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Sunday, August 29, 2010

Injury Recovery Principles: Crossing from Sickness into Health

This scene reminds me of the journey we all take during an illness or injury to regain our health. The Crossing from Sickness to Health needs a boat load of people at times to help us. For the normal sports medicine injury that I see, there may only be a few on that boat--patient, doctor, physical therapist, family and friends, shoe store personnel, internet resources, and referring source (like Yelp, Tribe, primary care physician, etc). For more complicated cases, that boat can be pretty full. Yet, sometimes with a full boat in these severe conditions, the patient can still feel very alone since they lose sight of the primary care provider steering the ship. In the crowd of people on that boat, no one is actually calling their name when the time comes to disembark, or change course. Perhaps that person in charge of steering has never been established in the first place, and the boat may not be able to be docked on the other side at the best end point.

I imagine sometimes that my patients feel alone in turbulent waters when they do not have good direction, or attempt to do it alone. In a world of super specialities, whom is looking out for that patient as the primary care giver. Every specialist, whether podiatrist, orthopedist, neurologist, etc, tends to look at the patient through some tunnel vision. The medical world needs to see the dilemma facing these patients when no one is truly guiding them. Patients are routinely told when they see a specialist to come back if they want surgery, come back if they want orthotics, come back if they want more physical therapy, etc, but how does the patient make these decisions. And when symptoms get worse, no wonder some patients choose some course of action, only because they do not know what else to do.

As health care providers, we need to prevent our patients from going it alone, and feeling that way. As patients, if your injury seems difficult or challenging, and the symptoms are lingering or worsening, we need to identify one person who will oversee the problem. One person who may steer that boat to the right landing dock. Podiatrists as a group tend to be generalists, as I am, or super specialists in surgery. When you see a health care provider, find out if they are the one to manage your injury, or only deal with one part. I love to manage my patient's foot problems from start to finish, get second opinions when I am stuck, get one of our MDs to treat their other problems, get the primary care doctor involved when necessary, and work with the physical therapists helping them. I believe email is working well for complicated patients keeping the communication flowing. I am looking into a computer program that patients can keep track of their symptoms, and then email when appropriate. Through this blog I am trying to engage my patients more to understand the complexities of medicine and where it may apply to them. There are no rigid answers, but patients need to find the right person for their injury, be it MD, Podiatrist, PT, Chiropractor, or other allied health professional, to help steer the course from illness to health. Good luck! 

Saturday, August 28, 2010

Jog For Jill: September 12, 2010 San Francisco, California

Jill is a family friend. She has a wonderful mom and dad, and 2 great brothers. Jill's Cal Crew team won the Pac-10 Championship days before her diagnosis at the end of her junior year. Jill fought a long year battle with lung cancer with unimaginable courage. This young woman's bravery and spirit touched the hearts and souls of all that knew her or that heard of her battle. This photo of Jill from the UC Berkeley website gives you a glimpse into who she was. The cancer finally won and Jill is physically no longer with us. Please look at the links below to sense her spirit that is still with us. Jill worked hard on an upcoming race here in San Francisco for the Lung Care Foundation. Since her death, they have dedicated the race to Jill Costello. I am hoping some of you will find time to run/walk the "Jog For Jill".

Please play this video for Jill

Vitamin D Deficiency: A Podiatrist View on the Crisis

Wouldn't you just love to be there? Where ever it is!! Of course, I have been stuck in the coldest summer in 40 years in San Francisco, California, which makes my day dreaming even worse. The image of the umbrellas on the beach highlights our need to protect our skin and avoid sun exposure. We lather up the Sunscreen as dutiful health conscious individuals but one of the side effects is a sudden crisis in Vitamin D Deficiency. What is the big deal? Vitamin D is essential to move calcium into your bones. As a podiatrist, I see too many patients low on Vitamin D and developing stress fractures and joint problems. So, find out your Vitamin D level (read the link below) at your next blood test.

Friday, August 27, 2010

Pediatric Flat Feet: Dr Ronald Valmassy discusses the Role of Prefabricated Orthotic Devices

     Dr Ronald Valmassy, my friend, my partner, and my mentor is one of the leading experts on children's feet problems. I am very grateful that Dr Valmassy is my first guest speaker on Dr Ronald Valmassy uses ProLab USA prefabricated orthotic devices to treat many growing children. His video highlights some of his thoughts behind this process.

Thursday, August 26, 2010

Bunions: Socks by Injinji

Injinji is a perfect sock for bunion and hammertoe sufferers. The link below is describes The Tips for Bunion Care and includes these great socks. They help the first and second toes from touching which dramatically increases their stability, and can slow down the progression of bunions. 

Wednesday, August 25, 2010

High Heels Shoes: A Fashion Accessory with Biomechanical Implications

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. The video above points to the pros and cons of wearing high heel shoes. The possible positive benefits include:
  1. Greater Arch Support over Flats
  2. Better Forward Shift of Body Weights over Flats
  3. A More Relaxed Hamstring, with Less Lower Back Tension
  4. With regular use, Foot, Ankle, Knee, and Hip Strengthening
  5. Heel Lift producing less strain on Achilles Tendon
But, these are weighed down by the possible negative effects including:
  1. Toe box crowding with gradual development of bunions and hammertoes
  2. Ankle and Knee in more unstable positions
  3. Positional Changes in the Low Back which may produce or aggravate symptoms
  4. Gradual shortening of the ankle tendon, and hamstrings with possible symptoms

Four very common recommendations for regular high heel wears 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 high 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)--see the separate post on Tips for Bunion Care and other related posts. I hope these simple, but effective,tips can allow you to wear high heel shoes for many years to come.

Tuesday, August 24, 2010

Hallux Rigidus: Surgery or No Surgery

     Hallux Rigidus means severe wear and tear on the big toe joint. The cartilage is tired, beat-up, and aggravated. The normal motion of the joint is significantly restricted, so attempts to move the joint normally can produce mild to severe pain. There is a lesser version of this called Hallux Limitus, which has significantly more motion, and a different treatment protocol.

     Hallux Rigidus develops over many years, with sometimes smoldering pain episodes, and may never really bother the patient. The joint is actually self-fusing, and getting less vulnerable. I had a great runner as a patient once that was having smoldering symptoms with severe advanced Hallux Rigidus. Luckily he ignored the surgeons, following simple conservative advice, and then proceeded to set a Guiness World Record for 6 marathons in 6 months all under 2 hours and 20 minutes!!

     But, some patients with Hallux Rigidus are not so charmed. They do something, quite ordinary usually, that develops moderate to severe pain. And they have trouble turning off that pain with self methods, x rays taken by the first doctor show the severe arthritis, and surgery is recommended. I maintain that Hallux Rigidus should be treated as a sore joint and nothing else. How do you get a sore joint calmed down? Usually, immobilization to rest the joint, shoes and orthotic devices to limit the big toe joint motion, taping to limit the toe motion, and then pile on the anti-inflammatory measures---icing, contrasts, meds, physical therapy, flector patches, topicals, accupuncture, and injections.

     The treatment of Hallux Rigidus is then divided into 2 columns--immobilization and anti-inflammatory. I challenge the doctors, physical therapists, and other health care providers to do all you can to calm the joint down and get it comfortable, even if this means 3 months in a removable cast (last resort). Once the joint is calmed down, and pain is gone, gradually increase activities pain free. See what it takes to stay pain free. See if there is any disability the patient does not want to live with, that you can guarantee with reasonable degree, would be removed if you did surgery.

     Let us say that you get the joint calmed down, but every time you try to run, the joint flares up. And you want to run, too young to give it up and you are willing to consider surgery. Xrays will show a bad joint with many bone spurs. There is no good surgery with Hallux Rigidus, so if I needed it, I would follow the KISS principle (see separate post). I follow the same thought process as with knees--cleanup with meniscus tears, more cleanup, a third cleanout when needed, a parital knee replacement when needed, and a total knee replacement when needed, and hopefully every surgery is the last surgery. So, with Hallux Rigidus, I recommend a joint cleanout (called arthroplasty or cheilectomy--try pronouncing those), perhaps another joint cleanout, a total replacement, another total replacement, and then a lot of deep thought before joint fusion is considered. Golden Rule of Foot: With Hallux Rigidus, Joint Fusion should be the last resort. 

Sunday, August 22, 2010

Morton's Neuroma: Treatment Options

Morton’s Neuroma: Treatment Options
Morton’s Neuroma denotes a swollen inflamed painful nerve classically between the third and fourth metatarsals, radiating into the third and fourth toes (toes are numbered one for the big toe and 5 for the pinky toe). It can also be between the second and third metatarsals, or between both the third/fourth and second/third just to make diagnosis more difficult. The nerve symptoms created can be more like numbness, tingling, buzzing, burning, sock rolled up sensation, etc on one side on the spectrum, to sharp, radiating, and electrical pain at a level 8 to 10 on the pain scale. One of my unfortunate patients described it as lava flowing in her foot!! One third of all patients only have numbness as the chief complaint, one third have a combo of numbness and some pain, and one third have only pain (lucky them!!) The pain can be so bad that the differential diagnosis could only be a broken bone, however the history of onset of pain does not match up with a fracture, and there is no swelling. Neuromas rarely have swelling.

When a patient presents with symptoms of Morton’s Neuroma, the treatment plan should address 8 areas. These are:

Mechanical support behind the metatarsal heads to off load the sore areas immediately in any shoes which produce pain (see post on Hapads)

Mechanical support of any over pronation affecting the ankle (see posts on biomechanics)

Shoe gear changes to minimize daily aggravation (various factors affect each case—amounts of cushion, heel lift, flexibility, tightness, stability, arch support)

Changes in digital (toe) motion with taping or Budin Splints

Tightness in the ligaments and other soft tissue around the toes and metatarsals

Anti-inflammatory measures to reduce the inflammation around the nerves (see posts on icing and contrast bathing)
Nerve stabilizing methods (see post on Neuro-Eze)

Diagnostic testing to determine where the source of the pain originates, whether or not there are classic neuromas present (MRI best)

Luckily, less than 10% of patients do I consider for surgery to remove the nerve if their symptoms do not improve well, but the other 90% can have a rocky road getting their symptoms under control. Remember, first and foremost that this is a nerve problem. Nerve problems hurt more than any other injury. There are more nerve endings on the bottom of your foot per square inch than any where else on the body. Nerve pain goes straight to the brain and is quite intolerable by most. The treatment should be aggressive and multi-factorial. It takes about 1 year of treatment in the recalcitrant cases (slow ones) to decide that surgery should be done. If you are in the unlucky 10% requiring surgery, 50% of you will heal quickly, and 50% will take up to two years to really feel somewhat better (if at all). So, 5% or 1 out of 20 patients with nerve pain still have nerve pain to some degree 3 years after I start treating them. So, try your hardest to be in the 95%.

Remember that nerve pain makes nerve pain by itself. So, the cycle of nerve pain spiraling out of control must be stopped. Golden Rule of Foot: Treat Neuroma/Nerve pain aggressively, or it will decide to stay around. When I first feel symptoms of numbness or pain in the front of your foot, seek immediate help (like reading this blog). But, there are so many aspects of treatment that the patient can only do like icing, shoe gear changes, add Hapads, start Neuro-Eze, limit pain producing activities (if there is pain), doing daily self massage, etc. When I first got into practice 29 years ago July 1981, 50% of all neuromas diagnosed were surgically removed. Now, less than 10% are surgerized (my own word!!) so medicine is moving in the right direction on this one.

Neuroma or nerve pain in the foot must be treated at the foot, but it can be caused by irritated nerves from back problems, ankle problems, sciatic nerve problems, and peripheral neuropathies (nerve diseases) from diabetes, B12 deficiencies, etc. Even with our most sophisticated workups on nerve pain, the nerve pain can occur 5+ years earlier than the diagnosis. These are some of the neuromas removed, and yet the patient feels little or no improvement. Medicine has to get better in this area.

I will have another post which will be a checklist of all the treatments you should have tried and failed before surgery is performed. But for now, let us focus on what should happen in the first 2 or 3 visits (probably over a 6 week period) with a doctor whose diagnosis is Morton’s Neuroma. These are:

Begin a program of anti-inflammatory measures, which is done daily, and could involve one or several cortisone shots (see post on cortisone shots)

Begin to change from all shoes that aggravate the symptoms (take each shoe separately since you may be surprised what feels okay)

Avoid barefoot walking

Begin some evaluation of the possible source of the nerve pain (low back evaluation at a minimum with straight leg raise and Tinel’s test at ankle)

Add some Hapad or other metatarsal arch support to all shoes that have adequate room

Begin some exercises that relax the tissues around the inflamed nerve (like toe waving exercises)

Begin some massage to desensitize the nerve with Neuro-Eze, some heat lotion (i.e. Ben Gay), or warm face cloth wrapped around foot as long as the massage doesn’t irritate the nerve

Begin controlling pronation if the ankle mechanics could cause pulling on the branch at the ankle (in what they call the tarsal tunnel)

Discuss the timing of possible MRI, Nerve Conduction Test, alcohol injections, course of cortisone injections, possible casting in removable boot

See you and your health care provider have some work to do. Work on shutting off the nerve painlessly, and as quick as possible, before the symptoms get worse.

Saturday, August 21, 2010

Calf Cramps: Common Causes and Diagnosis Not To Miss

     Calf cramps are a very common problem seen in my practice. I have experienced severe nocturnal cramps after too much basketball, or too many miles, as have many of my patients. I eat a daily banana with my morning coffee as a preventative measure. I need to drink more as the articles below discuss since dehydration is a big factor. I am always slightly dehydrated and have a mental block about drinking more (one of my many mental blocks). I have always found good stretching right after your workout of any muscle that cramps, and then one more time before bed, can greatly diminish or eliminate these cramps. If you have disc disease in your low back, the associated nerve root can cause severe leg cramps (after you lie down) in the muscle groups involved. Finding the right position of your spine in bed, and sometimes getting a new bed or mattress, can be important. So, dehydration, low potassium or sodium, low carbohydrates, tight muscles, strenuous exercise with a buildup of lactic acid or other waste products, low back irritation, and poor circulation are truly the main causes of cramps, mild to severe. Before I present my story about Doug, please glance through these links below so you can see what is out there for the consumer and why I want to tell (and slightly brag) Doug's story.

     Doug presented to my office for a 2 week followup appointment after fracturing his right 5th metatarsal and being placed in a removable cast. This is a routine procedure. After about 10 days in the cast, he no longer had any foot pain in the fracture area, but began to get calf cramping on the side of the fracture. The calf cramping steadily got worse over the 3 days before his normal followup visit. The night before his visit he could not sleep because of the pain caused by the cramping. Removing the cast did not help his symptoms, and stretching the muscles did not help. It is easily explained by some dehydration, some electrolyte imbalance (have another banana), some tightness developing in the cast in an already tight calf, and some restriction of the circulation from the velcro straps holding the cast on his leg. These are all common causes by themselves of cramping, and they are exaggerated when several co-exist together. I also thought Doug may have tweaked his low back with the cast, even though he had an Even-Up, which could have been a 5th factor. It could have been easy to have dismissed it, simply giving the typical advice of stretching, drinking, massage, but something was different that is hard to put into words.There is definitely a sixth sense that plays out here (and I believe in guardian angles also). Doug knew his body, and something was not making sense. Red Flags went up. Doug was concerned. I listened. We decided to rule out the one in ten thousand chance he had a blood clot in his leg. This is never mentioned in the articles above, because it is rare. He had none of the predisposing factors for blood clots, except the slight foot fracture.

Doug went that day to get an ultrasound to rule out a one in ten thousand chance that he had a blood clot, AKA Deep Vein Thrombosis. He called me 8 and 1/2 hours later, first availbability of getting that test, that the test was positive and he was on his way to the ER to be started on blood thinners. What a day!! Boy, did I feel good after that call that we had not missed it. But, Doug and his family probably felt better, much, much better, especially when you read the stats.

To all the articles on leg cramps, I say add an asterick for this possibility (call it Doug's Law). To Doug, I am glad you listened to your body, and I am glad this blog/this story can hopefully help someone else. Golden Rule of Foot: Increasing Leg Cramps over several days should be worked up for DVT.

WaterGym (for athletic rehabilitation): Recommended Website

     One of the best exercises we can do when injured is swim. Injured runners, cyclists, hikers, etc, for years have been getting into pools as part of their training and found it a great source of relaxation, muscle toning, stretching, and cardio. The watergym program, started by sensational Susanne Paynovich, has definitely taken water exercise to a new level. If you have access to a pool, have a foot or ankle injury (this is a podiatry blog)  which is limiting your ability to perform your normal workouts, or if you have the desire to add another dimension to your workouts, try watergym. You can go online, signup, watch some neat videos for free, enjoy other offers from watergym and feel the excitement. Good luck!!

Bunion Pain: Simple Shoe Lace Modification

For those of you who suffer from bunion pain, a simple lacing trip can help you avoid problems and allows you to wear some laced shoes that would normally irritate you. Simply re-lace the front area to skip the eyelet or loop closest to the bunion. In the photo above, the lacing had to be placed through the same loop twice to accomplish the feat. This keeps the shoe stable while minimizing the pressure on the bunion area. See the previous posts on tips for bunion care by clicking on the links below.

Friday, August 20, 2010

Plantar Fasciitis/Achilles Tendinitis: Stretches To Do and Not To Do

This short video demonstrates the 4 common weight bearing stretches for plantar fasciitis and achilles tendinitis. The Gastroc Stretch, the Soleus Stretch, and the Plantar Fascial Wall Stretch are all safe and can be done multiple times throughout the day to improve flexibility. The final stretch demonstrated called the Negative Heel Calf Stretch is potentially dangerous and places too much abnormal stress on the plantar fascia, heel, achilles tendon, and midfoot areas. The first 3 safe stretches have one major safety valve. That is that the stretch is done with the heel on the ground in a stable position. Please see the links below for other posts on these important exercises.

I sure hope these help!! Dr Blake

Thursday, August 19, 2010

Plantar Fasciitis: The All Important Wall Stretch

This video demonstrates the most important stretch for the plantar fascia. The plantar fascial wall stretch can be done hourly, but encouraged 5 times daily. There should never be any pain in the achilles, plantar fascia, or toes while stretching. The patients are encouraged to deep breath while stretching. See our previous videos on the Generalizations of Stretching, the 3 Important Achilles/Plantar Fascial Stretches, and the AM Plantar Fascial Stretches.

Tuesday, August 17, 2010

Injury Rehabilitation Principles: The Looking Good Syndrome

The “Looking Good” Syndrome: Confusion created right at the start of treatment

Many patients present to my office with a difficult problem and a pattern of treatment I would consider sub par. This sub par treatment may be performed by top physicians and physical therapists, and others in the health care system, all with good intentions. I am amazed at times at the treatment given, and I must think that the health care providers must have been burnt out when treating the patient. Why were these good clinicians giving patients such inadequate treatment? It took me awhile to see a pattern in these patients. I call this syndrome of inadequate care The Looking Good Syndrome, although I still grasp for a better title.

Yesterday I saw Helen for the first time. Helen matches the profile of this syndrome well, and I even told her so. She has had a significant ankle problem for several years, and very inadequate treatment. The injury to her ankle is very disabling and she is only 21 years old!! Helen is cheerful, very positive in nature, bubbling in personality, walked into the office without limping, and good looking by any definition (when you read this Helen please don’t blush). After examining her ankle, even though it was obvious she needed x rays and a MRI, I had to force the words that she needed these tests out of my mouth. There is a psychological block (and I sure hope some psychologist reading this can explain in the comment section) to spend the money, time, effort, etc. to order these tests since the patient is “Looking Good”.

The patient is too healthy looking to have a serious injury. Does that make sense? No!! Anyone can get a serious injury. But, no health care provider actually wants anyone to have a bad injury, and the reasons at any one moment can be numerous. A bad injury denotes possible diagnostic dilemmas, possible difficulties in treatment reflecting poorly on the provider, possible requirements of effort that a burnt out doctor, therapist, etc. may not want to expend, and the list goes on. But, for the average clinician, a serious injury to an otherwise healthy looking patient is just too sad on a human level, and so easily dismissed as something that the patient will recover from with ease. Should health care providers be allowed to be human in the 21st century? I hope so.

What are the components of Looking Good which affect this syndrome? First of all, it is the physical nature of the patient. Secondly, and probably the most important, it is the positive personality of the patient. This positive personality, when the health care provider is collecting initial impressions, may steer the course of treatment away from a potentially negative diagnosis. How is a negative diagnosis avoided? The proper tests to make that diagnosis are never done. If done, the results of the tests may be minimized. If you match the positive personality of the patient (glass is half full), with an otherwise negative (glass is half empty) doctor, trouble brews in setting the course correctly in developing a great treatment plan.

What does all this really mean? Patients who feel that they may have a serious injury need to push these health care providers along gently (they are not machines). Assume that they are human and actually don’t want to learn any bad news about you. You, on the other hand, want your body to work correctly for many years to come and need their help to make things right again. How are things made right again? First step is always in ordering the right tests, and then moving the treatment through the roadblocks, over the plateaus, and up to Grandma’s House (always a great place)!

Sunday, August 15, 2010

Marathon Training: Marathon Matt's Website

Running is a nature activity for the human body. This blog will have many posts on tips to keep you running. I highly recommend you subscribe to Marathon Matt's website, and if you live in the San Francisco Bay Area, perhaps check out his programs. Besides, he is a great guy!!!

High Heel Shoes: Wearers Need to Stretch Often to Avoid Problems: A New Study

This is a great article emphasizing why patients who wear high heels on a routine basis have problems with flatter shoes. The answer is fairly simple: stretch out the achilles tendons on a regular basis and enjoy those heels. See the separate blog post video on achilles stretches in the link below.

Saturday, August 14, 2010

Ankle Strengthening: Video on Eversion with Exercise Bands

Thera-Band is to exercise bands what Xerox is to copiers. I grew up as a podiatrist on Thera-bands, although never honestly knew there was a hyphen. And there are so many other good sources of traditional exercise bands and sports cords that will all do basically the same. The video demonstrates the most important exercise for ankle sprains, balance, supinators, and general foot and ankle strength. The peroneal tendons are vital for big toe joint stability, arch stability, and lateral (outside) ankle stability. The peroneus longus should be strengthened separately from the peroneus brevis as demonstrated well in the video. Home strengthening exercises should done daily in the beginning stages to make sure the habit develops, but gradually over the 2nd and 3rd months done every other day. I love my patients do 2 sets of 10 repetitions (reps) at a resistance that they can do daily, gradually increasing the tension on the band. With these exercise bands, as the exercise gets easy, the level of resistance is increased. Our current office system of exercise bands has 6 levels, and the patients are normally started on the easiest level. You can go very gradual with initially 2 sets of 10, then 2 sets of 15, 2 sets of 20, and then 2 sets of 25, before moving to the next color. Doing the exercise slow as Liz demonstrated well is important. Doing the exercise more in the evening or late afternoon is preferable, since you are tiring the ankle. If you do the exercise before vigorous activity, you could risk strain from fatigue. I love with patients and unstable ankles to eventually get them doing 2 sets of 25 reps with a bike inter tube (off the charts in resistance!!).

Plantar Fasciitis/Achilles Tendinitis Rest Splint Video

The use of a posterior sleeping splint for plantar fasciitis or achilles tendinitis was first introduced I believe by a physical therapist Don Chu, PT, in the San Francisco Bay Area in the 1980s. It has become a mainstay in the treatment of plantar fasciitis. The Bird & Cronin one is dispensed in our practice (and demonstrated in the video above), but I have used many. This is the basic style that I like. It can take 1 or 2 weeks before you can wear all night, so there can be some interrupted sleep initially. Patients, like my son Steve the attorney, who sit alot all day, can wear during the day also. It is better called a rest splint than a night splint. Anytime you can wear it for 30 minutes, go for it. You want the splint to hold your foot near a right angle with the ankle, and the side strips for pulling your foot upwards flexing the ankle, should be very loose. Many of my patients never need to pull any tighter. When you start wearing the splint, keep the side strips very loose, and be ready to take off the splint at 1 or 2 am for a week or so, especially if you are a light sleeper. The gentle prolonged stretch on the plantar fascia or achilles tendon is felt immediately with relief of the classic morning stiffness. This pain relief tends to carry on with less pain throughout the day also. It should be worn 1 month longer after the symptoms of plantar fasciitis and/or achilles tendinitis has resolved. When asking patients particularly about their treatment of plantar fasciitis, 20% responded that the splint was the most important factor in their treatment, and 60%+ responded it was helpful. It may be very helpful for you. Good luck.

Thursday, August 12, 2010

Foot and Ankle Exercises: Video on Flatfooted Balancing Exercises: The Best Functional Exercise with Variations

Search for balancing disks

   The Single Leg Flatfooted Balancing Exercise is one of the most useful exercises invented. I personally use it for my patients over 50 on balancing programs, and it is used in core rehab, knee rehab, ankle rehab, and foot rehab. It is one of the best methods of foot and ankle strengthening. Gradually the patient works up to 2 minutes with the eyes open, then up to 2 minutes with the eyes closed, then eyes open with the soft pillow, then up to 2 minutes soft pillow with the eyes closed. Some patients will purchase the thin rubber disks for greater difficulty and do other variations as seen with the basketball. I must emphasize that the supporting knee (weight bearing) is slightly bent to protect itself from hyperextending and this position adds to the difficulty balancing. The exercise can be initiated at any time of the day, but should be done normally in the last 2 hours of the evening before bed. This is due to the fatigue of the leg produced, as you increase the time, and you need sleep time to recover. You really do not want to do this exercise before other strenuous weight bearing exercises. Gradually, like any good strengthening exercise, you limit the exercise to 3 times per week. There should also be no pain anywhere with this exercise. If pain develops, stop, and if it repeats itself each time you try the exercise, seek advice on what is wrong, or how to modify.

Tuesday, August 10, 2010

Plantar Fasciitis: Video on AM Stretches for Plantar Fasciitis

     The 2 best ways of stretching the plantar fascia when you are experiencing plantar fasciitis in the morning is the AM towel stretches that the above video demonstrates and the posterior sleeping splint (discussed in a future post). The initial arch stretch is normally held for 30 seconds or 5 deep breathes, the 2nd stretch is deeper and held for 1 minute or 8 deep breathes, and the third stretch/massage for 2 minutes. Considerable relief of the morning soreness should be noted with typical plantar fasciitis. The third stretch/massage should be with very strong pressure on the heel. The patient should use a towel or sports cord that is long enough to minimize pressure on the back or shoulders. When pulling with the towel, there should be no undue stress on the back or shoulders or elbows or wrists. This stretch, by minimizing the morning pain, can greatly speed up the healing of this sometimes frustrating injury.

Sunday, August 8, 2010

Injury Rehabilitation: Am I looking at The Tip Of The Iceberg?

Each week I have patients that present with their first foot or ankle injury and I wonder whether I am looking at the Tip of the Iceberg of this and other future injuries. No matter how minor the injury appears, I wonder if it will be followed by another and another and another. What can I do as a health car provider to eliminate or at least minimize the onslaught of future injuries? How serious should I take these initial injuries which will heal relatively quickly? Should I always follow the KISS Principle (see separate post) and Keep It Simple Stupid when I think some of these injuries are definitely the Tip of the Iceberg? More pain is on the way.
What goes into the thought process of deciding who should get more treatment when relatively simple injuries present into my office? The treatment of any overuse injury (without an acute single episode) should always be directed at the one or two common causes, or the several possible causes for this individual patient. Take Achilles Tendonitis for example. The common causes of Achilles Tendonitis are:
1. Straight overuse situation in which the Achilles Tendon is put in major stress (i.e. stair running for the first time, or working out too many days in a row, etc.)

2. Very tight Achilles Tendons.

3. Worn out shoe gear with lack of stability or cushion at impact.

4. Unstable shoes, or excessive wearing of shoe gear with inadequate support (i.e. too much time in the flip flops, etc.)

5. Short leg with compensation of early heel lift.

6. Excessive pronation of the foot/ankle with excessive torque on the Achilles.

7. Excessive supination of the foot/ankle with lateral instability and over firing of the Achilles Tendon to stabilize the ankle joint complex.

8. Very loose Achilles Tendons from over stretching or patients with loose ligaments in general. This produces a weakness in the tendon (see future post on the force/length curve).

9. Weak Achilles Tendons from many reasons (just returning to regular exercise program, following prolonged casting, aging process, genetics, dietary, etc.)

10. Achilles Tendonitis secondary to another problem (heel spurs, ankle injuries, sciatica, tibial stress fractures, etc.)

After performing an initial history and physical examination, and making the diagnosis if possible, the clinician will try to assess the reasons this individual patient developed their injury. It is the experience of the clinician that separates them from other health care providers in getting to the cause(s) of some injuries. Some “reversal of cause” treatment must be initiated in all cases. But for some patients, looking below the surface level of water, below the Tip of the Iceberg, is really what is crucial. What factors could lead, if not addressed, to either prolonged injury/treatment, or frequent recurrences of the symptoms. This is so crucial, but in a busy medical practice, often times not proactively explored. The patient and clinician only stumbles into the discoveries.

When a ship’s captain looks at the iceberg approaching, the captain scrutinizes the situation, assesses the severity, and then makes an appropriate plan. Health care providers, and proactive patients, can be slower than the sea captain at final making these decisions, but must look at possible severity of the injury, and severity of the cause of injury, to come up with an appropriate plan. Since we can grade the severity of anything 3 typical ways—mild, moderate, and complex—let us look at these 2 factors in injury treatment from this angle. Perhaps then you can understand when under the Tip of the Iceberg danger may be lurking in the forms of prolonged treatment, possible incomplete healing, and frequent recurrences of the symptoms. After the initial assessment (history and physical), and perhaps after several follow up visits, the clinician will place the patient in one of 9 categories. These are:
1. Mild Injury/Mild Severity of Cause

2. Mild Injury/Moderate Severity of Cause

3. Mild Injury/Complex Severity of Cause

4. Moderate Injury/Mild Severity of Cause

5. Moderate Injury/Moderate Severity of Cause

6. Moderate Injury/Complex Severity of Cause

7. Severe Injury/Mild Severity of Cause

8. Severe Injury/Moderate Severity of Cause

9. Severe Injury/Complex Severity of Cause

With the Severe Injuries, the treatment is usually prolonged enough that the patient and doctor/therapist gradually work at recognizing and correcting all possible causes of the injury along the way. It is the Mild and Moderate Injuries, that the KISS principle and Tip of the Iceberg principles must be reconciled. It is when the injury is classified as mild or moderate that the health care provider must decide when to look under the Tip of the Iceberg and explore the depths of moderate to complex causes. It is in the 4 categories below that I find most problems in dealing with these injuries. These are:

1. Mild Injury/Moderate Severity of Cause

2. Mild Injury/Complex Severity of Cause

3. Moderate Injury/Moderate Severity of Cause

4. Moderate Injury/Complex Severity of Cause
In these cases, I see the most patients for 2nd opinions. Why is the injury not healing? Why does the injury keep coming back? The mild and moderate nature of the initial injury makes the health care system relax and not look to deep into cause of injury.

     I will end this discussion with one example of this dilemma. Since I already used Achilles Tendonitis above, I will finish using an example of Achilles Tendonitis. The patient had pain in the Achilles for 3 months prior to seeing the initial doctor. The patient was a runner who pronated too much, rarely stretched the Achilles, when stretching only did Negative Stretching off a curb (see separate post), was a vegetarian (not to pick on you guys too much!) but ate well, ran a lot of hills after moving from Dallas to San Francisco, and was told he had one leg shorter but never did anything about it. The initial treatment addressing the possible causes of the injury were Orthotic devices for the pronation, new motion control running shoes, power lacing see separate post), Achilles stretching 3 to 5 times a day, and running on flat ground, not hills until the symptoms got better. The doctor had categorized the patient mild injury/moderate cause of injury and had addressed the causes on the surface well. Was he/she just looking at the Tip of the Iceberg? What was below the surface that needed to be addressed? The patient after six months of treatment still was not much better in function. Running was still very limited. The initial treating doctor told him to stretch more and give it more time at their last visit (of 6 visits overall). This patient then sought a 2nd opinion.

On review of the injury itself, the right diagnosis had been made. The plan of treatment initiated was good, but never improved upon when the patient was struggling. Each of the treatments initiated were subpar in retrospect. The pronation was only partially corrected with the new Orthotic devices (but they were easy to modify to greatly improve), the running shoe store had convinced him to not get a motion control shoe since he had Orthotic devices (and the doctor never evaluated his running after the first visit), the power lacing was been done incorrectly (and was also modified), diet counseling came up with non optimal protein intake (something that will help the patient forever), measurement of his flexibility showed him off the charts in over flexibility (too flexible means too weak and this was improved with 6 weeks of no stretching at all—he thought I was crazy when I proposed that one), and exact measurement of his legs showed over ½” short leg on the injured side (treatment with heel lifts helped him immensely). Within several weeks, he was feeling much better, and by 8 weeks was back running regularly with a better diet, heel lift for the short leg, sensible stretching routine before and after exercise, no negative achilles stretching, stable Orthotic devices, stable shoes, proper power lacing, and a gradual re-strengthening home program under a physical therapist with 6 one/month visits to up the ante. Yes, under the Tip of the Iceberg for this athlete was a considerable short leg, a considerable dietary problem, slightly harder to treat pronation, and an Achilles that could become over flexible too easily. His mild injury did not initially respond since the cause of injury was misread as moderate, when it really was complex.

The Golden Rule of Foot: When treating athletic injuries, if the symptoms and function plateau, look under the Tip of the Iceberg to a deeper level of possible answers.

Saturday, August 7, 2010

Sports Medicine Humor #1: Ballet

Special thanks to Verna for this one:
A father took his young son to his first ballet performance

After the show was over, the father asked his son: "Well, did you like it."

The boy said "Yes dad, but I am confused by one thing."

The dad replied, "Well what is it son?"

"Dad, as I watched the dancers I noticed the girls all had to go on their toes alot."

The dad said "So??"

"Dad, couldn't they just get taller girls?"

Please submit any sports medicine humor to my email at and I will choose some for the blog itself. Thank you very much.

Diabetes: A Handy Link for Great Information

If you have any family members and/or friends with diabetes, unfortunately a rapidly growing disease in our society, please let them know about the website from my national association. The American Podiatric Medicine Association (APMA) is a strong fighter of this disease and every patient with diabetes should have a relationship a podiatrist. The link has information in both english and spanish. I hope this information can save many lives!!

Wednesday, August 4, 2010

Achilles Tendon Ruptures: Surgery or Cast--Which is Better

The MRI above shows a normal achilles tendon attaching into the back of the heel bone. Note that the thickness is uniform as it goes up the leg in its normal state. Cross sectional views will show a well compacted semi-lunar shape of uniform density. It is the most powerful tendon in our marvelously made bodies, able to lift 10 times body weight or more. But an injury to the achilles is devastating. The next 2 images show the tendon partially or completely torn.

This side view of the tendon, where normal tendon is dark colored, shows most of the tendon torn above the heel bone with tendon fibres in a state of major disarray.

This side view shows a complete tear of the achilles with only the side walls of the tendon sheath holding things together. The dense normal achilles tendon can be seen above and below the tear.

So what can be done? The patient whom has been diagnosed with an achilles tendon tear should be offered two choices---a surgical fix and casting. Both methods heal the tendon and by 1 year the results of both techniques are similar. Surgical fixation is intelligently and intuitively the best way. This was how I was trained to treat this injury, but Dr James Garrick, world renowned orthopedist, convinced me to cast patients. And they did great. In rehabilitating 100's of achilles ruptures, both surgically and casting alone, I have no doubt they are equally good techniques. We give our patients the option of surgery or casting. And, no matter what any one says, the rehabilitation to a strong, powerful achilles is 9 months to 2 years, with either technique. The fastest return to begin running was 5 1/2 months in a 66 year old patient who was casted, and no surgery. Casting has a slightly higher rate of re-rupture, surgery has post-operative complications that can be disabling. The re-ruptures in both groups normally occur in the 30 days after the cast comes off for good, and before the tendon is beginning to build decent strength. Contrary to what I read, modern day sophisticated achilles tendon rehab can restrengthen both methods to 100% of normal.

So, what are the major differences. For one, you must find a specialist that will cast you for 3 months, instead of doing surgery. This makes surgery win the popularity. Surgeons feel more comfortable with surgery, but sports medicine doctors, surgeons and non-surgeons tend to have more of an open-mind. The true purpose of this blog is to tell you the technique does work, and should be discussed. I wrote an article in the 1990's in the Journal of the American Podiatric Medical Association which can be found. Some patients are just poor surgical risks for whatever reason and this technique should be done. Casting can be started the day the diagnosis is made. The first 6 weeks the patient is non weight bearing (the big downer) and the foot is plantar flexed maximally (like a ballet dancer on pointe). The second 6 weeks the cast is gradually brought to a 90 degree angle. I personally want to change the cast every two weeks during this 12 week adventure, initially to plantar flex more, and then in the 2nd 6 weeks, to dorsiflex the cast to a 90% angle foot to leg. After the 12 weeks is ended the patient at least deserved an ice cream cone reward, and the removable cast period of 6 weeks begins.

With surgical correction, our surgeons recommend 2 to 6 weeks in a removable cast after 2 weeks in a fluffy compression cast non weight bearing. So the surgical patient begins the removable cast stage, 10 weeks earlier than the cast patients. During the first 4 weeks of the removable cast, the area is vulnerable to re rupture since it is so weak. Once the permanent casts come off, physical therapy begins 2-3 times/week for the next 3 months minimum. The casting group seems behind but has less surgical scarring to deal with. The complications with surgical repair of the achilles can be very difficult with infections, etc, and the cast patients have none of these to deal with.

By 8-9 months, surgical repair or cast repair seem to be on an even pace, with the same percentage running, walking, or still limping. Psychologically, many patients prefer the thought of the tendon having been sown together. Some patients, like me, try to avoid surgery, or their health status does not allow surgery, and casting for complete achilles tendon ruptures can be a very valuable treatment. The treatment of achilles tendon ruptures should be given your full attention for 1 full year so that you can enjoy a great tendon in the years to come. I hope this gives you a viable option to consider.

Tuesday, August 3, 2010 Great Place for Shoes: Recommended Website has won over the hearts of so many of my patients and mine that I must give them a shout!!
The 1 year, yes 365 day return policy, with free shipping both ways has made my difficult to fit, or just experienced, patients rave about this company. I have had patients with wide, narrow, high arched, or just unusually shaped feet have 10 to 15 pairs of shoes at any one time in their dining rooms, awaiting to be re boxed and shipped back. For these patients, this service is priceless. I applaud Zappos, as I have applauded Nordstroms for years, for their consumer friendly policy. They are both class acts. Thank you. Please try for your next search. And by the way, they sell more than shoes.

Monday, August 2, 2010

Diagnostic Injections: A Pearl Oft Overlooked

     Today I had a patient Valerie whom has a difficult problem to diagnose. She has already had a major ankle surgery by skilled, well-meaning, surgeons in January 2009. She is not only not better, but slightly worse. She knew right after her surgery that the symptoms that had driven her to surgery in the first place were still there, and now she had another source of pain. The surgical pain is pretty much gone now, but what to do with her original problem. I suggested to her that we should do diagnostic injections with long-acting local anesthesia. I use 0.5% Bupivacaine (same as Marcaine or Sensorcaine) for these injections. They take 20 to 30 minutes to numb the area injected, and stay numb for around 5 hours. Valerie is a perfect candidate for this procedure since she has so many possible sources of pain. Since she has had pain since 2004, she has had bone scans, x rays, MRIs, and CT scans. All these tests have shown irregularities in different areas. The problem with all these tests is that with all their sophisication, in the end, they do not definitely tell you what is hurting. They suggest, but can not confirm definitely. Thus, here is the role of diagnostic injections.

     Valerie's tests have pointed me towards 3 joints, one tendon, and several ligaments as the possible source of pain. When she comes into the office I will inject 1 ml of local into the most probable location first. I told her she must break the Golden Rule of Foot: Once pain begins with activity, you must stop that activity. For these diagnostic injections, she must come into the office sore. She must break the rule. She says it will probably take several days of breaking the rule before she gets her foot/ankle angry enough. After the first shot, she will walk around 30 minutes or more and see what the effect was of the shot. Did it eliminate 100% of the pain, none of the pain, or some amount in between. Yes, sometimes 2 or more structures may be responsible for the pain. Sometimes, it is one structure that is injured, and several other areas sore secondary to the swelling, scar formation, limping, etc. Yet, sometimes, more than 1 structure is injured or damaged, making these shots more confusing.

     1 ml of local is enough diagnostically in the small joints or tendons of the foot and ankle. Probably more is needed for injections into major joints, like the knee.1/4 ml is needed for small ligaments in the foot/ankle. Our office is also nicely equiped with stationary bikes, ellyptical machines, treadmills, etc, when patients have needed various ways to attempt to produce pain. This technique works best when they come in sore, get the injection, wait 30 minutes, then try to produce the pain again. The patient must know how to reproduce the pain for this to work well.

     If the first shot does not completely eliminate the pain, about 1 hour after the first injection, a second injection is given and the procedure repeated. Again, a response is noted after the patient retries to produce pain. If the second shot fails to completely eliminate pain, about 1 hour after the second shot, a third shot is given. And so it goes. Normally, one or two shots is all that is needed, since the shots are given in order of the highest to lowest likelihood of eliminating pain. But, I have gone to 5 injections, making it a 5 hour ordeal for the patient, before trully finding the source of pain. Since the injections themselves take 1 minute for the doctor to give, the patient need only schedule a normal followup visit, but have no plans for the rest of the day. The patient is worked in between other patients for the shots if needed, after the first shot.

     In the 29 plus years I have been using these shots, inspired by my partner and world renowned orthopedist Dr James Garrick, only 1 patient after multiple shots found no relief whatsoever. Many patients have had only partial relief after multiple shots, and thousands have had complete relief after one, two, or three injections. The diagnosis has been refined, and treatment can be advanced to more specific treatments. Even in the most cloudy situations of diagnosis, I have found these shots to lend some light and better direction. In Valerie's case, when we find the source of pain, I will have to repeat the procedure one more time on another day, to verify I get the same results. This is because she has had pain for so long, and already failed one surgery, I must get it right!!

    But, diagnostic injections can also be used in fairly straight forward cases. Here they are used to confirm the diagnosis everyone assumes is correct. An easy diagnosis you say. A slam dunk.  I can think of two patients that come to mind with straight forward problems. Both had surgery by two top top surgeons, which are higher than top surgeons, and both were utter failures. Both presented to my office for second opinions. Both needed one diagnostic injection into the joint next to the operated joint and their pain was 100% eliminated. One needed a second surgery (first surgery on the subtalar joint, second surgery on the ankle joint), and the other did great with orthotic devices and physical therapy (first surgery on the ankle unsuccessful, with the injection pointing to the subtalar joint as the source of pain). Dr Garrick always said that your surgical results would be greatly increased if you would validate pre-operatively that local anesthesia could completely eliminate the pain. And you may find that surgery is not needed if you find a source of pain that may be rehabilitated. I sure hope this helps you.

Sunday, August 1, 2010

Plantar Fasciitis: Video on The Big 3 Weight Bearing Stretches

     Patients suffering from plantar fasciitis need to work on three areas of treatment daily: mechanical changes, anti-inflammatory, and flexibility. Since the root cause of this injury is that the plantar fascia strains when pulled too far than how flexible it is, flexibility for most patients is the most important area of treatment. Yet, flexibility work on the plantar fascia must be teamed with anti-inflammatory and mechanical changes to protect the plantar fascia. I will have/already have a series of posts dealing with these aspects. This video is highlights 3 weight bearing stretches which are easily to do throughout the day. I have had one patient with bad arthritis in her big toe joint develop pain after the last plantar fascial stretch, so go easy on that one if you know the big toe has arthritis. Remember the Golden Rule of Foot: Never Stretch Through Pain.
     Other very important methods of stretching which we will soon discuss are A.R.T. (Active Release Therapy), posterior sleeping splints, morning towel stretches, rolling ice stretching (previous post), rolling heat stretching, contract/relax stretching, and avoiding negative heel stretching (see previous post). Remember you should be stable when you stretch (see recent post with video on Generalizations of Stretching). I hope this has been helpful for you.