always important to have, this plan of attack has different variables. These are:
·       Further diagnostic testingnow, or only if not getting better
·       What type of pain is the primary source at present: mechanically induced, inflammatory, or neuropathic?
·       Initial treatment planphysical therapy, home exercises, medications, casts, lifts or other shoe inserts, training adjustments (i.e., rest, alternative exercise), taping and other treatment modalities
·       Back-up treatment planif patient does not get better, if patient is better but wants faster relief, and if patient wants insurance to prevent re-flares (Golden Rule of Foot: Always Have a Plan B)

Patient Education Advice—the patient needs to know how to prevent recurrence of injuries by knowing the cause of a particular injury (and the causes of most injuries). This is so crucial in preventing the same injury from just coming back. It is one of the key reasons podiatry is so successful with athletics because we can find a cause to reverse. As the doctor or therapist maps out the proposed treatment plan, it is based on what the majority of patients with the same or similar problem became better with. I try to point out all the possibilities of diagnosis, cause, and treatment, and then allow the patient to decide how much expense, time, and energy he or she wants to build into the rehabilitation plan. Most patients are started on a home exercise program and other self-help ideas. X-rays are not routinely performed, since 90 percent of the time the injury is limited to soft tissue. Casting is done when walking is difficult, but removable casts/boots have revolutionized the process (if you have to get one, look into the Ovation Medical ones). Much less muscle atrophy is seen with removable casts/boots than the traditional permanent casts. Cortisone shots should be limited to only mandatory situations due to their possible weakening effects on the soft tissues. Never have tendons injected with long-acting cortisone since possible ruptures can occur. 
Patients are advised what the next step would be if the injury is not responding to treatment. Sometimes there are so many possibilities of treatment that they all cannot be covered in the initial visit. Surgery rarely is needed for a particular problem, so it is not normally mentioned at the initial visit. The doctor or therapist tries to discuss with the patient:
·       His/Her immediate concerns at the full diagnostic examination (if the diagnosis is still questionable, does the patient want/need X-rays, MRIs, etc.)
·       The patient's ability to begin therapy now, speeding up the process of healing (I can think of very few injuries, primarily neuropathic pain syndromes, which would not be helped by therapy)
·       Their concerns for a rapid (as fast as possible) recovery
For some health care providers, it will seem strange that some patients do not want the "best" fastest care. The problem is that with this "fast" care comes expense, time, and energy. These are commodities some patientsmost patientsare short on. Most of the time we settle on slower, but still effective, courses of action.
Problems arise when the doctor treats the patient on a slow course, cutting expenses, when the patient wants to be cured today, or even yesterday. Some patients must face reality. If they want the best, more effective treatment of their problem, they must give the time and energy and expense to accomplish it. Medical care costs are getting out of control, and paying for it more of a burden.

It is important to minimize the amount of patients going elsewhere when their treatment is slow or recurring. Again, communication is the key. The doctor or therapist must respect the patient as a person, and the patient must view the doctor/therapist as someone truly concerned. Sometimes, there are no good answers to a problem. I try to limit those to a small percentage. I find that if I can communicate with a patient, treatment goes well. If the patient never trusts me, communication will not go well, and the treatment will be shaky, with constant problems. Broken trust between doctor/therapist and patient is rarely fixable.
To be continued (this was an excerpt from my book "Secrets to Keep Moving").

Femoral Nerve Testing and Sensation in Foot and Leg

So often anterior thigh pain can be more from a neurological cause than a mechanical cause. This video of John Gibbons perfectly explains how to test for a femoral nerve involvement. It not only innervates the front of the thigh, but the front of the shin, inside border of the foot to the inside of the big toe. Localized numbness or pain at the medial side of the big toe can be part of a femoral nerve injury at the low back. 


Tuesday, December 10, 2019

Big Toe Injury: Email Advice for Possible Nerve Involvement

Dear Dr. Blake,

I had an injury in July 2019. I did some rock climbing and hiking (usual 
hobbies), and two days later I woke up with a pain in the ball of the 
foot.  The pain was coming and going. I went to an orthopedic doctor and he 
told me that probably I probably had an stress fracture ( clean x-rays) in 
the sesamoid and sent me home with a carbon insole  that did not work. 

After that I started using crutches and resting because I could not walk 
without pain. In August 23 2019 I had an MRI and in September 5 the doctor 
told me that according to the MRI the sesamoids were fine and the injury 
was a strain in the abductor hallucis very close to the sesamoid, and some 
arthritis in the first metatarsal joint   and that were the reasons why 
they thought that the pain was sesamoid related.  

He told me basically to do R.I.C.E and if the pain still on plateau to come back and get a 
cortisone injection in the joint to see if the pain was related to the 
muscle or the joint. After one month I did not feel any changes in my 
injury. I even got new shoes ( Hoka and Altra) with different insoles that 
felt better but still not any sign of healing.  Moreover, my toe was very 
stiff for not moving it for so long time. 

I went to the doctor to get an injection, but the injection in the joint but did nothing; the pain is 
coming from the tear and he is not very enthusiastic of injecting in the 
muscle and tendons. In October 15 the doctor told me that he did not know 
what to do with the injury, explained me some surgeries that he can do, but 
did not recommend it at that moment. The doctor sent me home and told me to 
get a bunion brace and  orthodics.

I decided to exercise to get my toe flexibility back.  By that time I had some vacation planned so I went 
vacation for two weeks and during my vacation I felt great.  I was able to 
walk 4 to 8 mile per day with very little or no discomfort. Moreover, my 
toe is flexible again.  However, after coming back from vacation the pain 
came back similar to September pain.

I am doing practically nothing ( less walking, more time sitting on my desk) compared to what I did on my 
vacations and the pain is worst. Sometimes I feel better walking that 
doing  nothing. I am coming back to do light legs workout to see if that 
work. A new doctor told me that I probably have sesamoiditis, even though 
the MRI did not show any problems with the sesamoid. I am stating physical 
therapist next week and getting new orthodics. after that if nothing work 
he recommended an injection.
Dr. Blake's comment: You are clearly describing neural tension, often reported at muscle or tendon tightness. 
     Nerve hypersensitivity can be the primary problem, or sets into the area secondarily as the problem gets more
     chronic. The initial issue was with rock climbing which can start a nerve irritation due to prolonged holding of 
     positions. Nerves love motion, hate prolonged stretching. The initial carbon insoles probably did not work 
     because they held the toe from bending thus increasing the neural tension. 
          I am glad sesamoid injury has been ruled out. You have to treat the mechanics with dancer's padding to off
     load the area (see Dr. Jill's dancer's pads). You have to treat the inflammation with 5 minutes of ice only or 
     contrast bathing. Typically nerves love heat not ice, but short times with ice 1-5 minutes is fine. Read about 
     neural gliding, neuro eze or neuro one topicals, and move the big toe actively every hour or so for one minute. 
     Move it up and down as long as there is no pain. Have the PT uses nerve treatments like TENs, and forget prolonged toe bending like with the downward dog for the next 6 months. I am not sure what shots will do. Hope this helps some. Rich


Monday, December 9, 2019

Golden Rules of Foot: Sacred Parts of any Practice of Medicine

                                     Golden Rules of Foot

There are rules that govern everything, and medicine is no exception. There are very special rules, which I call the “Golden Rules of Foot” that apply to all aspects of my practice of podiatry. I live by these rules. They are sacred to me. Where some rules are made to be broken, these rules are close to unbreakable. When I make a logical decision, based on much thought and consideration, to break one of these rules, I get mud on my face. These are rules with little or no exceptions whereas most general rules have many exceptions. When I practice the science of podiatry, the rules I was taught, or read in books, or hear at seminars, have many exceptions. This is the art of medicine. The Golden Rules of Foot are part-science and part-art. When they are learned and practiced, healing occurs. When they are broken, in my rush through the day, I typically regret it.

     Every health care provider will actually have their own Golden Rules, formed by years of their unique personalities, observations, and patient experiences. But, Golden Rules can be learned instantly, when we are open to learning (our life long task!). Golden Rules typically do not take a long time to become embedded because they speak to our souls as true from the start.

Golden Rule of Foot: Whereas the human spirit is very sacred, the golden rules of foot are also sacred.
                                         The Balance between Art and Science in Medicine

     It is not the purpose of this posting to go over every rule, but I want to expose the reader to them

in some way. I challenge the health care provider to come up with 50 or so of their own Golden 

Rules of Foot. Again, there are rules and there are Golden Rules, and it is important to make the 

distinction of what is unbreakable. Golden Rules should be unbreakable. Here are 56 examples of 

my Golden Rules.

Some of the Golden Rules for Rehabilitation:
Golden Rule of Foot: Begin strengthening the area the moment you are injured.
Golden Rule of Foot: In overuse injuries, we injure the weakest link in the chain. It is our job
                                   to find out why it is the weak link.
Golden Rule of Foot: Most overuse injuries have 3 causes to look for (at least).
Golden Rule of Foot: The foot is the foundation of the body, and if off by a little, can cause injuries to occur. Always look in treatment to make the body more stable starting at the foot.
Golden Rule of Foot: Listen to your body. It will not lie to you.
Golden Rule of Foot: Never push through pain that begins in a workout, progressively gets worse, and produces limping.
Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen, aspirin, etc.
Golden Rule of Foot: About 80% of healing occurs in 20% of the overall time, with the remaining 20% taking 80% of the total time.
Golden Rule of Foot: Good pain normally dwells in the 0 to 2 pain level (scale 0 to 10).
Golden Rule of Foot: Obtain 0-2 pain levels when treating injuries as soon as possible with whatever means possible and maintain that level through the rehabilitation of the injury. 
Golden Rule of Foot: When 80% of the symptoms are reduced, and normal walking occurs without limping, a return to an activity regimen can be initiated.
Golden Rule of Foot: Treat neuroma/nerve pain aggressively, or it will decide to stay around.
                                    Nerves can cause their own pain, making the original problem worse.
Golden Rule of Foot: Place yourself back into the immobilization phase when you have consistent flare-ups or are getting worse.
Golden Rule of Foot: Allow time for rehabilitation to succeed or to fail, so you can possibly avoid unnecessary surgery or you will know you need surgery.
Golden Rule of Foot: If you are advised on elective surgery, get a second independent opinion, and do not tell the second doctor what the first doctor wanted to do. You want an independent consultation.
Golden Rule of Foot: When rehabilitating an injury, always have a Plan B.
Golden Rule of Foot: If there is swelling or internal joint stiffness, you must work on it daily.
Golden Rule of Foot: Our feet deserve our utmost concern, respect, and care.
Golden Rule of Foot: Do not make treatments more complex than they need to be.
Golden Rule of Foot: If you can find a stretch that makes the painful area feel better, and you are halfway home to full rehabilitation.
Golden Rule of Foot: Keep It Simple Stupid in your treatments whenever possible.
Golden Rule of Foot: In restoring full function, there are many effective treatments available, so experiment or get other opinions.
Golden Rule of Foot: For every day in a cast or boot, it takes two days to get back to normal.
Golden Rule of Foot: We lose 1% of muscle strength daily with an injury, and only gain back 1/4% daily as we rehabilitate.
Golden Rule of Foot: Never get a cortisone shot when you are not sure it is needed, and if other good treatments are available.
Golden Rule of Foot: Never get a long acting cortisone shot into or near a tendon.
Golden Rule of Foot: Submersion is the best way to apply ice or heat.

Some of the Golden Rules for Diagnosis:
Golden Rule of Foot: Treat the patient, not the test.

Golden Rule of Foot: When taking X-rays of the feet, take them standing whenever possible to show alignment issues.
Golden Rule of Foot: An x-ray may not show a stress fracture in the first 2 weeks of an injury, or ever for that matter.
Golden Rule of Foot: Always think that pain can have 3 sources: Mechanical, Inflammatory, and/or Neurological.
Golden Rule of Foot: When the pain is superficial and not responding, look for a deeper problem.
Golden Rule of Foot: Watching a patient walk or run can be crucial in finding the cause of their problem(s).
Golden Rule of Foot: If an injury comes on acutely, and there is noticeable swelling in the area, the diagnosis is stress fracture until proven otherwise.
Golden Rules for Running

Golden Rule of Foot: If you cannot run 5 miles, see if you can run 1 mile, or even 1 minute.
Golden Rule of Foot: It is better to run one second than not at all during the rehabilitation process so you can tell your providers your  activity level accurately.
Golden Rule of Foot: When you can walk 30 minutes at a good pace without pain and without limping after an injury for three straight days, then you are ready to start a walk/run program.
Golden Rule of Foot: Training should allow of periods of recovery (typically 36 hours)
Golden Rule of Foot: Do not change shoes within six weeks of the start of a marathon.
Golden Rule of Foot: Do not change shoe type, running style, or orthotic design when you are increasing your activity levels weekly.
Golden Rule of Foot: Alternation is Important in Training with various distances, surfaces, shoes, and speeds.

Golden Rules for Ballet
Golden Rule of Foot: In treating a ballet dancer, it is important to review their technique.
Golden Rule of Foot: In treating ballet dancers, you must investigate the activities that they 
                                   do when not dancing also. 
Golden Rule of Foot: En pointe should begin when the dancer is skeletally mature, 12-13 years old, has good technique, and a minimum of three years of ballet experience.

Golden Rules for Home Treatments
Golden Rule of Foot: When in doubt to heat or ice, use ice.
Golden Rule of Foot: After an injury, try to attain a pain-free environment as soon as possible (0-2 pain levels).
Golden Rule of Foot: Athletes must understand Good and Bad pain.
Golden Rule of Foot: Strengthening Programs should be done in the evening within two 
                                   hours of bed to allow the area to rest after fatigued. 
Golden Rule of Foot: Stretching should never hurt, and if needed, should be done 3 times a day. 

Golden Rules for Short Leg Treatment
Golden Rule of Foot: With lift therapy, start low and go slow.
Golden Rule of Foot: Keep lifts and orthotic devices separate.
Golden Rule of Foot: Low Back and Hip Pain produces by walking is Short Leg Syndrome 
                                   until proven otherwise.

Golden Rules for Orthotic Therapy
Golden Rule of Foot: When designing or wearing orthotic devices for plantar fasciitis, the patient must feel the weight is being transferred from the painful heel area into the arch, and the patient must feel that the heel area is being suspended or cushioned. Without these two factors occurring, the orthotic devices will not be as helpful as possible.
Golden Rule of Foot: When dispensing orthotic devices (or receiving them), there should never be any pain.
Golden Rule of Foot: When getting used to new orthotic devices, always blame any new
pains on the new devices.
            Golden Rule of Foot: Never introduce new orthotics into an athlete increasing their mileage (like in marathon training). This should be during maintenance running periods.  

Golden Rule for Running Shoes
Golden Rule of Foot: If pain is produced by one pair of shoes but not the other, stay in the pain-free pair.
Golden Rule of Foot: Look for Asymmetrical Wear Patterns as a sign of something wrong.

This above was an excerpt from my book: Secrets to Keep Moving.