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Monday, June 27, 2011

Quiz Answers #2: Answers to Daily Sports Medicine Quiz

Here are the answers to yesterday's quiz.

#1 True

#2 YogaToes place a very natural stretch in the direction of straigthening all the toes. It would be difficult to hold the stretch long enough with your hands to get the same stretch. Like all stretches, there should be no pain. It can take time to get used to them.

#3 4 Heat to 1 Ice

#4 Full Length Lifts

#5 L4

#6 The 7 generalizations of stretching are: hold each stretch 30-60 seconds, no bouncing, deep breathe, alternate between sides, warmup before stretching, stretch after exercise, and never stretch through pain.

#7 Outside or baby toe side (lateral)

#8 Adequate plaster fill to ensure first ray allowed to plantarflex

#9 HbA1c

#10 Rest

Sunday, June 26, 2011

Quiz #2: Daily Sports Medicine Quiz

As with all the upcoming quizzes, answers will be posted the next day.


1. Tears in the Plantar Fascia normally require 3 monthes in a removable cast/boot. True/False
2 Why are YogaToes (or the knockoffs) helpful for bunions?
3. What is the ratio of heat to ice in contrast bathing to reduce swelling? (with the most amount of heat).
4. In treating short leg syndrome, are heel lifts or full length lifts preferrable?
5. What lower back nerve root may be involved with pain on the outside of the big toe joint (bunion side)?
6. What are the 7 generalizations of stretching?
7. What side of a running shoe is a valgus midsole wedge put into?
8. In designing an Inverted Orthotic Device, what precautions need to happen under the first metatarsal of the positive cast?
9. In a diabetic patient, what test is very crucial and should be under 7.0?
10. R.I.C.E. stands for what?

Saturday, June 25, 2011

Gradual Process of Weaning Out Of A Cast/Removable Boot

Dr Blake's Note: This patient is recovering from a broken sesamoid bone under her big toe joint (first metatarsal) and is beginning the process of weaning out of the removable cast.

Hello, Dr. Blake,

I hope you are well! I still read your blog faithfully, even though I am getting much better.

I am resending a message from about a month ago, since I have discovered that some of my AOL account messages are not getting through to people so you may never have received this. It basically asks about how to wean out of a boot; also curious about your thoughts on rocker soles.
I also want to tell you that I think your site may have changed health care for many sufferers in Seattle and Washington; I found the "Even-Up" there, and no one here has ever seen one-- I've been introducing it to this area singlehandedly. Well, I just got a call from the Orthopedics Dept here where I work asking where I got my EvenUp! Now their patients will be told about them!

EvenUp seen on the left foot with the Removable Cast right foot

Dr Blake's Note: This is what it is all about in the evolving health care system. Spread the word when you hear of people with health issues. The internet is opening up new horizons. Bravo to this wonderful patient!!
Thanks again for everything,

Ann, Thanks and I am very proud that I can make a difference, and you too. We are a team together trying to help the health of foot sufferers.

 I think the rocker shoes, especially when you are having foot problems, are too unstable, and too unpredictable. So I would avoid them for the forseeable future.

 Golden Rule of Foot: Weaning from the cast needs to be painfree.

 Golden Rule of Foot: You can wean out of the cast if you are painfree in the cast for at least 2 weeks.

 Most people begin to wean out of the cast after work, evenings and weekends when they can think about their foot and be extra slow and careful. Many times the work environment is too busy, and you just can not think about your foot as much.

When they have accomplished this initial painfree transfer from cast to no cast, they begin weaning off at work. You begin weaning by starting with 1 hour in your shoes, inserts with accommodation, spica taping.

You gradually add 30 minutes to 1 hour per day of time out of the cast as long as there is no increase in pain.

Many patients need to level out at a certain level if pain begins after a certain amount.   Stay in the painfree zone. This is why the typical weaning process can take from 2 to 8 weeks.

Read the posts on the Magical 80% Rule and Good vs Bad Pain, since as we increase function, pain may be slightly increased.

 Do Not Experience Bad Pain (pain over level 3), pain that you would want to limp.

 Hope this helps. Email me at if i am not clear. Rich
And here is the immediate response from the patient.
Hi, Dr. Blake,

Once again, THANK YOU. These specifics and ideas and estimates of time frames are SO helpful (and very clear), and I have not gotten that level of information from my care providers here so I've sort of been making it up (and overdoing it, as it turns out). I am now thinking I'd better go to see one of the Seattle folks you recommended to me, since it's not really fair to keep asking you for specifics like this! I'll let you know how it goes.

Dr Blake's Note: It can be hard to give specifics without all the information, but I hope some the generalizations I present can be helpful to patients.

I am so grateful. And hope you have a wonderful weekend!


Answers to Daily Sports Medicine Quiz #1

Quiz #1 Answers

1. No

2. 2nd Stage

3. Hunter's Response

4. No

5. Cortisone and Alcohol

6. Mechanical Changes, Flexibility, Anti-Inflammatory

7. Relieves Pressure 1st Metatarsal (Ball of Foot)

8. 35 Degree Inverted

9. Doppler Ultrasound

10. Tendinitis

Friday, June 24, 2011

Quiz #1: Daily Sports Medicine Quiz

All answers to the upcoming daily quizzes will be posted the following day.

Quiz #1

1. Complete achilles tendon ruptures always need surgical repair. True/False
2. In what stage of bunion development do you start to see the big toe drift towards
    the 2nd toe?
3. What is the name of the intense vasodilatation phase when using ice therapy?
4. One of the common compensatory patterns of short leg syndrome is early heel
    lift of the long leg. True/False
5. What are the 2 most common types of therapeutic injections for Morton's Neuromas?
6. What are the 3 general categories in the treatment for plantar fasciitis?
7. What is a Dancer's Pad?
8. With a relaxed heel position of 10 degrees heel valgus, what is the initial inversion Rx
    for the Inverted Orthotic Technique?
9. What test should be ordered when a patient presents with calf cramps severe enough to 
    interfere with sleep?
10. The acronym B.R.I.S.S. is used in the treatment of what condition?

Good Luck. Dr Rich Blake

Thursday, June 23, 2011

Heel Pain and Physical Therapy Modialities

The following video briefly goes over some physical therapy modalities commonly used in the treatment of heel pain, such as plantar fasciitis and plantar heel bursitis.

Ultrasound is commonly used as a source of deep heat.

Ultrasound is typically used for 5 minutes.

Ultrasound must be kept moving to prevent burns.

Interferential is used to reduce pain, swelling, and muscle spasm.

Interferential must be diagonally crossed.

Interferential is typically used for 15 minutes.

Deep tissue work is used to breakdown scar adhesions. A skilled manual therapist can even break down a bursae, but it is very tricky to not inflame the bursitis further.

Wednesday, June 22, 2011

Stationary Bike Seat Height for Injury Rehabilitation

The following video demonstrates the principles of starting a patient on a stationary bike during injury rehabilitation.

With many foot injuries, the stationary bike is an excellent rehab tool. No matter where the pain is normally the foot position on the pedal can be adjusted to find a comfortable spot. With many ankle injuries, the seat height can be lowered so that the ankle does not have to bend. When you do lower the seat height, the knees are bent more than normal, and the gears should be eased up abit to have less resistance.

Tuesday, June 21, 2011

Achilles Tendon/Plantar Fascia Injuries: Role of Calf Tightness

Calf Tightness is an often missed as the cause of achilles or plantar fascial injuries. This short video demonstrates one of the techniques used in breaking down tightness in the calf that can cause achilles tightness. Self massage with ethaform roller, rolling pins (yes used for cooking), or other devices like the Stick should be implemented if you note that the sore side is also tighter when stretching the achilles tendon.

Monday, June 20, 2011

Anatomy of the Posterior Tibial Tendon

Injuries to the posterior tibial tendon on the inside (medial) aspect of the ankle include: posterior tibial shin splints, posterior tibial tendinitis, posterior tibial tendon dysfunction, os tibial externum syndrome, and arch pain. In fact, the posterior tibial tendon can even be involved with tibial stress fractures. It is the body's strongest defense against over pronation and arch collapse. When a patient pronates excessively, the weakest link in the chain is affected. It is very important that the anatomy of the posterior tibial tendon from origin to insertion is understood when treating pain along its course, since other structures with different treatment regimens can be painful and many misdiagnoses occur. I hope this video clearly demonstrates the anatomy of this frequently injured structure.

Sunday, June 19, 2011

Taping for Posterior Tibial Tendon Dysfunction/Tendinitis

This video presents the use of 2 inch Kinesiotape to help support the arch relaxing the pull of the posterior tibial tendon. The various injuries associated with over pronation and the posterior tibial tendon are helped with this taping technique. The injuries include (although not exclusive): posterior or medial shin splints, posterior tibial tendinitis, os tibial externum syndrome, arch strain, and tibial stress fractures. This form of taping is a common adjunct to stable shoes, orthotic devices, and power lacing. For those of you unfamiliar with power lacing, the video below shows this powerful stabilizing technique.

Saturday, June 18, 2011

Posterior Tibial Tendon Dysfunction: Important Muscle Testing

The following video demonstrates the 4 muscles/tendons that need to be evaluated for pain and/or weakness in the treatment of posterior tibial tendon dysfunction.

Pain in this area commonly generalized as posterior tibial tendon soreness must be differentiated from the other tendons. Plus, in strengthening the posterior tibial tendon, it is very important to truly isolate it from the other possibly stronger tendons. See the video below on the 4 common ways of strengthening the posterior tibial tendon.

Taping for Achilles Injuries (Longer Version)

The following video discusses how to tape for achilles tendon injuries. This is a common modification of a previously shown version (link below). When trying to rest the achilles tendon, tape immobilization, orthotic devices, heel lifts, braces, heel shoes/boots, and removable or permanent casts are all part of the treatment arsenal.

The previous video on another version is featured below.

Achilles Tendon Injuries and Zone of Ischemia

This short video introduces the importance of immediate treatment of achilles tendon pain especially when swelling is noted. The area 2 to 5 cm above the attachment of the achilles tendon in the body of the tendon is called "The Zone of Ischemia". It is an area of relative poor blood supply. When an injury to the achilles tendon occurs, if there is swelling in this zone of ischemia, the normal circulation is cut off and healing potential comes to a halt rather quickly. This is why athletes fear achilles tendon injuries since they can be so chronic. It is vital to work on the swelling with physical therapy, accupuncture, ice packs, heat in careful amounts, and contrast baths.

Wednesday, June 15, 2011

Evaluation of Heel Pain

Dr Rich Blake demonstrates the typical evaluation of heel pain with emphasis on area of plantar fasciitis, heel bursitis, achilles tendinitis, heel stress fractures and localized or referred nerve pain in this video.

Taping for 2nd Metatarsal Pain

Many patients develop pain in and around the 2nd toe and metatarsal. Along with Budin Splints (see separate posting), kinesiotaping can be used well to immobilize the second and/or third metatarsal joints.

Tuesday, June 7, 2011

Posterior Tibial Tendon Strengthening Exercises

Dear Dr. Blake,

Please post the link to the specific exercises that isolate and gradually strengthen the posterior tibial tendon. Any exercises (resisted adduction, e.g.) that I've tried hurt.

Thanks! Yvonne

Dear Yvonne, Thanks for the email. I hope the above video helps you understand the 4 basic forms of strengthening exercises used in the treatment of posterior tibial tendon dysfunction. Gradually the patient is progressed from Active Range of Motion to Isometric to Progressive Resistance to Functional. Heat (in the form of warm water soaks, heat linaments, or heating pads) is used often to loosen up the tendon before exercise for 10 minutes. If walking is not painful, 5 minutes of walking can get the blood pumping. Ice should be used after for 10 minutes, normally an ice pack over the sore area. NO Pain can be experienced during the exercise. If you are still having trouble strengthening without pain, try the numbing effects of ice. Ice the area for 5 minutes, then let the tissue unthaw for 20 minutes, and then try the exercise. Should work until the tendon is significantly damaged. Then ice 20 minutes afterwards. I sure hope this helps. Rich

Sunday, June 5, 2011

Fatigued?? Overworked?? No Time for Friends??

The Medical Board of California is encouraging overworked physicians, like myself, to read a good book entitled: The Fatigue Prescription: Four Steps To Renewing Your Energy, Health, and Life by Dr Linda Hawes Clever. After some review, and after personally failing the Renew-O-Meter, I felt it probably applies to alot of my readers also. Please look at the 2 links below and take the test to see where you stand. If you are recovering from an injury, you need to get some balance back into your life to heal well. If you have upcoming surgery, you will need some balance to handle the demands on your life. If your kids are growing older, and you are only watching from a distance, renew now!!! If you are planning an important event in one or two years that will consume alot of your time and energy, get in balance now. Hope someone, maybe even me, is helped by Dr Clever's thoughts.

Taping for Achilles Tendinitis

ELASTIKON Elastic Tape One Roll: 2'' x 180'' Stretched - EachMcDavid Two Pack 30-Yard Rolls Underwrap, Green

     Taping for achilles tendinitis is coming back into vogue with the use of kinesiotape. But, since I presently have no experience with this version of kinesiotaping, I thought I would show you several tried and true methods to tape achilles tendons (this video has one of those versions). The treatment of achilles tendinitis from a mechanical standpoint is to limit some of the ankle dorsiflexion (forward bend of the ankle/not pointing downward like a ballerina). The 4 methods commonly used are: heel lifts, orthotic devices (not full length), taping, and running shoes for everyday wear for their extra heel lift over cross trainers, flats, etc. Of course, most boots, clogs, heels, wedges also have this characteristic.

     The three products you would have to purchase are: 3 inch elastikon, 1 and 1/2 inch athletic tape, and prewrap (see links above) which are all readily available. You would tape for athletic activities, or prolonged walking, but some tape all day long. I will have another video soon on a slightly different version.

     Remember with achilles tendinitis you need to ice, stretch, strengthen, and protect. See previous post on achilles tendinitis (often spelled tendonitis).

Friday, June 3, 2011

Posterior Tibial Tendon Dysfunction: Email Answer

Dear Dr. Blake,

I have searched your informative blog and not found much on PTTD. I really enjoyed reading your tailored approach to each patient in your blog comments, and I am hoping you can give me some useful insights. I do like and trust my podiatrist, but I am in a quandary and want to explore every avenue before summitting to surgery.
(Dr Blake's comment: PTTD stands for Posterior Tibial Tendon Dysfunction. This is the most important tendon for supporting the arch. Complete tearing of that tendon always leads to complete arch collapse. So this is a very serious problem).
I am a 40 year woman in excellent shape, trying to avoid surgery for PTTD. . I found you in reference to your use of inverted orthoses and I am wondering if I consistent use of them might help me. I have consulted with two podiatrists and both have agreed on the PTTD diagnosis, now I just need to figure out my plan.
(Dr Blake's comment: The Inverted Orthotic Technique is the most sophisicated foot orthotic for arch support and is always used for PTTD. There are only a handful of orthotic labs in the US that may them, but a relatively easy technique to learn).
HIstory and background:

I sprained both ankles in my early 20's, the left ankle was a more severe sprain.
(Dr Blake's Comment: this probably left her with some weakness in her arch).
I have had pain in the arch ankle area of my feet for the past six or seven six years, always when wearing improper footwear (heels). The pain always stopped when I went back to supportive/comfortable shoes.
(Dr Blake's Comment: this is the classic presentation of PTTD where the symptoms begin gradually in the arch and/or ankle areas).
I work-out in the gym  four times a week (weights, elliptical, stair climbing machine) and have always hiked for exercise (usually once a week).

My problem became severe when, on a two-week trip in SE Asia in the Nov. '09, I wore flip-flops almost exclusively. We did tons of walking, and at for the first time I noticed my feet burning and tingling in the evenings. I did not connect this sensation to my other painful flare-ups, because I had always assumed it was my high heels causing it. It did not occur to me that I could hurt my feet wearing flip-flops.
(Dr Blake's comment: Again, the symptoms of PTTD gradually begin to change affecting other activities, although one day of aggressive walking in flip-flops if you have a predisposition can cause symptoms).
Over the next six months I experienced increasing pain in both feet upon getting out of bed and standing up first thing in the morning. My left ankle and arch started to look slightly swollen, but I did not see a doctor.
(Dr Blake's comment: This is probably the first mistake, if you see swelling, the body is actively trying to heal something, and may need some help and guidance).
I finally sought treatment when, after a run last summer (August '10) , I was in so much pain in both feet that I had trouble walking. I experienced shooting pains up the calves up both legs at night and my left ankle and arch was red and painfully swollen.
(Dr Blake's comment: Here she is in the Immobilization/Anti-inflammatory Phase of Rehabilitation. You must create a painfree environment and allow the tendon time to heal. You normally need a removable boot, followed by brace, followed by orthotic device. You normally need to combine immobilization with ice and contrast bathing to reduce swelling in the tendon. You normally begin strengthening the tendon painfree from the first visit. Emphasis on the painfree).
First podiatrist diagnosed stage 1 PTTD and prescribed orthotics. Second podiatrist concurred and added ice/anti-inflammatory therapy and in addition put me in a walking boot until my inflammation subsided. After six weeks in boot I went to just wearing the orthotics and sometimes Dansko shoes. My right foot felt 98% better, and my left foot was improved to the point where I could often walk with no pain (always wearing orthotics).
(Dr Blake's comment: Stage 1 the tendon is inflammed, but fully functional. Stage 2 the tendon has some tearing, and begins to not support the arch well. Stage 3 the tendon tears enough to not be functional, and the arch begins to collapse. Stage 4 the tendon completely tears and the arch completely collapses).

Which brings me to my present situation; I am in pain a lot of the time once again, as sometimes want to be barefoot (live at the beach, have a six-year old daughter), wear an attractive (flat) sandal with support, but find that I cannot do so without incurring a lot of pain in my left foot. As I write this I am back in my walking boot as left inside ankle/heel area is throbbing with a dull pain. I wore shoes without orthotic devices yesterday and I'm now paying the price!
(Dr Blake's comment: Golden Rule of Foot: Create a Painfree Environment or else the problem will not heal. This is especially true with PTTD. You need to create a painfree environment. You must stay in that boot until the pain goes away).

Upon hearing all of this from me, my podiatrist has finally recommended surgery. He is of the opinion that that is the only solution for my particular situation. I tend to agree, but I feel overwhelmed when I hear the reality of the recovery. Is there any chance he is wrong? Could I religiously wear the inverted orthoses and "heal" my left foot the way my right foot was improved? Or should I just "suck it up" and do the surgery so I can have a chance for a real recovery and a lifestyle that will resemble "normal" again?
(Dr Blake's Comment: yes, yes, maybe)

Dear Joann,
     Thanks for the email. When patients present to my office with this scenario, I just try to start over. Pretend the injury just happened. Try to put a healing environment together for them to hopefully end with a successful rehabilitation. Sometimes the decisions are hard to make, but we make them and stand by them.
     So, what must you do now? What will allow you to heal? First of all, surgery is only needed 100% for Stage 3 and 4. Does not sound like you are there. Your focus must be immobilization, anti-inflammatory, and restrengthening. Nothing from this point should hurt. The activities should not hurt, the strengthening exercises should not hurt, and the physical therapy should not hurt. Definitely read my post on Good vs Bad Pain and live by it.
     Since the posterior tibial is the strongest arch support tendon, help it out as much as you can to do it's job. This is accomplished with taping techniques, the Inverted Orthotic, stable shoes, wedging of shoes, power lacing, and bracing. Your podiatrist/therapist and you need to create a stable environment, whether it is pre or post surgery. So if a surgeon does not know how to create a stable environment for your tendon, if he/she does surgery, they most likely will not know how to rehab it after.

     Here are so many strengthening exercises for the posterior tibial tendon that is normally easy to gradually build up the strength. Remember, if you try to strengthen a muscle/tendon, and you produce a pain response, the tendon is the end gets weaker.
     What helps control inflammation? Icing (if they is no swelling or after activity), contrast bathing if there is swelling, physical therapy, accupuncture, many topical creams (some by Rx and some OTC), and oral medications. I like to stay away from months and months of oral medications, but short courses when the inflammation is flared is fine. 

So Joann, I will try to dedicate alot of my blogging over the next month to this issue. My recommendations for you right now:
  1. Stay in the Removable boot for the left side until you can walk without pain for 2 weeks.
  2. Purchase an Evenup for the right side to protect your back.
  3. Begin icing 3 times daily for 10 minutes both sides. The left should have evening contrast bathes starting at one and one due to the throbbing. 
  4. Get an Inverted Orthotic Device for both sides, or some type of orthotic that does not allow your foot to pronate at all. You will need this to gradually wean off the cast.
  5. Begin some posterior tibial tendon strengthening each evening followed by 10 minute ice bath.
  6. Get bilatteral ankle MRIs to document June 2011 status of both your tendons.
  7. Find out the stage of your posterior tibial tendon disease and comment on this blog. I will reply.
I sure hope this helps. Rich

Low Dye Taping Modifications

This video is a sequelae to the recent video on Low Dye Taping. Here common modifications to the Low Dye Taping for arch/plantar fascia pain or just overall reduction in pronation are presented by our Athletic Trainer, Aphrodite.