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Saturday, July 23, 2011

Falling: Tips to help you to Prevent Falls

The below video goes over some of the basics in a Fall Prevention Program. So if you are worried about yourself or a loved one, please have them evaluated and see if common sense procedures like improving Range of Motion and Balance can help prevent a nasty, and many times, life threatening fall.

The summary of points made in the video is:
  • Look at problems in range of motion of various joints that can be corrected
  • Look at lower extremity and core strength
  • Evaluate gait patterns looking for possible problems
  • Evaluate the shoes the patient wears for possible instability and their basic foot structure
  • Look at all postural issue like hunching over or leaning to one side
  • Evaluate whether walking aids, like hiking poles, may be helpful
  • Evaluate whether sitting technique may need to be changed
  • Discuss the history of previous falls or episodes of instability for clues as to cause and correction

Wednesday, July 20, 2011

Podiatry Talk: Over Pronation in the Left Foot

Dr Blake's Intro: This very dedicated podiatrist was so kind to call me about 3 patients she was going to prescribe orthotic devices for just prior to my July 4th Holiday. You can sense the passion and kindness that all of us would like to find in the doctors/therapists that help us. Don't worry if the numbers or abbrev are confusing. I will try to explain the gist of it.

Here is the back of a right foot (could not find a left in my immediate files) very pronated (EV) or everted. The ruler represents vertical or straight up and down (where you want your foot to be in general)

Here is Julio's same right foot very pronated with the goniometer we can use to measure the exact angle from vertical. Comparing the right to left can give you a great understanding of the degree of arch flattening of one foot over another.

Dear Rich,

I wanted to Thank-you for trying to reach me on Th am before your ( much deserved vacation for the 4th of July ). I know what is like on the last day at work before an upcoming holiday/ vacation/ absence planned. It seems as though "everyone and their mother" + grandmother + father+ child+ ...uncle... needs you... Pun intended : )

So many people in pain or in precarious weight bearing situations- (like the pts I described to you ) rely on your expertise and it all takes time. It was very thoughtful of you to squeeze me in as well.

Dr Blake's Note: my voicemail must have been cut off, however this form of communication should prove more useful.I listened to your VM to me & I am not sure what happened, but you broke off in mid sentence and the recording abruptly ended. I thought I might be able to reiterate what you would do with the patients I presented and you could let me know if I have down your complete answer.  Below I have included a recap since it has been awhile.

Dr Blake's Note: The podiatrist describes the complicated biomechanics of three patients all in their 70s and all with collapsed (everted or pronated) left feet. I think there are 2 common forces that produce unequal wear and tear on our musculo-skeletal system as we age: The presence of limb dominance produced by being right handed or left handed where right handed people have the left side as their support leg and break it down quicker, and the limb dominance of having a short leg. 80% of people have a short leg and it seems to me the majority have the long leg on the left. The longer leg has more compression forces as the body levels itself out at the spine throwing more weight to the left. The limb dominance seen in a long left leg in an adult is typically greater weight bearing on the left.

PT Backgrounds/Recap: The patients are 75+ yrs. in age with c/o recent balance problems. Each patient has their mid arch L ft collapsing with palpable bone plantarly. All have slightly boney dorsal prominences at 1st met heads.

Dr Blake's Note: There are 2 major reasons for balance problems (ie the patient feels unsteady on their feet. With one foot beginning to have arch collapse only on one side, the delicate symmetrical balance between the feet are thrown off and instability ensues. And pure arch collapse on one or both sides leads to great feelings of unsteadiness. From a patient's standpoint, they have a difficult time knowing where the instability is coming from. The medical world also wants to blame things like this on their age, failing to recognize it can be a simple (ha ha!!) foot problem, with a sometimes simple solution. Evaluation of foot structure, especially looking for anything assymmetical like uneven pronation, should be part of any balance program/fall prevention program.

R.S.= Pt Male:175lbs, 5'10 The gentleman has more severe balance issues in that he shuffles,uses a walker and does not walk much. He has severe gout with tender tophi on his great toes IPJs. B/L: Tibial valgum and Extensor Substitution

Left: Tight plantar fascial band upon palpation with Pl Fasciitis pains in arch and more distal than heel region; slight hip drop, hits EV on heel strike
STJ: 14 Inv, 10 Ev ; RCSP: 2 Ev NCSP: 90 Foreft (FF) is 3 Pronated/Ev on Rearft (RF)

Right: STJ: 12 Inv, 4 Ev ; RCSP:1- 2Inv NCSP: 4Inv FF to RF is 90 ; slight Rt shoulder drop

Dr Blake's Note: Simply put the left arch is collapsed with the heel everting (see photo above). The left hip drop show limb dominance to the left, therefore more compression forces, further collapsing the left foot. The slight right shoulder drop is typically seen in a right handed individual.

C.H.= Pt Female:156 lbs, 5'6 States that she feels a "pulling" & feels like she is "walking on rocks" in and out of shoes. Likes to walk for exercise.

slightlyskewed-shaped,very pronated Left: STJ: 16 Inv; 9 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 11 Supinated/Inv on RF slight L shoulder & hip drop

Dr Blake's Note: She is more everted than the first patient. She has the same left sided hip drop increasing the compression forces on the left. Uniquely, she has a very tilted or supinated Forefoot to Rearfoot relationship. This is opposite of the heel angle. The more supinated or inverted the forefoot is, the more eversion or pronation force is placed on the heel. The higher this number goes, the worse the problem.
RT: STJ: 30 Inv; 4 Ev ; RCSP: 2-3 Inv NCSP: 2 Inv FF is 19 Supinated/Inv on RF
Dr Blake's Note: I find this foot very unstable. The right foot has such higher forefoot supinatus or inversion, yet can not evert the heel. See the heel still a few degrees inverted. When the numbers don't match up, the body can not do something important to life and it begins to break down. This patient has two bad feet and not a good leg to stand on. Here symptoms match this degree of instability.

J.P. = 82yo. rode a bike until 75yrs. leans to L in gait female: 170 lbs, 5' genu valgum
Dr Blake's Note: Here is the third patient with the lean to the left side. Is it the chicken or the egg?
slightly skewed-shaped,very pronated Left: STJ: 23 Inv; 15 Ev ; RCSP: 5 Ev NCSP: 2 Inv FF is 4 Supinated/Inv on RF slight L shoulder & hip drop

RT: STJ: 22 Inv; 4 Ev ; RCSP: 90 NCSP: 2 Inv FF is 1 pronated/Ev on RF

Dr Blake's Note: When I was left the telephone message, there were no specifics. Now that we have the specifics, the RX can be more finetuned.
So Rich your recommendation was to use a polyprop shell, covered with pink plastizote, with leather glued as the topmost cover. The poly shell should be at: A) 5/32" if I have a grinder such that I could grind down the arch if needing more flexibility/softer tics or B) 1/8" and the following materials could be added: korex (1)Thickness?)  (Dr Blake: 1/4 inch) or grinding rubber? could be added under the arch-how far along the device? (Dr Blake: from just in front of the post to the highest part of the arch) to the  to add more stability as needed, but the point was to hold that arch up as much as can be tolerated.

Dr Blake's Note: The 3 biggest problems I see with these patients that can lead to poor correction of the foot mechanics are:
  1. The pronation or arch support correction is placed equal with no real difference in correcting the more everted foot. Big Mistake!! The flatter foot should end up with the higher arch support (Newton's Law: The side that has more force to flatten the arch, should have a higher support to unflatten it).
  2. When you are over 70 years old, no matter how much support you need, it is assummed you must only be able to tolerate less supportive soft supports. Big Mistake #2.
  3. You are not treated like a 20 year old, where perfection is sought in all treatment areas. Good enough is too often accepted, when better may be alot better. What do you expect for your age? And when medicare does not pay for orthotics, low expictations abound. Not if this is my mom or dad or me???

You discussed a discounted intro pair and what would the intro pair be made from? Do you recommend using cork or crepe as a shell?
Dr Blake's Note: When I am prescribing orthotic devices and I am unclear of the right inital correction to give, I typically tell the patient that the first pair is my trial pair (which I may hit the mark on the first try, or may have to learn from). Since I figure both I and the patient are teammates in this endeavor, we should share equally in the costs for any orthotic that is truly transitional (although without we would have not been able to get to the final result). I would leave the cost discount to the patient in each doctor/therapist's hands. I did not mean to imply that the trial pair was of any material different than what you feel is best for the patient. I use three common materials in this quest: plastazote for some support and max cushion, 1/8 inch poly for some support and cushion, and 5/32 inch poly for significant support (for heavier patients the 5/32 inch is changed to 3/16 inch poly).

You also pointed out that you would RF post and with a hi RF valgus you might pour inverted (the Blake) & / or Kirby skive. At what point do you decide to do either or both? Then you were cut off.

Dr Blake's Note: So much of this is up to the skill level of the lab. I have toyed around with this for years and have concluded many things. These include:
  1. When the Resting Heel Position is over 2 degrees valgus/everted, you can not just rely on arch support, the medial side of the heel must take some of the force to control pronation. This, of course, can be accomplished by either some form of inverted pour, or a Kirby skive. There are many sublties that can effect the correction like FF supinatus/varus vs FF pronatus/valgus, whether the heel is rounded or flat on the bottom, and whether their is a low arch or high arch.
  2. When the presenting complaint is in the arch, the patient normally likes more heel correction (Inverted vs Kirby) and less arch correction.
  3. Less arch correction can be accomplished with sweet spots,  plantar fascial grooves, or softer materials, but it is a mistake to low the entire arch.

I usually like to make an actual dell in the orthotic device to semi off weight this most depressed point of the arch in order to support it & alleviate pressure. This would match the weight -bearing position. Around the "dell for the boney prominence" I just created, I leave ~1cm raised unskived doughnut section.(unskived immediately adjacent to the "dell for the boney prominence" Then I gradually skive around a ~1cm doughnut which is full thickness to blend with the arch. Dr Blake's Note: Here is a nice example of a Sweet Spot being created.

I am very interested in whatever you have to say and appreciate your thoughts and time.  I  thank you for your pearls of wisdom. I hope you had a great vacation. I look forward to hearing from you. Take Care.

Sincerely, Karen

Karen, Thank you and I know I am late with this response. I hope taking this time on my blog will prove more meaningful than my cursory voicemail comments. So of all of the orthotic devices we have available what should be done.

With as long winded as this post, I best get right to the point. I hope you can follow based on the earlier discussion points. I will try to always prescribe differently for the right and left feet, so we have 6 feet presented to prescribe the initial orthotic to, and learn from. With this learning process, we may have hit gold early, or at least seen how the patient responds to the certain correction. All these orthotic devices should be with 5/32 inch poly to start, 0 degree birkocork rearfoot posts, with 23 mm Heel Cups Left and 21 mm Heel Cups Right and unless I mention a change or possible modification below.

RS #1 Left Pour 2 degrees Inverted or 2 mm Kirby Skive (Skive best effect with a rounded plantar heel and pour inverted best with flatter heel), maximum arch support with minimal fill yet sweet spot accommodation created.
            Right Pour Vertical.

CH #2 Left With the High FF Supinatus on both feet with CH I use the resting heel position to calculate the Inverted Pour. Here 25 degree Inverted pour will correct for 5 degree Ev RCSP. Maximum Arch Support with minimal fill and sweet spot accommodation.
            Right 15 degree Inverted Technique with Maximum Arch Support.

JP #3 Left 4 mm Kirby Skive with maximal arch support or 5 degrees inverted pour. It is good when you have the negative cast to look at the heel and arch from the medial side and imagine how the arch would change when you add a Kirby vs just Inverted Pour. Remember the Higher the Arch initially, the more effect an Inverted Pour with Maximal Support would have over a lower arch. This is also true with a flatter heel. Kirby Skives are better with rounder heels in general.
          Right Pour Vertical.

Karen, I must go for now. Took 3 nights to answer your great email. Hope it makes some sense. Rich

Saturday, July 16, 2011

Bunion Pain: Ball and Ringer Stretcher to the Rescue

FootFitter Bunion Stretcher Ball & Ring, Cast Iron

This is a great product that the podiatrists in my office have been using for years. It can not only be used for bunion areas to produce a gentle stretch, but for other pressure spots also. My patient Lynda last Thursday reminded me that she purchased this several years ago and has been stretching her shoes to alleviate the pressure around her bunions every since. You want to go easy so it may take a few nights. If you push too hard, the bump produced can be cosmetically unappealing.

Light Weight Hiking Boots when ankle protection important

Hi Dr. Blake,

I was surfing to research taping methods for my posterior tibial tendon problem, and ended up on your site. How funny to end up on your site, because you were my Dr. (& my husbands) when we lived in S.F. 12 years ago before we moved here to D.C. And, a few weeks ago I was at my local pod's office, Stephen Pribut, and he mentioned that he had seen you.
Dr Blake's Note: Dr Stephen Pribut is a great sports medicine podiatrist in the D.C. area.
Anyway, I loved all your info on this issue but I had a quick question. I am taking a walking tour through Eastern Europe this summer and wanted to get some shoes which would be good for this condition. Any suggestions? I realize you may not be able to specify a brand (I'm looking at Keen's where I can replace their insole with my orthotic {which you got me started wearing BTW}) but are tie shoes better than say straps across the insole?

Thx for any advice you can offer.


Hey Susan, It is great to hear from you. Definitely, you want to stay with tie-on shoes and learn to power lace (see separate post). If you have foot problems, you really should consider the light weight hiking shoes on my post from several days ago. These will work with your orthotics well and give you 20% more protection than a traditional shoe. The shoes commonly recommended in that category are (in no particular order):
  1. Kayland Zephyr
  2. Keen Voyageur (Mid or Lowcut)
  3. Merrell Moab Mid or Ventilator (low cut)
  4. Vasque Breeze (Mid) or Scree Low (low cut)
  5. Asolo Stynger GTX
  6. Montrail Women's/Men's Mountain Masochist Mid GTX
  7. Lowa Renegade II GTX (low cut)

Susan, Hope this gives you a start. I am not sure which ones are at REI, or the local shoe stores. Good luck and happy hiking!!

Friday, July 15, 2011

Bunion Pain: Or Is It?

Many patients present to my office with painful bunions hoping to avoid surgery. Or, even worse, having had surgery only to find out they still have significant pain. Bunions themselves only hurt due to pressure against a shoe from the bump that is produced.

Bunion on the right foot may develop pain from the bump.
Patients with bunions can present with sesamoiditis (two bones under the big toe joint), first metatarsal joint capsulitis (inflammation of the joint), hallux limitus (some joint tightness with possible arthritis), and hallux rigidus (definite arthritic joint). The treatment of bunions alone is different from bunions with sesamoiditis, bunions with capsulitis, bunions with hallux limitus, and bunions with hallux rigidus. I hope the video helps the patient with a bunion ask better questions of the doctor (ie Is this a bunion with hallux limitus?). I hope they also understand that a bunion needs specific treatments and the other causes of pain around the big toe joint each need specific treatments separate from the bunion.

Thursday, July 14, 2011

Athletic Shoe Recommended List: 2010/2011 Center For Sports Medicine (Part I)

2010/2011 Athletic Shoe Recommendation List (Part I)

Compiled by the 5 Podiatrists at the Center For Sports Medicine, Saint Francis Memorial Hospital, San Francisco. This list is updated every year since 1985. It represents specific shoes and /or companies that make stable shoes which work well with our patients. There are many shoes that should make this list that we are personally not used to enough to recommend. So, it is not an all-inclusive list.

Remy Ardizzone, DPM

Richard Blake, DPM

Jane Denton, DPM

Jason Hiatt, DPM

Ronald Valmassy, DPM

RUNNING-Maximum Motion Control

Asics Evolution

Brooks Addiction

Brooks Ariel

Brooks Beast

Mizuno Wave Renegade

New Balance 1012

New Balance 1123

RUNNING-Moderate Motion Control

Aetrex Boss Runner

Aetrex Rhino Runner

Asics 2150

Asics Foundation

Asics Kayano

Brooks Adrenline

Ecco RPX 6030

Etonic Minado MC

Mizuno Wave Creation

New Balance 817

New Balance 1224

Nike Air Structure Triax

Nike Equalon

Reebok Premier Rd Plus

Saucony Pro Grid Omni

Saucony Grid Stabil

Saucony Grid Hurricane


Adidas Response Trail

Adidas Adistara Revolt

Adidas Supernova Riot

Asics Gel Trabuco

Asics 2140 Trail

Brooks Cascadia

Fila Flow Refuge

Merrell Cruise Control

Montrail Hardrock

Montrail Mountain

New Balance 875, 910

Saucony Pro Grid Guide Trail

Salomon XA Pro 3D Ultra

Vasque Velocity XCR


Asics 160TR

New Balance 859, 1210

WALKING (Running shoes can be used and can be more stable)

Brooks Addiction Walker (lace, Velcro)

New Balance 845

New Balance 926, 927

New Balance 660

Saucony Pro Grid Stabil Walker


Adidas Barricade

New Balance 1004

New Balance CT654

New Balance CT803

K-Swiss Glaciator

K-Swiss Defier

Wilson Pro Staff

SOCCER-(Turf Shoes)

Adidas Mondial Team

Puma Liga

Adidas Samba Classic

Adidas Absolodo


Adidas TRX Predator Absolodo

Adidas Copa Mundial

Adidas Adipure

Nike Total 90 Laser

Nike Tiempo Legend

Nike Tiempo Mystic

Nike Ronaldinho

Nike Air Legend

Nike Talaria

Puma King

HIKING BOOTS (Light Weight)

Kayland Zephyr

Keen Voyageur

Merrell Cham-Arc

Merrell Moab

Vasque Breeze


Asolo Attiva GTX

Asolo Stynger

Asolo Fugitiv

Kayland Zephyr

Kayland Vertigo Light

Lowa Kody

Lowa Renegade

Montrail Torre GTX

Vasque Wasatch

HIKING BOOTS (Heavy Weight)

Asolo TPS 520

Asolo Powermatic 200

Kayland Vertigo High

New Balance MO 1500

Zamberlan Lhasa

Zamberlan Civetta

Wednesday, July 13, 2011

Prolonged Heat and Ice Stretching for Chronically Tight Achilles

This video for me introduces a very important stretching technique for the chronically tight muscle/tendon groups or the acutely tight post surgery, casting, burns, etc. The principle of Prolonged Heat Ice Stretching was first written up of post knee surgeries that left very tight quadriceps by the researchers at Temple University in Philadelphia. I have successfully used the technique to stretch out tight achilles/calf, hamstrings, and quads/patellar tendons.

The basic idea is to use heat to stretch the tendon, and while continuing to hold that stretch, ice is applied to physiologically freeze the tendon in this new position (resetting the golgi tendon organs within the muscle fibres). The art is to protect the other joints involved and find out how long each stretch should be held. The Temple Study used 30 minutes heat followed by 15 minutes ice (50% of the heat in terms of time), but even 10 minutes heat followed by 5 minutes of ice can be very useful. In fact, this is my starting point with patients when I introduce the technique.

The achilles/calf stretch demonstrated here can be done standing on a slant board for probably a deeper stretch (also ideal when stretching both sides at once), although getting the ice pack to stay in place can be a challenge. In the sitting position as the video demonstrates care must be taken to protect the back, elbows, shoulders, and knees. The patient is sitting with excellent back support, the towel must be long enough not to stress the shoulders and elbows, and a towel is rolled up and placed behind the knee to protect the knee from hyperextending. Listen to your body. If pain develops, stop immediately.

Achilles Stretch Weight Bearing with Ice in Place

Side View Achilles Stretch with Ice in Place on Slant Board
Patients arms are resting comfortably on a platform on table
Many doctors recommend surgically releasing tight tendons. This may be an excellent way to rehab and lengthen the tendon without surgery. It is important for the physician or therapist involved to measure the tendons periodically to see if the stretch is helpful. I usually supplement this stretch done 2 or 3 times per week with 3 times daily normal weight bearing achilles stretches with can be done in other posts on this blog.

Tuesday, July 12, 2011

Email Regarding Good vs Bad Pain (Weaning off Crutches after Foot Fracture)

Brooke broke her right fifth metarsal on 6/16/11 and was placed on crutches and a removable boot with accommodation. My initial visit was 6/22/11 and followup on 7/6/11 now 4 days ago.On the 7/6 visit, I discussed with Brooke trying to wean off the crutches with the full protection of the removable boot.

Base of 5th Met Fx

Hi Dr. Blake, I was in last Wed. when you got me started walking without my crutches. All has been going really well until today  (7/9/11) when I woke up with soreness at the site of the break.

Yesterday I tried wearing a Superfeet insole that I had on hand in my boot, and I'm wondering if this is what caused the pain. Or maybe I just overdid it and walked too much yesterday. I was on my feet for a couple hours straight in the afternoon.

It's not sharp pain. I would describe it as slight tenderness when I put weight on it. Probably pain level is around 1.5-2 out of 10. So not really bad, but definitely more than I've had in the last week (which has been 0). Do you think I should stay off if it completely and go back to the crutches for a day or two? Is this amount of pain OK? Can I keep walking on it without crutches?
Dr Blake's Note: Her pain level is less than the restrictions she prescribes needs. However, I find patients are very protective since they want do have no setbacks.I am not wearing the insole today.
Thanks so much for your help!


Here is my response to Brooke. 
Brooke, Hope you don't mind I put your question on my blog this week. Of course no names, but I get this question all the time. Hopefully, you have read the post on good and bad pain, but when it comes to yourself, logic and reality sometimes do not match. It is hard to stay objective with your own body. Definitely level 2 is good pain, even if it is in the fracture area (weakest link in the chain right now). I find people over protective, which is okay because we have to feel good with what is going on as we Listen To Our Bodies. It would be fine to slow down the no crutches by at least bringing them with you for the next several days, or go back on them for a few hours after the pain (but not 2 days back on the crutches with only level 2 pain). Not sure of the role of the Superfeet, but if you feel pain again, take it out, and see if the pain dissipates. Experiment. If the pain increases over the next several days, then we know we have to slow down and go back on the crutches. See yesterday's post on Activity and Pain Scale Log and consider doing one yourself and emailing me. Hope this helps. Rich
Here is Brooke's response on 7/12/11
Hi Dr. Blake, this is very helpful. Thank you. I did read your post on Good vs. Bad Pain. It makes sense, although at the time I read it I wasn't totally sure how it applied to me since I'm not an athlete and my pain isn't happening because of working out. I reread it, and I guess just putting weight on it and walking counts as my work out these days. What you say about sharp pain versus soreness makes sense, and I don't have sharp pain. My pain didn't disapate after a day, but I'll keep an eye on it and consider tracking it.

thanks so much for your response. I'm very eager to be done with these crutches!

By all means, use this for your blog!

Base of 5th Met Fracture Side View

Sunday, July 10, 2011

Email Activity Followup: An Excellent Method in Helping to Treat Some Injuries

Joe had severely injured both feet several years ago. For 2 years he hardly walked, and this is when I first met him. He had injured his big toe joints and walked on the heels only of MBT shoes. It was a fantastic adaptation of this shoe. First thing I needed to do was to see if he could begin to walk on his full foot. This took many months to accomplish. It was also hard to wrap my fingers around his problem with our monthly followup visits. The monthly ups and downs of his pain levels based on what he did was hard to follow. So, March of this year, I had Joe email me a activity report based on the standard pain level . I will have a post just on the pain scale. It is based on a scale of pain from 0 to 10. As Joe began to walk, stand, bike, etc I wanted to follow his pain to understand it better. I told him we want to keep him in the 0-2 good pain area, but occasionally drifting to 3 or 4 is okay. Joe had kept his pain level between 0 and 1 for 2 years by not walking, but his muscles and bones were atrophing terribly. The golden rule of foot is if it takes 2 years to heal something, it will take 2 more years to rebuild the strength. I knew Joe and I had a long haul together. We had to do it right. This daily activity log with pain level during really keeps us honest and on the right course. EOD stands for End of Day. PL stands for Pain Level.

This is what Joe sends me and I respond only when I think necessary.

July 1 Walking 45 min Standing 40 min PL1-2 Biking 50 min PL1-2 EOD PL: 2-3

July 2 Walking 40 min Standing 25 min PL 1-2 Biking 25 min PL1-2 EOD PL: 3

July 3 Walking 15 min Standing 30 min PL: 1-2 EOD PL: 1-2

July 4 Walking 1 hr Standing 3.5 hrs PL: 2 Biking 45 min PL: 0-1 EOD PL: 3-4

Here I sent Joe an email to increase his icing and decrease his activity.
July 5 Walking 30 min Standing 1 hr PL: 2 Biking 45 min PL: 0-1 EOD PL: 3

July 6 Walking 25 min Standing 40 min PL: 1-2 Biking 35 min PL:0-1 EOD PL: 1-2

July 7 Birks Walk: 25 Standing: 35 PL: 1-2 Keens Walk: 5 Stand: 5 PL: 1 Biking 45 min PL: 0-1 EOD PL: 1-2

Joe has been walking in Birkenstock sandals without bending his foot to push off the ground. We are introducing Keen enclosed shoes as a step forward towards normalcy. Joe awaits some new tests to see how he is doing. I am ordering a new MRI (last one 6 months ago) and a bone scan. Yet, I think the activity and pain scale log may be giving us a great picture of how well he his doing.

Scar Breakdown Self Help Video

This video discusses the general principles behind self mobilization or breakdown of painful or thickened scars. There has also been an explosion of products that are silicone gel based to wear over the scar. Dr Blake is most familiar with Dr Blaine's product, but must emphasize that there may be much better products on the market now. The concept of cross frictional massage first introduced by Dr Cyriax is emphasized.

Saturday, July 9, 2011

Bunions: 4 Stages of Development

Here the 4 stages of bunion development are discussed. The emphasis is on stabilizing the bunion in Stage 2 for as long as possible. In most cases, rapid increase in the size of the bunion does not occur until Stage 3 due to the retrograde forces on the bunion as the big toe pushes off the ground in a misaligned position. The vital importance of simple, perhaps too simple for this high tech world, toe separators can not be emphasized enough.

Quiz #4: Answers to Daily Sports Medicine Quiz

Quiz #4: Here are the answers to Thursday's quiz

  1. Plantar Fascial Tear, Plantar Heel Bursitis, Calcaneal (Heel Bone) Stress Fracture, Nerve Entrapment (Baxter's Nerve), and Referred Nerve Pain possibly related to low back.
  3. No, heat during the first 3 or 4 days after an acute injury can lead to more swelling in the area since it is during the Inflammatory Phase of Injury.
  4. 1 mile max.
  5. You have to pass the Hard Walk Test walking 30 minutes without pain without any limp before starting the Walk/Run Program.
  6. Some surgical areas, like bunions, neuromas, plantar fasciitis, etc, are treated by surgeons and non-surgeons. In these areas, if your only advice has been from a surgeon who wants to do surgery, getting a 2nd opinion to find out if there are other options is important.
  7. AAPSM is the acronym for the American Academy of Podiatric Sports Medicine. The members are dedicated to foot and ankle care in the athletic population. Dr Rich Blake is a former president of this esteemed academy. Their website has useful information on sports medicine topics and members locations for treatment.
  8. Walk 3 minutes Run 7 minutes and repeat 3 times for 30 minutes.
  9. KISS stands for Keep It Simple Stupid. In a high tech world, the pull of society is towards complex. So many simple tried and true methods of successfully treating sports medicine simply are going by the waste side due to this push toward high tech.
  10. Pronated.

Podiatry Video Quiz #1: Why can swelling around the achilles tendon cause an Injury to the Achilles Tendon to become difficult to treat?

Podiatry Video Quiz #1: Why can swelling around the Achilles Tendon cause an Injury to the Achilles Tendon to become difficult to treat?

Thursday, July 7, 2011

Quiz #4: Daily Sports Medicine Quiz

Quiz #4: Answers will be posted tomorrow.

  1. Name 5 common diagnoses that cause heel pain that are in the differential for plantar fasciitis?
  2. What is the website to purchase those 5 finger socks great for bunion patients to gently stretch the toes out?
  3. True/False. During the first 3 days after an injury, heat can be very beneficial to bring blood into the area for healing.
  4. For a runner, how long should you run your first workout in brand new custom made functional orthotic devices?
  5. What is the Golden Rule of Foot for the three days before starting a Walk/Run Program?
  6. Since surgeons and non-surgeons look at the world differently, why is it important to get 2nd opinions before undergoing elective surgery even from a nonsurgeon experienced in the area?
  7. Why are the initials AAPSM so important to Dr Rich Blake and for patients with foot pain?
  8. What is Level 7 in the typical Walk Run Program based on a 30 minute workout?
  9. What does the acronym K.I.S.S. stand for and why is it important in sports medicine?
  10. In looking at old worn inserts, one side had more of the inside arch worn away. Would it be correct at saying that that side pronated or supinated more than the other side?

Tuesday, July 5, 2011

Golden Rule of Foot #3: Think Outside The Box

     When treating patients for a perceived diagnosis (like plantar fasciitis or Morton's neuromas), there are very standard protocols that can help. Doctors and therapists learn these in school and use them diligently on patients. But protocols in actuality are built on generalizations. General rules can become generalizations when they are only 50% (give or take a few percentage points) accurate. It is amazing how emotionally tied we are to these generalizations. They are our rock of stability in the very unstable world of medicine. We need these to function. Or do we?

     I have been very blessed at working in a multi-disciplinary practice. We have general podiatists (like me and Dr Denton), surgical podiatrists, general MDs, surgical MDs, general physical therapists, and specialist physical therapists (ie Dancemedicine approach or manual only approach). Being exposed to this variety of health care providers has given me an understanding that protocols are mere guidelines. My protocol may not be another's protocol. Sometimes we will end up in the same place, sometimes not.

     So I go along and apply my protocols and see how the patient responds. If they are doing well then great, and we keep moving along on my protocol of apparent success. And at anytime, they may not be doing so great, and I may have to change to a different approach (someone else' protocol). The next Golden Rule of Foot is about perfecting your skills, but for how let's focus on Thinking Outside the Box.

     I have a Box of Knowledge of Medicine that I practice with trying to help patients. For most part, I am comfortable with that knowledge. It has become part of my skillset. When a patient presents with a problem, I immediately judge if their problem and my box are compatible. As I learn about the Boxes of other practitioners, I may refer that patient immediately to another, or at least keep that possibility in mind. If the compatibility is strong, I may be able to stay inside my box during the entire treatment course. If the compatibility is less than strong, my box may be inadequate, and the treatment may need to go another direction.

     So, Thinking Outside The Box is really 2 distinct issues acting on the universe at the same time. A health care provider is called to Think Outside The Box when the patient is not responding to a simple protocol, perhaps in reality based on a weak generalization. Recognizing that the protocol is not working, the practitioner should change courses. Sounds easy, but protocols can become part of your mantra, part of your soul. This is why for some practitioners this aspect of changing course is difficult, even in the situation of an unresponsive patient.

    The second issue at work here is not the protocol, but the Box itself for that practitioner. I love when Gene Hackman put the dot on the basketball in "Hoosiers" as the Box for the players, the center ring of the ball (circumference) was the coach's Box, and the volume of the entire basketball was the true Box of Knowledge needed. Sometimes I feel like I know 1/4 the volume of that ball, and sometimes only the circumference. If, on good days, I only know 1/4 of all the possibilities, Thinking Outside The Box means that I recognize that someone else may know the answer.

     There is a certain peace in medicine knowing that you know a part of a big Box of Knowledge. I think I can do a good job, sometimes great job, practicing in my Box of Knowledge and occasionally, when needed, thinking Outside That Box. Whether that means scraping one protocol for another, or being downright ingenious with my own template for a specific patient, or allowing myself the peace of referring to another whose Box is different than mine. True learning will occur in these situations as your Box will become alittle bigger.

Sunday, July 3, 2011

Quiz #3: Daily Sports Medicine Quiz

The answers to this quiz will be in tomorrow's posting.

Quiz #3

  1. When stretching a tight muscle/tendon, why is deep breathing encouraged?
  2. Why is white vinegar a good soaking medium when treating toenail fungus?
  3. Is the Denton Modification for orthotic devices used for pronators or supinators?
  4. True/False. Power Lacing is a great method to help heels from slipping up and down in a shoe, especially if you are wearing orthotic devices.
  5. Ice massage is normally done in what direction along a tendon for tendonitis?
  6. In observing gait patterns, limb dominance to one side in adults is normally seen to the long or short side?
  7. A medical history of problems occurring to mainly one side of the body (ie. right knee pain in 2007, right ankle pain in 2004, and right hip pain in 2000) could indicate what?
  8. In treating bunions, what device is a more direct treatment (and should always be done), custom made foot orthotic devices or medium gel toe separators?
  9. What is a Budin Splint?
  10. When does the cortison part of a cortisone shot that is mixed when local anesthetic normally begin to really work?

Friday, July 1, 2011

Accessory Navicular: An Accessory You May Want To Do Without

Dr Blake's Note: This email was received several days ago from a patient suffering from a syndrome of pain produced by a weakened attachment of the posterior tibial tendon into the navicular. The posterior tibial tendon is the strongest supporter of the arch. The weakened attachment is due to an extra bone next to the navicular at the height of the arch. This extra bone occurs in probably 5% of the population and is called accessory navicular, os navicularis, os tibial externum, and the extra ankle bone. In only 10% of those patients with it does it occur on the other side also (bilatteral).

Hello Dr. Blake,

I am a 29 year old who has been suffering from a lot of foot pain
since early childhood-- it wasn't until I was in highschool that the
Dr. examined me standing and realized that my arches "collapse".
Finally they took an x-ray and found that I have bilateral accessory
naviculars. I have since worn orthotics and attempt to wear very
stable shoes (i.e. Saucony Hurricane). Due to the pain, I cannot do
high impact sports, and walking long distances usually results in pain
and limping. (I will also get shooting pain up my shins, in my knees,
or in my thighs/hips). There are not too many shoes I can wear
comfortably, and even with my orthotics I will have pain if I walk
more than a mile or so.

Xray shows accessory navicular under the navicular at the height of the arch.

Dr Blake's Note: The os tibial externum begins to form around 8-9 years old, and should be fully formed at 16 years old. It can fully attach bone wise, or partially attach with cartilage or fibrous tissue. These last 2 attachments are particularly weak and can cause pain.

This MRI view of an Accessory Navicular shows it inferior and  closer to the heel than the big toe. 

In the past, my foot doctor has suggested that if pain cannot be
improved with orthotics, I should consider having them surgically
removed. The Dr. mentioned that most people have pain from the bones
rubbing on shoes, etc, which I have never found rubbing to be a
problem, more like pain from disalignment. I did so PT for a while,
and much of the focus was on stretching and strengthening muscles,
especially my hips. While this did help with aches in
knees/hips/thighs at the time, I don't really feel like my overall
strength or balance has improved.

Dr Blake's Note: I have never had a patient with this syndrome with pain limited to shoe rubbing, since orthotic devices, shoe padding, and taping all take the pressure off the outside of the bone. The real pain is from something else, and that is what needs to be discovered . Discovering where the pain is coming from hopefully will enable the patient to avoid surgery, since the treatment can be directed at that, or if surgery is necessary, make sure the right surgery is performed.

I also have very poor balance, tight achilles tendons and hamstrings,
and weak muscles.I did so PT for a while, and much of the focus was on
stretching and strengthening muscles, especially my hips. While this
did help with aches in knees/hips/thighs at the time, I don't really
feel like my overall strength or balance has improved.

Dr Blake's Note: If you read the sections on posterior tibial and arch strengthening, you will understand the complexity to strengthening through pain. If the tendon is damaged, you will not be able to strengthen it, and surgery may be necessary. If the tendon is not damaged, it is vitally important to attempt to isolate it and strengthen it, painfree, and not strengthen the peroneals at all.

I also apparently have possibly pinched nerves between my big
toe/second/possibly third toe at times when walking-- the area above
and between by big and second toe will swell a bit and I get
tingling/pain//numbness in my third toe sometimes when walking.

Dr Blake's Note: The significance of this statement is Lindsey may have a version of Tarsal Tunnel syndrome which gives posterior tibial symptoms, and also superficial toe nerve symptoms. This would be a rare situation, so I will ignore it right now.

Recently, I made the silly mistake of wearing sandals to the mall.
After walking around, my right foot began paining, and has been
getting worse (now on day two night). The pain is located directly
below my ankle on the inside in a very localized spot, and has been
swollen. I have been icing it and it helped minimally (I also tried
tylenol). It hurts regardless of movement, bearing weight, etc.

Dr Blake's note: also perhaps Tarsal Tunnel??

Dr Blake's note: Like many of these chronic problems, they can become acute at times. The mistake made now is not to recognize that you have to treat this acute injury first, and deal with the chronic injury after. Lindsey is now in the Acute Phase of Rehabilitation (for this chronic injury). The treatment is immobilization and anti-inflammatory. Get yourself into a removable Anklizer Boot (see referenced in blog search) and ice 3 to 4 times a day for 15 minutes. If the ice irritates the local nerves, ice 3 inches above the area, and consider a Rx of voltaren gel 4 times daily or Flector Patches every 12 hours. Should be better in 1 to 2 weeks.

I tend to "hold my arches up" and transfer more weight to the outside
edges of my feet, because letting my arches collapse immediately
causes pain and irritation.

Dr Blake's Note: This is what the orthotic devices must do for a patient. They must be designed to hold up the arch, perhaps along with Kinesiotape, so that the patient doesn't strain the tissue further doing it using muscles and tendons abnormally.

I was told by my Dr. that the tendon holding my arch up is partially
connected to the accessory navicular, making my arch unstable and
collapse. ( I have also been told in the past that I have "loose
ligaments-- but I have noticed that while I am very flexible in some
joints, I am extremely tight elsewhere)

Dr Blake's Note: If you image that only 1/2 of your achilles tendon attached where it should, and the other 1/2 attached into a soft ligament, you would not have only 1/2 the strength, you would have next to nothing. As the achilles pulls, the weakest link in the chain (the part not attaching into solid bone) would begin to strain, and the whole achilles begin to hurt. Same with the accessory navicular, the part of the posterior tibial tendon that does not attach into solid navicular begins to strain trying to stabilize the foot, slow down pronation of the foot, ankle, knee, and pain ensues. It can not do it's job properly.

I am not sure what sort of direction is best with this problem. I
don't know if this swelling/pain is from the extra bones and would
diminish with surgery, or not. The pain is so frustrating and keeps me
from being active too much at all-- I enjoy dance, walking, yoga,
cycling and swimming-- but often walking and dance are limited (and
running out of the question) due to the pain it will cause.

Dr Blake's Note: Once the acute pain is gone, and you are back to the chronic pain, you need to get this worked up. I will give my final recommendations below, but you must know my recommendations center around a world that I would like, maybe not practical.

It seems like my pain is not the usual for accessory navicular (as
according to Dr.) so I am not sure if this is an unusual case? Any
advice or information on this would be great. This has been causing
trouble for most of my life (i.e. being unable to enjoy
walks/hikes/sports, having trouble falling asleep due to pain, pain
and limping at work).



Lindsey, Most of the pain from this syndrome can be from inflammation at the attachment of the posterior tibial into the accessory navicular, actual tearing of the tendon itself, injury to the spring ligament just under this bone, chronic movement of the accessory bone on the parent bone (navicular) like in a fracture non-union, or orginating from another structure (both tarsal coalition and tarsal tunnel syndromes can have similiar presentations at times. Please read the post entitled (Tip of the Iceberg) since sometimes the apparent problem is actually not what is producing pain.

     You are definitely a surgical candidate due to the length of time you have had this. That being said you need a good workup to make sure they operate on the right area and do the right thing for you. And, you may find along the way that you don't need surgery.

     So, if I could prioritize wish lists for you, they would like this:

Orthaheel Wave Sandal which can be varus wedged on the outersole

MRI view on the partial bone attachment of the accessory navicular. 
  1.  Get the acute pain calmed down with an Anklizer Boot, an EvenUp for the other side, anti-inflammatory. You will need the boot and EvenUp again. 
  2. Get an MRI to look at the tendon, attachment of the bones, spring ligament, tarsal coalition, and tarsal tunnel areas.
  3. If the MRI shows alot of bone activity, get a bone scan.
  4. Talk to a Physical Therapist about isolating the posterior tibial tendon. Can you do at least isometrics without pain? Begin strengthening the tendon, same exercises are needed post operatively. Strengthening should only be done in the hour before bed, and ice after even if it does not hurt.
  5. Get an orthotic that is comfortable, but supports your arch. Are there doctors or therapists in your area that use a version of the Inverted Orthotic Technique? You must feel that the orthotic works so well that you do not need to pull up your arch. 
  6. Ice three times daily period. For 15 minutes each. Since you can wrap ice around the top and inside of your foot and walk around the house, at least you can do other things. 
  7. Learn to Kinesiotape your arch (see separate post). Tape daily. You can ice through it.
  8. Do not go around with sandals or barefoot. Dansko clogs may work. A compromise may be an Orthaheel or Chaco Sandal with Kinesiotape.
  9. Feel free to send me any tests along the way. You have a big journey. Hang in there. Be Logical. I hope this has helped. Rich