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Monday, October 31, 2011

Top 100 Biomechanics Guideline #51: Shoe Modifications may be Necessary to Increase Flexibility

This diagram demonstrates the normal foot motion I observe in gait as the foot moves. This post emphasizes the SMOOTH TRANSITION FROM HEEL TO TOE  vs  Sagittal Plane Blockade which can cause many problems.
Cuts are made into the midsole of the shoe in the ball of the foot area  (metatarsals)  to help patients move easily through their shoes. The cuts are normally 1/4 inch apart, normally 5 in number, and do not go all the way through the bottom of the shoe, and do not go all the way to the medial or lateral sides of the shoe.

There are many painful situations that require wonderful, thick, padding in the front of the shoe, and great flexibility as well. Most shoes that have a lot of forefoot padding can cause some reduction in the ability of the patient to move freely and comfortably through their foot from heel contact to push off. When this heel to front motion is blocked, even slightly, stress can be taken up in the knees, hips, and low back. We thick just flexing the ball of the foot a couple of times will do the trick. But, the EVA material commonly used for the midsole tends to stiffen up only minutes after you stop wearing them. 

Biomechanics experts have coined the term "Sagittal Plane Blockade" to reflect this blockage of motion from heel to toe. Remember my earlier post on the components of foot motion that should normally be there as you walk or run. Your foot motion should be smooth, non-jerky, centered at push off between the 2nd and 3rd toes, or the 2nd and 1st toes. 

Sunday, October 30, 2011

Hamstring Stretches: Proper Stretching Technique

Here are two methods for stretching the lower part of the hamstrings (the big muscle group in the back of your thigh). Stretching of the hamstrings, quadriceps, and calf/achilles is a vital part of most pre and post workout regimens. The young man on the left is using improper technique, whereas the young lady on the right using stress-free perfect technique. Watch the video below to see if you can pick up on his problem.

Also read one of my original posts on hamstring stretches for more elaboration of the point. When you stretch your hamstrings or hammies, do not try to touch your toes or you may be just stressing out your back.

Talus Injury and Initial MRI Followup Post Ankle Sprain

Fifth Metatarsal Base Fractures: Xray Review and Discussion

Tuesday, October 25, 2011

Can Foods Help Lessen Pain: Acute and even Chronic??

A healthy diet can help with our various pain syndromes. And, poor diets can increase pain, and not just because the healing process does not get the right nutrients. From greens, strawberries, red wine, salmon, and other foods the pain cycle can be lessened. Maybe what our moms were saying is true?

Sunday, October 23, 2011

Plantar Fascial Tear: Physical Examination Finding

Here is another link that may be helpful.

Toe Pain: Foam Toe Caps May Be Helpful

Shin Splints: They Could Be Stress Fractures

     This time of the year (September and October) is made for Shin Splints. Cross Country season is starting and all high school and some college coaches are drowning in Shin Pain. Most of the time the athlete's pain is related to the bone and muscles not being used to the activity and overuse occurs. A shin splint technically is when the muscle pulls so hard on the bone that the lining of the bone (called the periostium) is pulled away from the bone causing bleeding between the bone and bone covering. This normally is improved with time, icing, some stretching, and activity modifications.

      However, when the bone is weaker (poor base of running, low Vit D or Calcium, low estrogen, abnormal bone structure) than the muscle, the bone may actually be the weakest link in the chain and break. This break in the bone normally remains a stress hairline fracture not detectable by normal xrays. Only in rare cases does the bone break all the way through into a complete fracture. The complete fractures are easy to diagnosis, due to the intense pain. A hairline stress fracture, also called a fatigue fracture of the bone, can at times be run on for weeks and even months. Top athletes, with apparently high pain thresholds, have presented to our office with 3 to 5 stress fractures and still running with so-called "shin splint pain".

     So, when shin splints are not improving with the simple measures of relative rest, ice, shin sleeves, cross training, shoe changes, etc, I advocate the use of a bone scan. It is positive within several days of a stress fracture, and is less expensive than an MRI. In our hospital, for the same price you get both legs for comparison, where MRIs are now being charged for only one side at a time and small areas at a time. 

    Christina, a freshman X-Country runner in high school presented with significant pain right greater than the left tibias. Definitely she could not run through this pain. Bone Scans below documented a stress fracture only on the left side. The right tibia had generalized increase uptake of the dye which we call pre-tibial stress fracture or tibial stress reaction. Stress reaction can hurt just as much as a stress fracture, although heal quicker.

On this front view of the tibias, see the intense dye uptake in the middle of the left tibia. Since Christina is fourteen, she is still growing so her growth plates near the knees and ankles are still very active.

Here is a side view of both tibias with the left again showing the spot where the tibia broke.

     This is also a good example of why MRIs probably would have mislead us in Christina's case. Christina had more pain on her right side. Due to the expense of MRIs, and the fact that each side has a separate cost, I probably would have only done the right side. I would not have found the fracture, and probably allowed her to run sooner. We never will know. So consider getting a limited bone scan instead of an MRI when shin splints are not improving. Thank you Christina for being a good model, but sorry your shins hurt.

Friday, October 21, 2011

Marc Evans: Triathalon Coach Launchs New Website

For all you triathletes, I hope you can glean some of the great wisdom from the Internationally-Renowned Coach, and my friend, Marc Evans.

Kinesiotape Advice from Aphrodite Daphnis, ATC

This is an email sent to me from my patient Ruth today.

Kinesiotape for big toe joint pain

Kinesiotape for Arch Support
Hey Dr Blake,

First I just wanted to apologize. I have had to cancel several appointments for a fitting of my second pair of orthotics due to work and family emergencies. All OK now and I should be in next Thurday for my appointment. Sorry you had to keep these in your storeroom!

Also, hope I can get some guidance in better use of the kineseology tape. I find it increases my stamina and reduces pain but generally it tends to roll up and if I shower it gets worse. I rarely use it more than 1 day before I need to take it off. Maybe your assistant can show me more tips when I come in.
Thanks for everything. Ruth
Hi Ruth,

There are a few tricks to helping the Kinesio tape stay on your skin longer.

First, make sure you prep your skin with rubbing alcohol before applying the tape. This will reduce the amount of dirt and oil on your skin, which will allow the tape to adhere to your skin better. The same concept applies to hair. If necessary, shave the area before applying the tape.

In addition, once you apply the tape, make sure you rub it for up to one minute (or until the glue activates).

Lastly, refrain from showering, swimming, or participating in strenuous activity for at least 30 minutes after applying the tape. After showering, pat the tape dry with a towel instead of rubbing it. This will prevent the tape from curling/peeling off.

Hopefully these tips will solve your problem. Please let me know if you have additional questions or concerns.


Tuesday, October 18, 2011

Swollen Big Toe: Email Advice

This is a comment I received on the below blog post yesterday. I need to emphasize that my comments are no substitute for someone who can feel the toe, see the toe, and order appropriate tests. I have to only talk in generalizations.


Dr Blake's comment: With a toe like this is either infection or gout. The redness is the most important sign of infection or gout. Other causes of swelling like arthritis, tendonitis, ganglion cysts, etc do not have the redness associated.

Dr Blake's comment: Gout can give you these transient symptoms that come and go. Infections normally just get worse and worse until the right treatment is started. The tackies (please see the great Wikipedia definition) must put very unique pressure/stress on the big toe that irritates it enough to set off the gouty inflammatory reaction which is lying in wait for something stimulus to irritate the soft tissue. It could be actual pressure (like tightness) or how it makes the toe work.

Dr Blake's comment: I would love to see what those Tackies do (but you may not be in San Francisco ??South Africa??) Definitely if the tackies irritate it only now, later there may be other triggers. So definitely get your Uric Acid Levels tested for Gout. Have xrays taken to rule out other causes of bone/joint inflammation. You may need a arthritis doctor to order a series of arthritis lab tests.

Dr Blake's comment: The recent blood tests may have uric acid. See the blog post above for more info on that. If you are in the high normal range for uric acid, you probably have this syndrome I am discussing. If you are in the middle normal range, other causes of inflammation must be evaluated. Common lab tests are CRP (c reactive protein, HLA-B27, Rheumatoid Factor, sed rate, CBC with differential, etc). You really want a smart person ordering, since if you find a problem, you need advice on what to do with that information.

Monday, October 17, 2011

Hallux Limitus/Rigidus: Email Advice

Hi Dr. Blake,

I have been feverishly searching the internet looking for answers for pain relief from hallux limitus/rigidus (far worse in the left foot, but also present in the right).
Dr Blake's Comment: Hallux Limitus/Rigidus technically means a restriction of motion across the most important joint in your foot---the big toe joint, aka first metatarsophalangeal joint. This limitation can be functional, structural, or a combination. Functional limitations of the joint can be due to over pronation which jams the joint down into the ground as the arch collapses. Structional limitations imply mild (limitus) or moderate/severe (rigidus) arthritis.

I came across your site which seemed to be the most informative between your blog posts and replies to comments and videos. I would love to come out to San Francisco to see you; however, I live in Virginia, so I'm hoping you can recommend someone closer to home.
Dr Blake's Comment: Three of my very favorite podiatrists out there are Ayne Furman, Steve Pribut, and Paul Taylor. Go to the website of the American Academy of Podiatric Sports Medicine ( for their info. They are all great caring podiatrists.

 I have been struggling with this issue for over 2 years, and recently the pain has become an on-going issue rather than flairs here and there. I have attached my x-rays if you would like to take a look at them. So far I have been to 3 podiatrists and not happy with any of them for various reasons.
Dr Blake's comment: I did review the xrays which revealed little sign of any arthritis (great news!!)

The first doc was probably the most helpful but his personality and that of his nurse (spouse) and office staff was just off.
Dr Blake's comment: Unfortunately those chosen for medicine, can be brillant (not me) but their personalities remind me of fish out of water. They have had to sell their soul at a young age to get into medicine, and never developed good social skills (I am sort of like this!!) Doc Martin on TV is like this, and I am surrounded by Doc Martins on a daily basis. Medicine is just too hard to get into and stay in. Not sure what the answer, but we need our docs to keep going personality-flawed or not!!

That was over 2 years ago when the pain first started. He actually assessed my gait along with taking x-rays and doing a physical exam. He made me custom orthotics for dress shoes, of which I found 1 suitable pair that I could actually wear without them killing my feet after searching tirelessly for months.
Dr Blake's comment: Hallux Limitus/Rigidus is not an orthotic issue generally. Orthotics for dress shoes normally stop before the ball of the foot and are designed to increase motion across the ball of the foot. If this is the sore joint, forget it. It probably has to be one shoe that has the right amount of inflexibility in the front of the foot, and the exact right amount of heel lift, and the exact amount of forefoot cushion to work. Zappos is great, but sometimes, miracles are needed for a dress orthotic to work. Now, if the dress orthotic has a built in ball of the foot stiffener to limit motion, it could work better. I said could didn't I.

 I have seen 2 other docs in the past 4 weeks.
Dr Blake's comment: It is wonderful to start getting some opinions, but the dilemma everyone has, and the reason for your email, who will help you sort out the different information. Sometimes, what seems to be different is actually the same info packaged differently. Can be very confusing!! Don't forget about your PCP or a good sports medicine PT to help sort this out. In my ideal world, podiatrists would do a better job being the PCP for feet, allowing room for second opinions, and even another podiatrist making orthotics, or doing surgery, if better qualified. Too much ego out there.

 The first gave me a medrol dose pack for the inflammation, which after a few days made me feel like I had the never ending flu, aching from head to toe (including swelling and pain in my ankle where I apparently have an old fracture from 20 years ago - doc #2 pointed it out the bone spurs on my x-rays. It never bothered me other than the annoying popping and cracking sounds, but all of a sudden I'm in constant pain. Is it conincidence it started hurting while I was on the prednisone due to compensation from the big toe pain, or something to do with the prednisone causing me pain all over my body?)
Dr Blake's comment: Swelling in any area can function as a cast limiting painful motion. As swelling is pulled from that area, and the joint involved moves more, pain from arthritis/bone spurs can crop up. Hopefully, within a week or two all will re-equalize in your body. Prednisone is also slightly unpredictable. It should reduce swelling and make you more wired. I have more then my share of patients that the swelling gets worse, and they are knocked out. Sometimes, life is unpredictable, but with Prednisone, this happens quite frequently. And it pisses me off, pardon my French.

. When I showed him a pair of Dansko clogs that I had purchased for his opinion, he took a look at them in the box and said they were good.
Dr Blake's comment: That breaks all the secret rules of podiatrists. You can not tell how a shoe or insert will function unless you watch it perform.

 I told him of my shoe shopping frustrations, and he basically said I was going to have to just keep on shopping until I found something that was comfortable to me.
Dr Blake's comment: Have you found shoes that feel good without the orthotics? If you could only go shopping with Kinesio Spica Taping and 1/8th inch adhesive felt Morton's or Reverse Morton's Pads (whichever feels the best) I bet you would have a better experience. See other blog posts regarding these.

 I told the second doc about the issues with the medrol dose pack and that I got no relief from the pain as well as the new pain in on top of my foot/ankle. He built up the arches of my dress shoe orthotics and sold me a pair  of orthotics for tennis shoes to which he did the same. After 2 weeks, still no relief. He said the Danskos were too stiff and my current dress shoe was too flimsy, and I needed to find a happy medium (but still no good advice on what to look for).
Dr Blake's comment: It is overwhelming, since you are trying to fit an orthotic, and make your foot more comfortable. I would start again with spica taping at least with no padding, unless this kind doc could show you how. Start icing the front of your ankle 15 minutes three times per day to calm down the irritation, and at the same time ice the top of both big toe joints.

 I followed up with him 2 weeks later (Monday) with intense pain in my arches and continued pain from the hallux rigidus, swollen/painful foot from old fracture.
Dr Blake's comment: Again, this is not primarily an orthotic issue, so I would cease and dissist (sp?) until further notice. The higher the arch, the more pressure in the front of your ankle.

 He convinced me to get a cortisone injection for the hallux rigidus pain. I have at home for the past 2 1/2 days unable to do much of anything other than ice it and rest. I know people can have more pain for several days after getting a cortisone shot.
Dr Blake's comment: 1 cortisone shot will not hurt you, but I would minimize them. They can take 3 to 7 days to work, and then mask pain for up to 9 months.

 My main concern is that I keep getting these sharp stabbing pains on the bottom of my foot intermittently when I walk. It it almost a pins and needles type sensation, but in a very small area at one time rather than the whole foot). I tried to call the doctor's office today to get their opinion; however, my doctor and his nurse were out of the office today, and the secretary didn't feel like my issue was that urgent to bother the other nurse in the office.
Dr Blake's comment: Where is the pins and needles? If it is post injection, the injection probably just stimulated one the nerves running alongside the joint. It should pass. Nerve pain however, and numbness/burning/tingling are part of the symptoms patients get when the nerves are upset, can gradually develop when their is chronic pain. Could end up needing a nerve guy (neurologist/physiatrist) to calm the nerves down.

PLEASE HELP!!! I'm desperate for pain relief, answers, and suggestions on how to get my life back. Thank you in advance!

In Good Health,


Emily, I hope some of my comments helped. Since it took me 3 weeks to respond to your email due to my vacation in Hawaii (when can I go again???), give me an update to answer my questions and tell me your thoughts on taping, padding, etc.

Sunday, October 16, 2011

Sesamoid Injury: Email Advice

Hi Dr. Blake,

Thank you so much for your blog, I appreciate the information I have found there. I have a question for you about a sesamoid fracture that I believe is fibular one, on the pinky toe side.

Sitting under the first metatarsal at the ball of the foot are two sesamoid bones, which have the same function as the knee cap. These bones protect the big toe joint from impact and create more power at push off by increasing the lever arm of the tendons under the first metatarsal. So, if you talk about sesamoids, you normally talk about power and protection. The one closest to the 2nd toe is called the lateral or fibular sesamoid.
 I was sparring in karate and stepped on someone's foot, rolled mine, toes under, and stomped on the top of the foot. It is now seven months since the injury and I am still walking on the outside of my foot due to the pain when walking directly on the flat foot.

The pain is better, but still causes a limp and is red and slightly swollen. I had an MRI 4 months ago which is when they saw the fracture. I have used the bone growth stimulator now for 52 days and I have worn a boot for 4 months but am now mostly wearing tennis shoes for work with my foot wrapped to prevent the toe from moving upward.

 I am at the point where the ortho says the next step is to do a bone graft and wrap it with wires to hold the graph in place but he wants me to see a podiatrist first, which I will in two weeks. I have seen on your site about removing the bone all together, but not a bone graft. My question for you is this- do you have any information about the bone graft?
Dr Blake's comment: I have heard of a bone graft for a non-union of a large bone, but never for the sesamoid. The problem with this is that if the joint between the sesamoid and the first metatarsal is not smooth with normal cartilage, arthritis will set in causing just as much pain as with the broken sesamoid. I can not imagine how they could predict the amount of new bone that would form with a bone graft. Again, I am not a surgeon, and I have just never seen this in anyone. Therefore, you would want to talk to patients whom have had it and returned to normal activity before entertaining this novel approach.

You mentioned that the fibular sesamoid is the less vital of the two, what do you mean by that?
Dr Blake's comment: When I went through my surgical training, the fibular sesamoid was removed routinely during bunion surgery, and patients did well. The fibular sesamoid helps pull the big toe towards the second, and the tibial sesamoid pulls the big toe towards the other foot. They are in harmony working together to keep the toe straight in normal situations. As we age, and begin to develop even a early stage II bunion, the role of the fibular sesamoid can speed up the formation of the bunion. This is one of the reasons if you were to lose one sesamoid, most feel it would be better to lose the fibular sesamoid. And, as we use our first metatarsal to push off the ground, the tibial sesamoid normally takes more weight than the fibular sesamoid as the metatarsal plantarflexes and everts, thus more important in weight bearing during pushoff.

If the bone is removed what will be the consequences?
Dr Blake's comment: You remove the bone to eliminate the pain allowing a return to full activity, to hopefully prevent arthritis from developing under the first metatarsal due to the poor fit of the previously broken bone and the cartilage, and to re-establish proper biomechanics to the body without favoring/limping/etc. Your trade-off is that you weaken the joint by removing a vital component and performing the surgery. Any weakened joint must be protected by foot strengthening, types of shoe gear, padding, orthotics, etc, really whatever it takes to move painfree and biomechanically sound. The joint will never be perfect again, whcih is why we want to be 100% sure when we do surgery that the area would be better off by the surgery (normally the surgeon assumes that without surgery some permanent damage will occur, so surgery is the least of the 2 evils).  And when we remove the tibial sesamoid we also deal with the increased risk of bunion formation.  

I have pain in the ball of my foot on the inside and outside of it, the arch and the top of the foot, the big toe is numb most of the time and has very little range of motion. One of my students bumped the toe of my foot with her shoe and it was very painful and this last week I have had a cramp in the toe off and on. Is there a possibility that I have other injuries other than just the sesamoid bone?
Dr Blake's comment: When you fail to create a painfree environment, the pain gets heightened to protect you, the body feels constant attack so increases the swelling and you favor to protect by using all sorts of muscles and tendons in an improper way. I would much prefer someone walk normally with a removable cast and crutches if needed, then limp in tennis shoes for this reason. Therefore, all the various pains you have are pretty typical for a 7 month injury, in some stage of healing. The MRI should have caught other injuries if present, but I know that is not perfect.

 I completely understand that you can't give me specific answers, but any other information you can send would be greatly appreciated. I am very concerned about having surgery, but then again I can't keep dealing with the injury as it is. I have been practicing karate for about 10 years and kick boxing for about 1 year and since the injury I haven't been able to have my fun and exercise which is driving me crazy!
Dr Blake's comment: Not being an expert in martial arts, or marital arts, I can not imagine getting back into training for awhile. Surgery to remove the sesamoid is your best bet, but can you wear some type of dancer's pad (see blog) to protect it. When the sport does not allow protection, it takes much longer if at all to get back. But, one day at a time.

Hapad company ( makes some great pads to off weight the sesamoid or other areas of the foot. These are Small Longitudinal Medial Arch Pad with an adhesive backing used right behind the sesamoids to off weight.

Here is your classic dancer's pad, but if you feel better, martial art's pad.

 I really hope this is not the end of my martial arts career as I had planned to test for my third degree black belt this winter. Thank you for you help.
Dr Blake's comment: correction next fall at the earliest.

Tammy, Good luck, and I hope this helps. Rich

Pregnancy and falls

Pregnancy and falls

The 2 crucial components of this article were:
1) If you are pregnant and you continue to exercise, you are probably less likely to fall.
2) Following pregnancy, with the body still changing, gait changes from normalcy may need to be addressed when return to exercise, or just daily living, is producing pain syndromes.

Join Marathon Matt for Inspiring Training Sessions Year Round

Marathon Matt inspires people to run, and helps them train safely. Even if you have run 1/2 or full marathons before, you can learn alot from him. Dr Rich Blake   If you need more motivation to run that first step, see this video entitled "Spirit of the Marathon". I have completed 4 marathons, it does change your conscious of who you are.

Saturday, October 15, 2011

Posterior Tibial Tendon Dysfunction: Correspondence from a Sufferer scheduling Surgery

Joann has been kind enough to share more information about her struggles with the terrible problem of posterior tibial tendon dysfunction which leads to severe breakdown of the arch of the foot. The link below is our initial correspondance.

Hello Dr. Blake!

Feel free to edit this as needed....I got a little long-winded. Thanks for listening!

It's JoAnn from June 2011; PTTD stage 1. Thank you so much for your reply to me, and your devotion on your blog to this issue. I'm happy to say that I am pretty much pain free now in my left arch. It has been a long haul-over one year since I started treatment-but when I think about the fact that I have more than like been (unknowingly) hurting my tendon through overuse/under support for over a decade, I guess that's not so crazy.

It's been tough giving up most of my intense physical activities, and I'm sick of the stationary bike, I will tell you that! I am definitely not in the same great physical shape I was before this began, but I feel I can regain the lost ground in a few month's time. The important thing is, I feel amazed that I can work a normal day (I'm a teacher) and not be limping by day's end. This is where I was when I wrote in June. I am sure you have heard this a million times, but I will never take my health for granted again.

So, it's been six months since I wrote to you in desperation; and haven't done everything you recommended, either, which has no doubt hindered my progress. I have just been wearing my orthotics, and icing as needed. I am ready now, however, to see if I can make even more progress, and start doing my exercises to strengthen my tendon. I am watching the videos on your blog to learn how to properly execute them.

My question for you today one that is haunting me daily, and something I didn't address in my first email. My podiatrist has told me in blunt terms that due to the structure of my foot (in layman's terms, he called it "overly flexible"), a problem like mine will only get worse over time: NEVER BETTER. Because of this, I have scheduled surgery for December; the surgery involves five different procedures, which according to my doc will basically "rebuild" the structure of my foot. In your opinion, are there cases like mine where a foot's bone structure is such that simply makes worsening PTTD inevitable? I really don't want to have surgery (who does?), but nor do I want to live in some fantasy world, do all of this work/PT, only to have my PTTD reoccur once I resume my active lifestyle (MY DREAM). In other words, sure I feel better now because I am babying my foot, wearing only the proper footwear, and being "perfect". But I want to get my active life back; are my odds for having that reality better with surgery? Or can I really achieve it with physical therapy? Without knowing my case, I am sure you can't really answer definitively.

Again, thanks a million.


Dr Blake's Comment: Wow, JoAnn, what a thing to tell you!! Amazing how docs and PTs think they are helping you when they say something like that. Giving you the preverbial "dose of reality" you need. And yes, I have never seen your feet, so I can only really speak in generalizations. From his/her prespective, unless they are unethical, they believe they are right. And sure may be!!

I just had a patient with Stage I PTTD problems run a marathon with no problems, although was reinforced with orthotic devices, shoe wedging, motion control shoes, ankle brace, and power lacing. Can not remember if she was also kinesiotaping her arch, but probably was. Never seen a PTTD patient post surgery do that, but they probably can. If I only used the little sampling of patients I have, I would have to conclude surgical repaired patients are less active, but I am not sure. Most of my surgical patients, whether it is knee, hip, ankle or feet, have some limitation post surgery. Sometimes, it is only psychological, since once you go through the surgery, you want to protect the area forever. So, my gut level, what you will have to do post surgery is the same things you should do pre-surgery to avoid the surgery in the first place.

The type of surgery you are talking about in December is preventative surgery. I do not think this really exists since surgery can have complications, and surgery always weakens the area. The big toe joint is forever physiologically weaker after bunion surgery, the ankle joint is forever weaker, the knee joint is forever weaker, and it takes alot of work to get most of the stability back post surgery. I always tell my patients that surgery brings with it even with the best surgeon on the face of the earth, and even mars or jupiter, a 10% chance of complications, and 10% of these can leave permanent problems. These are small odds for most, but not if it is you that got the complication in what would be deemed elective, preventative, surgery.

And every procedure within 1 surgery, you mentioned they are considering 5 for you, has its own chance of complications. So  you have really a 50% chance of some complication slowing you down, and a 5% chance that complication will have some permanence (suggestive some form of disability).

JoAnn, if you are still reading this, and not just turned me off and looking at YouTube, let's place where you are now. You have a significant injury, and you are in the rest/immobilization phase of rehabilitation. You have a long way to go over the next 2 years to get very very strong and powerful in your foot and ankle. The stronger you become in avoiding surgery, even if you need surgery, your strength will speed up the post-op rehabilitation. As you try to rehab this ankle of yours, you need to find a smart PT who can guide you carefully through the strengthening process. It may take a few PTs to find one whom is locked in. But he/she will be the one if you need surgery to rehabilitate you. How very frustrating would it be to have to search for a great PT after surgery, when the tissue is more fragile, and poor PT can make the difference between great results and okay/fair results. I think you would deserve great results.

So, if you have been reading the blog, you know my bias. You hopefully can tell that every small aspect of the surgery, and the rehabilitation, can make big differences. The team you should compile if you are serious about this is a great surgeon who gets his patients running after this surgery (you should be allowed to talk to several of these patients pre-operatively. They will also give you insights into other aspects of what you are going to go through), a great doctor to run your rehabilitation, and a great physical therapist to see that every aspect of the rehab goes well.

Personally, as I end now, I think you should cancel your surgery for one year, and get strong. Get that foot and ankle strong. Make sure every part of the puzzle is in place. Then, if you need surgery, it will be no longer preventative, but because the tendon is not doing well as you gradually increase its stress. Go slow over the next year. Keep any pain within 0-2 levels. Add 10% to your workouts weekly, initially that is painfully slow. If you are walking 30 minutes now painfree, start a walk/run program with 5 workouts per level, and workouts every other day. If all goes well you are running 30 minutes in 100 days, and then more serious running can occur. Own the blog post on good vs bad pain. Believe me, there is no lesson you will now, that won't help you if you eventually need surgery.

Finally, I see patients all the time with loose ligaments who need some orthotics to function, but never advance in 20 plus years with their Stage I PTTD. A few do, but it is not inevitable. Do not believe that. Tomorrow your arch could collapse, and you could move up the surgery. But, it may never collapse. Perhaps other patients stories can come out between now and December to influence you one way or the other. Good luck JoAnn. Rich

Iron Man Triathalon: Congratulations Dr Matt Werd from Florida

If you want a small introducation to what occurs in one of the greatest feats I know of then listen to the story told by Dr Matt Werd (past president of the American Academy of Podiatric Sports Medicine). Truly a remarkable tale!!! Congrats Matt!!

The AAPSM is proud to announce that past president Matt Werd, DPM from Lakeland, Florida recently returned from Hawaii after completing the Ironman Kona Race. Congratulations Matt. Here is a letter submitted by Dr. Werd regarding his experience:

Aloha! --Just back from the Big Island of Hawaii, wanted to give a big thanks to all who gave support in completing the "most grueling 1-day endurance event in the world".

It was an incredible day of racing in some of the harshest conditions, but was able to soak it all in and enjoy (almost!) every minute of it, with Heather and all three kids on-site as support crew. Many have asked about the race, so here is a brief insider's recap of the race in Kona:

Prior to start of race, all competitors were required to weigh in, and I tipped scale at 168 pounds and in best shape of life...

Swim: Favorite part of the race, crystal clear visibility in 20-80 feet deep water, multi-colored coral and bright schools of fish entire 2.4-mile out-and-back course in the Pacific Ocean. NBC helicopters buzzed overhead, while scuba divers with cameras were positioned on the ocean floor looking up filming. Water temps near 80 degrees, so no wetsuit; mild ocean swells caused all swimmers to rise and fall rhythmically. Began the day by treading water with 1900+ others at 640am to be in position - just to the left of the floating Ford SUV - for the 7am deep-water start. After the canon blast, made it to the 1.2 mile turnaround at sailboat in 31 minutes, but took 45 minutes to return against mild current- felt like swimming against a water-treadmill. Swallowed at least 3 gulps of salt water unfortunately, which would come into play later (see Run info!).

Bike: Had a fast and fun bike ride through lava fields on the Queen K Highway. Cycling up to turnaround in Hawi, got to see the pros screaming downhill on way back to Kona, Lieto was in 1st, but when I saw Crowie surprisingly not far back in 1st chase group, knew he would be Champion because of his fast run- he did win for the 3rd time and broke the course-record. Julie Dibbens was 1st female on bike but knew she could not hold it on run; Chrissie Wellington erased a 22+minute-deficit on marathon to win her 4th Kona. Yes, the legendary 40-60 mph winds were as bad and even worse than anticipated... get this, on the road to Hawi, I put out a ton of power to just maintain 11-13mph for 4-5 miles before the turnaround, then on the way back down, hit and sustained 48+ mph! Total elevation gain for the 112-mile bike was 5200+ feet. Cross/headwinds were maddening on final 30+ miles, just tried to hold speed around 19-20mph. Mantra on bike was to finish strong with a 20 mph average and "save energy to setup the run". Stuck to my race-tested nutrition/hydration plan on bike, although could tell near end of bike something was not feeling right. I did supplement by drinking some on-course Ironman Perform drink; other athletes afterward told me they got sick from drinking this stuff- not sure if this caused any later effects? Got out of 2nd transition exactly at planned pace; now, a 4-hour marathon was all that was needed for a sub-11 hour finish.

Run: Usually start marathon off feeling good with a few 8-830 min miles, but knew immediately this day was going to be a different... Faced with a Hawaii-heat that hit like a blast furnace - with fumes radiating off the black asphalt and lava fields - serious issues on the run started immediately (i.e., severe muscle cramping, blurred vision, nausea/throwing up every other mile, and an inability to ingest any nutrition/water) and this continued for the rest of the race. Paused just after mile 1 to get a few pictures with support crew Heather and our 3 kids Madalyn, Matthew, and Melody, and warned Heather that it was going to be a long, long day with a late finish- still 25 miles to go. Time to "Embrace the Suck" as Macca (last year's Kona Champion) had signed and written on my race bib # a few days before the race - ironically, Macca dropped out of his 1st Kona due to similar issues. At 10 miles, on the steep climb up Palani Road, I was forced to jog, then walk, then sit, then throw up and then finally just wait 20+ minutes until I could massage severe muscle cramps in legs, enough to start walking and moving again. At this point, the thought of not finishing and/or dropping out became real. The decision was made to forget the time-average on the run and to just salvage the day by at least crossing the finish line on Ali'i Drive. Funny thing I never noticed before; seems the slower you go, the louder people cheer! The final several hundred meters of the run to the finish on Ali'i Drive is sacred ground, and despite a most-challenging marathon, an incredible energy rush supplied the final burst to propel down the finisher's chute with the crowds cheering, the Jumbotron showed the finish line approaching, and Mike Riley's voice broadcast over the speakers shouting, "Matt Werd from Lakeland, Florida, You are an Ironman!"

Post-race: The surge of adrenaline continued briefly, but I was severely dehydrated and desperately needed copious amounts of fluids. When I checked in at the medical tent, I was weighed and compared to my pre-race weight, and astoundingly, my weight was now 153 pounds; so, I had lost 15 pounds since the start of the day. The tent was overflowing with other athletes in similar condition, all hooked up to IVs, and I found out that many of the professionals had actually dropped out and did not even finish- small consolation. After receiving three 1-liter IV bags of Intravenous Saline Fluid, a shot of Phenergan and Tigan for nausea, the day was complete with the Hawaii Ironman Finisher Medal! Despite my finish time far from what was anticipated from my previous PR of 10 1/2 hours, it was an incredible experience to be a participant.

The 2011 Ford Ironman World Championship will be broadcast on NBC Sports on December 10, 2011 from 4:30 to 6 EST.
Dr Blake's Comments: Are these people insane or what?? Just partially kidding Matt!

How to make your own lifts for a Short Leg

Hi, I contacted you earlier about hip height and leg length. I am using a heel lift, but I was wondering where I could get foot lifts for the height I need. If there are easy to purchase local supplies I would make them, but I don't have access to a grinder so maybe that wouldn't work. I need them to be non-compressible because I'd like to run again. The hip height difference is 9mm. I don't assume you sell them?

Thanks again,

Good to hear from you again Jody. Sorry I don't sell them, but you can purchase the same material I use from JMS Plastics (1 sheet of 1/8th inch rubber cork will do) and have a local shoe repair guy bevel the front part. See the links below to help. 3 of these will be your 9mm. Good luck and happy running. Also try the Walk/Run program since you have not run for awhile.

Friday, October 14, 2011

Epiphyseal Injury: Email Followup and Advice

Dr Blake's Note: I had seen Andy with an injury to the growth plate of his 2nd metatarsal head. Andy is a young man with no slow twitch muscles, so very fast, with a gait of running up onto the ball of his feet. His push off with every step placed all his body weight (magnified by his speed and power) onto the injured area. Accommodative padding and advice regarding good vs bad pain was given. The padding was to float the 2nd metatarsal head and place pressure around it. 

Dr. Blake,

I brought my 13-yr-old son (he was 12 at the time of the visit), Andy, in to see you about three weeks ago because he had had pain in the front of his left foot for most of the summer. We had seen another podiatrist, who had advised him not to run or play soccer (his favorite sports) for about 6 weeks. You diagnosed the problem as strain in his epiphyseal plate, because his second toe is longer than his big toe, and since he is a fast runner who runs on the balls of his feet, that second toe was receiving the brunt of the impact on every step forward. You cut out a piece of foam for his shoes with a depression for the second toe to fall into, so that it wouldn't be the first part of the foot to hit the ground. You said he could go back to running/soccer every other day, and also advised that he ice his foot 2x/day.

Here an example of a typically long 2nd metatarsal  compared to the first which at push off will need to take over 100% of body weight.

Here is an example of 2 foot inserts with accommodations cut for the big toe and 5th Metatarsal. Andy need the accommodation to the 2nd metatarsal.

It seems to have worked. Strangely, he had a bit of foot pain in his whole foot for a few days last week (which might have been just one of those transitory pains people get), but that went away. More importantly, the problem in the front of his foot seems to have diminished or at least reduced to a 1 or 2 (maximum), to use the pain scale you described, and seems to only occur in the morning sometimes.

Some questions:
What do you suggest going forward? Resume his full athletic schedule (soccer about 4x/week, running 1-2x/week)?
Dr Blake's comment: Since Andy is not out of pain, increase the workouts next week to 4 days, and if all goes well, 5 days the next week, and 6 days the next week. Since Andy was able to increase activity, the injury is getting less fragile.

Continue icing? Anything else?
Dr Blake's comment: As activity is increased, the pain must stay the same, or diminish. Icing up to 3 times a day is a must, at least twice based on the symptoms.

What about the foam? Continue to use it?
Dr Blake's comment: Yes, some form of accommodation will be important until the growth plate fuses at the age of 14/15.

As his foot grows, I guess we'll have to continue to increase the size of the foam insert? You'd said that human feet stop growing at 14 or 15, if I remember correctly. Does that mean we only have to be concerned about this issue for another year or two?
Dr Blake's comment: Most likely, unless the growth plate has been damaged permanently, but that is very unlikely.

I want to thank you again for the time you took and the concern you showed to make sure that you understood the problem and came up with a solution to the problem. Andy was really unhappy about not being able to do sports. Your efforts made a big difference to him and improved the quality of his life, and we are very grateful.

Take care.

Maury and Andy, You are welcome. Rich Blake

Thursday, October 13, 2011

Followup on Sundays 10.9.11 Post: Possible Sesamoid Injury

Here is a followup to my post on 10.9.11 (it was my last one).

Thank you for your advice. I recently had an MRI, I was told that I had a bipartite and that there was no fracture. I'm sorry I should have been more specific. I am currently waiting for a Nerve Conduction Study (NCS)

Dr Blake's Note: When there is a possibility  between bipartite sesamoid and fractured sesamoid, the MRI is usually definitive, so I am very happy that you got the MRI to rule out the fracture. Now you have to figure out what another possible source of such terrible pain, and nerve pain is a great possibility produced by the orginal trauma to the foot or a jarring to the back. Back injuries like this may never present with back pain, only pain along the distribuation of the nerve involved. Lumbar 4 nerve root goes right down into the big toe.
This past Friday I had an appointment with my Dr and came home in a non weight bearing cast to help alleviate the sesamoid pain :( other than being very inconvenient, the pain in the ball of my foot has subsided some.

Dr Blake's note: This sounds like a great move because when there is pain not improving, you must seek to create a pain free environment.

 The nerve pain and the sesamoid pain are being looked at as two separate issues. I have not been offered any medication for the nerve pain. I currently take 800mg ibuprofen regularly (yes my tummy is not happy) Although I still continue to have the nerve pain, twitching, tingling, and burning sensations in my big toe :(

Dr Blake's note: Nerve pain has its own set of meds different from anti-inflammatory. I have never know the NSAIDs to help pure nerve pain. You need pain killers like Vicodin, Neurontin, Lyrica, Nortrypline, etc.
I did ask for clarification on the surgery, because I'm very concerned since my last surgery is when the nerve symptoms began. He said he would be removing a piece of the bipartite.

Dr Blake's note: I am not a surgeon, but I have never heard of this. It may be cutting edge, experimental in my mind. Does the surgeon feel the pain is being caused by the pieces of the sesamoid moving? Sometimes the two pieces of a bipartite sesamoid are held together by loose ligaments which tear with trauma. From that point forward, the sesamoid pieces move abnormally on each other causing pain and inflammation. However, if that was the case, I would assume that the MRI would show some form of bony or joint inflammation, not just a bipartite sesamoid. Since the pieces are not adding up totally, and the fact that I think this must be a relatively new procedure, I would make sure the nerve guy treats all of the nerve pain throughly before considering surgery.

I was also told that there was significant arthritic changes to my big toe? Could that be a reason for the stiffness and pain also?

Dr Blake's note: Significant Arthritic Changes mean Hallux Limitus or Rigidus, which is a totally different animal. Read some of my posts on this. Make sure if this is the cause of your pain, and you are going to have surgery, that you attempt to treat that condition appropriately before surgery. I am still confused about the MRI showing only bipartite sesamoid, and somewhere you being total you have significant arithitic changes?? Isn't this fun. Now you have 3 possibilities of your pain: 1) Sprained bipartite sesamoid with excessive motion between the pieces on weight bearing causing pain (this is where the surgeon may be going when he talks about removing a piece), 2) nerve trauma and chronic nerve pain, and 3) hallux limitus/rigidus with severe arthritic pain. Unfortunately, all 3 of these conditions may need surgery. Fortunately, all 3 of these conditions can respond to conservative treatments, if we know which one to treat. At least, the surgeon, who probably knows all this, will get a good laugh out of this. Surgeons do like to be black and white in their approach.

Thank you for your time, and yes your reply was very helpful!!

Dr Blake's note: You are welcome.

Sunday, October 9, 2011

Pain in the Ball of the Foot: Email Advice

Dr Blake,

I just came across your blog! Long story gets longer...In Dec 2008 I jumped over a large puddle on asphalt wearing tennis shoes, immediately I had a very sharp pain in the ball of my foot at the base of my big toe. I worked the rest of the day and when I got home I took some Advil and iced my foot and went to bed. The next day I could not put any weight at all on my left foot or even put on a shoe. I made an appointment and saw a podiatrist that stated with x-rays that I had a fracture at the base of my big toe joint, and a fractured 1st metatarsal. I was given an above the calf boot and crutches. The pain never subsided. It was then determined that the pain was from my bunion and bunion surgery was performed. Only to still have the same horrible pain on the bottom of my foot, numbness from the arch of my foot to the tip of my toe, and a big toe that no longer bends at the end and very minimal at the large joint at the base of my toe.

Now 3 years later... I had just come to the conclusion this was going to be how my foot would be and I was going to just have to live with it. I began to lightly walk jog. Within one week, the pain that had never really gone away was so unbearable I thought I re-broke my foot. This time I went to an orthopedic foot Dr. after reviewing all of my x-rays from previous injury and new x-rays from now, it was determined I had never broken my foot and that I had a bipartite sesamoid bone. His diagnosis has been sesamoiditits. It has been 5 months and I have tried to cut out a pad so that area of my foot is over the hole. I have also tried gel pads that sit behind the sesamoid area. The pain is now 24/7. It wakes me up in the middle of the night; I have a really hard time even being up on my feet. The orthopedic Dr. has decided that it would be beneficial to shave down the sesamoid bone and "hope" that it will reduce the pain. I’m so scared to have surgery! I already have what appears to permanent numbness and I’m very scared to have another surgery. I’m 39 years old and am terrified that my foot has been permanently injured. Do you have any suggestions?



Dawn, First of all I must put in the disclaimer that I can only speak in generalizations and can never take the place of a doctor that can look at your foot and see all the tests, etc. That being said, these are my initial thoughts.

     You probably landed hard and broke one or both of the sesamoids under the big toe joint. This is much easier to do (since they are lower to the ground) then to break the first metatarsal and big toe bone. See the image below on the anatomy.
The bottom of this image is the floor. The sesamoids are great protection for the first metatarsal and will break before it will.
Bipartite sesamoids look like fractures, fractures can look like bipartite sesamoids, bipartite sesamoids can fracture, so I am never sure on xray what is going on. A bone scan or MRI is needed to tell the difference between the 2. Let us assume you have a broken bipartite sesamoid which never healed.

Now, sesamoids are notorious for slowly healing, and some fail in that process despite appropriate treatment. So do not take anything personally. Your sesamoid was not mad at you or something like that. You need to get an MRI to verify the bone is damaged. A bipartite sesamoid has normal bone density on MRI, and a fractured sesamoid is all full of fluid.
Anatomical Skeleton of the foot showing the 2 sesamoid bones under the first metatarsal (ball of the foot).

CT image of a broken or bipartite sesamoid (looks like either to me). Turns out both sesamoids were hurt in this patient, yet both became asymptomatic with removable casting.

Sesamoid accommodation placed under the bladder in a removable boot.

Remember to wear socks like this when you stop loving your foot. It will help get the love back.

These poppies will always make me happy.
When you injure the sesamoids, there is alot of nerve pain symptoms. There are alot of nerves in this area which become hyper-sensitive to protect the area. Chronic pain in an area can also lead to more pain (pain begets pain). Chronic swelling in an injured area can produce pain as the tissue gets starved for blood flow (the same ischemic pain as in angina). Also, and one of the reasons you need to know if you have truly hurt the sesamoid, another cause of your pain could be nerve trauma pain. If you read through my blog, you will see mucho treatments for sesamoid injuries which you have not been doing. You will also see reference to treatment of nerve pain, which is rarely immobilization and allowing the pain to continue.

So Dawn, please get the MRI to decide if it was a sesamoid injury (which will probably have to be removed, but you should do great with that). If you do have a sesamoid injury, see if you can get the pain calmed down for several months (the old break the pain cycle routine!!) before considering surgery. See a nerve specialist now to make sure your nerve pain, probably initially secondary to the sesamoid injury, is now advanced to some version of complex regional pain syndrome (meaning that it is taking on a mind of its own). CRPS has its own set of treatments, and even when surgery is anticipated, surgery is normally delayed under the pain syndrome can get under control.

Thank you for your email Dawn, and I wish you luck. You can write a comment to this post any time you would like over the next few months, or years, as you learn more info, or if you have more questions. Did I answer your basic question? Rich Blake

Rich and Patty Blake gearing up early for another Halloween Party.

PS. I have never seen anyone have their sesamoid shaved.

Saturday, October 8, 2011

Plantar Fascial Tears: Diagnostic Methods

Email sent October 7th, 2011 regarding post on plantar fascial tears under the heel.

very informative. gr8 job. i do have a question, however, if the only method of diagnosis available is x-ray, would this be enough to form a diagnosis? what other methods of diagnosis do u suggest or clinical measures to take?

lizzy, medical student

Here a Plantar Fascial Tear is noted at the attachment into the heel on an MRI. See the disruption of the normal fibres in the area.
Lizzy, Thank you for your great question. MRI is the best in my hands, but ultrasonography probably is also good (just no experience). Xray only shows bones clearly, but I do know that there is a way to highlight soft tissue better on xray (again no experience). When you pull up on the big toe, many patients have a bowstringing of the plantar fascia where it pops out under the arch. If there is a difference between the 2 sides, with less or no bowstringing on the injured side, that would be a great clue that a tear has occurred. The history of over-loading the front of the foot with the heel suspended or non-supported (like a negative heel stretch with calf raise or jump rope routine) when the pain developed is also a good clue.

A negative heel stretch (where the heel drops below the plane of the front of the foot) or prolonged non-weightbearing of the heel (like with jump rope) can produce plantar fascial tearing.
 Pain with plantar fasciitis is very gradual onset, with a tear the pain has a sudden onset. The 3 most common conditions on the bottom of the heel that cause swelling are: calcaneal fracture (gross or stress fractures), plantar fascial tear, and plantar heel bursitis. See the following video that talks more about differentiating fracture, fasciits, and bursitis (but it may help you begin to know the difference). I sure hope this helps some. Unfortunately, there are false positives and negatives with these physical tests, that I still feel the most comfortable with the MRI if I am going to place a patient in a removable boot for 3 months. Before MRIs, soft tissue windows for CT Scans were used (alot of radiation), and xerograms (can not remember how useful that was).

I will try to produce a video soon on the bowstringing of the plantar fascia to show you. Until then, I found this nice video that demonstrates the plantar fascia bowstringing.

Wednesday, October 5, 2011

Heel Pain: Perhaps It Is Not Always Related to Pronation

These are 2 old inserts of mine clearly demonstrating that I pound my heels. See the Wear and Tear in the heel area right greater than left indicating excessive heel pressures. I love when patients bring in old orthotics, even old shoe inserts, so I can get a good picture as to their biomechanics. With the way I pound my heels, if I get heel pain, I better find a way to cushion them.

 So my last patient today, October 5th, 2011 had 3 years of heel pain and relatively excessive pronation (moderate at best). Three pairs of orthotics from different podiatrists, 3 cortisone shots, a night splint, some xrays and a right MRI (his worse side) failed to give him any relief or understanding of his problem. The following plastic based orthotic devices are representative of the pair he had, but even harder plastic posts.
 When evaluating his gait, I felt that his pronation was well controlled, but that his heel strike was very hard. I had first observed that part watching him initially walk barefoot. Then he failed the big question: Do you feel that the heel is being suspended (protected) and the pressure is being transferred to the arch? His answer was "no" and even thought the pronation looked well controlled he felt no pressure in the arch from the orthotic device.

I rectified that immediately by completely removing the heel posts, thinning all the plastic under the heel to almost nothing, adding 3 layers of 1/8th inch neopreme padding (2 on top of the heel cup, and 1 below), and adding arch reinforcement. When I asked again the same question, the smile on his face was something to behold!! I will probably end up redoing the orthotic devices, but for today I was trying to see why his "good stabilizing" orthotic devices were not helping. No one looked at the force of his heel strike.
 This represents the heel padding used to cushion the force at heel strike.

 Here are the famous blue dots to add heel cushion before placing on the topcover of an orthotic device.

Here is the schema I was for watching foot motion. The green is considered normal. The "loud or hard heel strike" observation for Kirk was crucial today to finding the why of his 3 years of heel pain. Gait evaluation wins again (at least another small battle, one day at a time).

I think this emphasizes that with heel pain, just controlling pronation is not always right, just cushioning the heel is not always right, but a combination of the two is crucial.