Foot and Ankle Problems By Dr. Richard Blake
Welcome to the Podiatry Blog of Dr Richard Blake of San Francisco. Please email your questions to rlb756@gmail.com. Please consider donating to this blog if I was able to help in some way. Rich
Monday, March 1, 2021
Use of Bike Shoes for Immobilization of Various Foot Injuries: And a big help for bad backs
Sunday, February 28, 2021
Heel Pain Overload Syndrome Review
Gout-like Pain Post Vaccine Shots: Common Symptom for a Podiatrist to Hear About
Dr. Blake's Comment: Sorry this happened to you. I am seeing alot of this post Covid 19 Vaccine. I am treating it like a gout attack, which it may be. Gout attacks are brought on by changes in the metabolism something that can occur dramatically with vaccine shots. If you were in my office, I would take an x-ray but that will be inconclusive (however an important baseline). I would have you super hydrate next week (at least 4 eight ounce glasses of water minimum), 3 advil 4 times a day for next 5 days, and the important ice soak 10 minutes (cold water with ice cubes) three times a day. I would fit you for a removable boot and apply a dancer's pad to float the big toe joint just so you can get around. If it was not feeling a ton better in a week, I would order both uric acid levels and an MRi (as you could have a stress fracture say in the sesamoids under the big toe joint or just some arthritis popping up). I sure hope this helps. Everyone (about 5 patients so far) that have got this post Covid shot immediately got better with this approach. Rich
Pain in the Back of the Heel: Could the Pain be from this big spur when the Pain is only 10 days old?
Saturday, February 27, 2021
Assessing Correction with the Inverted Orthotic Technique
Tuesday, February 23, 2021
The Effect on the Knee and Hip with the Inverted Orthotic Device
Monday, February 22, 2021
Sesamoid Fracture Article Review
Sunday, February 21, 2021
Balance: More Exercises to Up Your Overall Stability
Saturday, February 20, 2021
Static Stretching Helps Hamstring Flexibility: Research Proves
Sunday, February 7, 2021
General Approach to See Patients
I thought I would share the general thought process I take with patients day in and day out. This 14 step approach has served me well (and of course complexed when a patient has multiple injuries and problems at the same time). Still the process of talking, evaluating, making decisions, and then seeing the patient in followup is time tried and true. Rich
First, let’s review the general biomechanical approach for the first few visits (this can be accomplished in 1-3 visits based on the time you are allowed per patient). These are the common steps in a general biomechanical approach for the first several visits dealing with a new patient or new problem:
History and Chief Complaint of the injury and the patient’s understanding why they were injured.
Gait evaluation of walking (running is crucial if their activity requires running) to decide on gait patterns and if the patient’s complaint matches). And, if you are fortunate to use a computerized system it can help you here.
Physical examination of the injured part (begin to separate the 3 sources of pain: mechanical, inflammatory, and neuropathic).
Physical examination of possible biomechanics involved.
Is there biomechanical asymmetry?
Tentative working diagnosis made (your best guess).
Common Differential Diagnosis: common not rare (a good possibility, not all of the distant possibilities).
Occam’s Razor (simplest solution is most likely the solution) and the Rule of 3 (3 most common causes and their treatment) for initial treatment help.
What Phase of Rehabilitation is the patient in at this visit? Immobilization, Re-Strengthening, Return to Activity.
Should we do Imaging at this point?
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.
Second Decision: How Much Inflammation needs to be Addressed?
Third Decision: Is there any neurological component that should be treated?
Fourth Decision: What mechanical changes can I make in the first few visits that may help the pain relief, better biomechanics, and cause reversal?
Patient #1
History and Chief Complaint A 22 year old ballet dancer presents mid season with right big toe joint pain.
The rehearsals for Swan Lake had been very intense the last few weeks before her pain began. She feels that she just bruised it somehow and that it is really no big deal. She never had this problem before and can not remember doing anything. The pain is aching, not sharp. The pain is the dorsal joint, not medial or plantar. She would describe pain as 4-5 when performing, 3 when getting out of bed, 1-2 when walking around with a feel that she is walking on the outside of her foot a little, and 0 at rest.
Gait Evaluation In this case, a ballet technique examination may be necessary if the problem is recalcitrant or keeps reoccurring, as this sounds like a ballet overuse injury. At the initial visit, the patient wore some flip flops as it was her day off, but barefoot she was a mild pronator, and she did not appear to limp. She did not bring in her ballet shoes for evaluation. Even if you do not know ballet well, the shoes can help in the wear patterns right to left both in the ballet pointe shoes and ballet slippers.
Physical Examination The examination reveals slight big toe swelling, no redness, no palpable pain, mild stage 2 bunion, and negative tendon and ligament stress tests. The patient had hypermobile metatarsal phalangeal joints, with over 90 degrees of big toe joint dorsiflexion, and a long first toe only on the injured side.
Cursory Biomechanical Examination and Asymmetry Noted Different from the normal physical examination of the injury, this looks further into the biomechanics of the patient that could have caused the injury or will slow down the rehabilitation, or just allow the problem to come back over and over again. The cursory biomechanical review included excessive ranges of motion allowing possible excessive big toe joint stress (as noted above), a pes cavus foot type with slight hallux hammertoe, forefoot valgus foot type, callus formation under the first and fifth metatarsals, first ray motion more than 10 mm but abnormally plantar flexed, a relaxed calcaneal stance position 5 everted right 3 everted left, no tight achilles tendons, pronation worse on the injured right side, great FHL strength. Therefore, marked biomechanical stresses (which will be discussed below), which could all be related in some way to our injury cause and upcoming treatment plan.
Tentative Working Diagnosis (your best guess) is based on your experience, historical review, and physical examination. Definitely ballet can overuse the big toe joint. My best guess would be a sprain of the big toe joint as a stress fracture would be more swollen.
Common Differential Diagnosis (2ndary Working Diagnosis) is not a list of the 10 possibilities in a standard differential, but the next best guess if proven that the tentative working diagnosis is wrong. For me, in the sports arena, overuse injuries are stress fractures or stress reactions until proven otherwise even though the examination does not match her pain level.
Occam’s Razor and Rule of 3 Occam’s Razor to me means the simplest solution is usually the solution. In this case, the simplest solution is to stop ballet until all the symptoms are fine, and then gradually wean back into ballet. Here is where the Rule of 3 helps out tremendously. Most ballet dancers would seek care elsewhere if told to stop dancing. The Rule of 3 means that we need to find 3 treatments based on our examination of possible causes that should help the patient progress. And, you can add 3 more next visit also if needed. The joint was sore and the dancer probably sprained her joint, so taping the joint to immobilize some is one good treatment. With a bunion deformity and a long hallux, the big toe joint typically gets stretched medially and pinched laterally, so the taping can try to correct that. Since the patient has a plantar flexed first metatarsal (typically causing more pressure on the first metatarsal), a dancer’s pad (aka Reverse Morton’s Extension) can help. And #3, using a Hapad adhesive felt arch support in all her ballet shoes, and her day to day shoes can both off weight the sore area and prevent the excessive pronation she presents with. Therefore the Rule of 3 helped us start treating based on her specific biomechanics.
What Phase of Rehabilitation? This patient is typically like so many patients really between phases. She needs some activity modification (in an attempt to get her pain more consistently 0-2). She also needs to ice, and will get some daily PT for anti-inflammation since she is in a ballet group. These are Phase 1 treatments, but she will continue to dance as we experiment with padding, taping, etc, so I would put her in the Return to Activity Phase 3. She is hurt, but she can dance completely, therefore she is definitely Phase 3. Phase 1 you are completely restricting her activity, and Phase 2 she can not dance professionally but you are working her through her sports routines. If she worsens as we attempt to get a handle on the injury, we may have to put her into Phase 1 or 2. Sometimes this is a big rehab failure, when the patient is not put into the right phase of restriction when they present with worsening symptoms. The patient should improve each visit, or changes are needed.
Should We Image? This is presenting as a minor soft tissue injury, so imaging will be delayed.
First Decision: How to Reduce Pain 0-2 This is for everything. The pain 4-5 when performing is too high. We have to reduce her rehearsals, and experiment with the above treatments to see if the pain can be reduced (our local dance medicine expert Joey Levinson had her get wider shoes just after her visit that helped). I prefer not to use NSAIDs at all as it masks pain and slows down bone healing (which we presently do not know if she has). Therefore my standard anti-inflammatory cocktail is icing twice daily, and contrast bathing each evening.
Second Decision: Inflammation Concerns This blends into the first decision as working on any inflammation (swelling, sudden stiffness, redness) found is crucial at helping these patients. If inflammation is found, and there was only a slight amount of swelling in this case, it needs to be addressed. My icing twice daily (especially just after she aggravates it) is important.
Third Decision: Any Nerve Component? This appears hard for patients and doctors to assess. Nerve pain can be numbness, radiating, electric, buzzing, vibrating, sharp, and just a hyper-sensitivity. Chronic pain (pain over 3 months) can lead to nerve hyper-sensitivity or tissue neural tension. The pain from nerves alone rarely swell, and it is characterized as pain out of proportion to the physical findings. In this case, no nerve pain was discovered or considered.
Fourth Decision: Initial Mechanical Changes This is now I end my initial visit with the patient--with 3 or 4 easy but effective mechanical treatments. Many times they are in a prescription to purchase. Sometimes, I am able to dispense something I have in my laboratory, or show them some tape technique (I pretty much love to tape all of my patients if I can find something to help them). Some of these treatments will be temporary until a more permanent fix can be found or made. Some of these day one treatments are forever (like toe separators for bunion improvement). In this case, the initial mechanical treatments were spica taping with an effort to straighten the bunion deformity, dancer’s padding instructions for her to attempt (luckily she had a PT who worked half days at the ballet), and medium Hapad longitudinal medial arch pads for pronation control and off weighting.
For this individual patient, the initial treatment was completely successful. It did take about 4 weeks with reduced dancing (50%) to really get her symptoms in control. For this injury, I did see her one other time for ballet slipper and pointe shoe application of arch supports (Hapad adhesive felt) and dancer’s pads. She was advised to wear medium gel toe separators long term for her bunions. Due to the pronation right greater than left, I had wanted her to get orthotic devices for her daily shoes (athletic and fashion casual) but I am not sure if that ever happened. That was for long term prevention.
Saturday, January 30, 2021
Sesamoid AVN Help: Info emailed from patient
Friday, January 29, 2021
Old Plantar Fascial Tear: Email Advice
Hi Dr Blake,
I have just experienced a severe pain in my left arch reminiscent to the tear in my plantar fascia from 8 or 9 years ago. You treated the tear and I was in a boot for 90 days. Since then I have worn the orthotics you designed...religiously. No problems until yesterday. The pain feels like the pain I had years ago just before it tore.
What should I be doing? I don’t want to go through another torn plantar fascia?
Please respond and let me know next steps. Your next appointment is not open until 2/8.
Thank you.
Dr. Blake’s comment: It is so important that you create the 0-2 pain level consistently as quickly as possible. If that means you have to be back in a boot until I see you, please do it. Remember to ice 3 times a day 10 minutes each for the next 4 days, than cut to twice a day. No achilles stretching or arch massage until we feel sure it is not a tear. See if anything you are doing really picks on it, and try to avoid for the next 2 weeks. Normally takes 4 to 14 days to either be obvious an injury, or just a small strain of the tissue. Hope this helps. Rich
Thursday, January 28, 2021
Arm Swing: A Vital Part of Pain Free Gait
Wednesday, January 27, 2021
Sesamoid Fracture in a Dancer: Email Advice
Tuesday, January 26, 2021
Monday, January 25, 2021
Right and Left Handed: Its Influence on Mechanics
I have had the personal experience of spraining my left ankle in basketball multiple times. It is not fun. You learn, as an athlete, that right handed players land first with their left foot in basketball and that is the typical foot that lands on someone else’s foot and rolls it. This injury influenced by your hand dominance has been a fascination for me in my career of podiatry. It is always fun after watching someone walk to tell them they are left handed and be correct!!!
Right Handed vs Left Handed: Effect on Lower Extremity Biomechanics
Ask any ballet dancer if they are dominant on their right or left side because they are right handed or left handed and they will say no!!! They spend their whole careers fighting any dominance of strength and coordination from being right or left handed. But for most of us, we use one side of our bodies a lot better, stronger, gracefully, than the other side. I am right handed and I have long played basketball as if I have no left hand--pretty gruesome sight to behold at times!!
If you are right handed, your right side is your movement side (the side you kick the ball with), and your left side is your support side (the one you plant for stability before you kick the ball). And vice versa if you are left handed. And there are shades of this that I see in patients, and myself, from very dominant handed to almost ambidextrous.
So a very common pattern of problems I see concerns the instability (weakness) on the support side. This can be very dangerous and slows down or speeds up rehabilitation. For an example, let us take a left ankle sprain in a right handed patient. The injury is to their support leg. The leg they support with is technically injured and unsupportive. And this can dramatically slow down rehab. The more dominant they are to their right side, and the more they rely on the left side for support, the more a left sided ankle sprain is disabling. Patients also hate to make their movement leg into their support leg. It feels so unnatural to them. So, it is much better for a right handed patient to sprain their right ankle, they seem to heal from and handle this injury better. When a right handed patient sprains their left ankle, they must regain that stability as quickly as possible with boots, braces, casts, taping and strengthening exercises. When a right handed patient sprains their right ankle, the goal is protecting it, but emphasizing getting motion back fast.
I hope this explains a common problem seen in a podiatry practice when an injury occurs to one side. I like to ask if they are right or left handed to make some correlation with the movement side vs the support side. I have seen many variations of problems created with this phenomenon. Recognizing this syndrome can help in subtle ways patients recover sooner.
This is an excerpt from my book “Secrets to Keep Moving”.
Sunday, January 24, 2021
High Heel Shoes: Pros and Cons
I remember working with a back doctor, an osteopath by training, who told me that high heel shoes got a bad rap!! She said of her back patients, half felt better in some heel and half needed to wear flats. It depended a lot on the curve of their spine. It definitely got me thinking about general rules that were only half right, but practiced as if it was the gospel of truth.
High Heel Shoes have been loved and maligned for years. A True Love Hate Affair.
From a Podiatrist's perspective, these wonders of the fashion world have many interesting biomechanical aspects. Let me explain the pros and cons of wearing high heel shoes. The possible positive benefits include:
- Greater Arch Support over Flats
- Better Forward Shift of Body Weight over Flats
- A More Relaxed Hamstring, with Less Lower Back Tension
- With regular use, Foot, Ankle, Knee, and Hip Strengthening
- Heel Lift producing less strain on Achilles Tendon
But, these are weighed down by the possible negative effects including:
- Toe box crowding with gradual development of bunions and hammertoes
- Ankle and Knee in more unstable positions
- Positional Changes in the Low Back which may produce or aggravate symptoms (increased lordosis).
- Gradual shortening of the ankle tendon, and hamstrings with possible symptoms.
Four very common recommendations for regular high heel wearDrs include: A) stretch the Achilles 3 times daily, B) stretch the hamstrings once daily, C) vary the heel height several times a day, with the lower or higher heeled shoe having more toe box (yes, switch shoes--possibly a chance to shop!!), and D) use bunion protection with medium gel toe separators and Yoga Toes (or knockoffs). I hope these simple, but effective, tips can allow you to wear high heel shoes for many years to come.
The following was adapted from my book “Secrets to Keep Moving”.