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Thursday, April 26, 2012

Sesamoid Injuries: Email Advice

Dr. Blake! Thanks for posting and explaining the MRI of the sesamoid. I found this in search of deciding wether the cost of a MRI will be useful in aiding my tibial sesamoid fracture. I wish I had started doing research earlier. I am learning new things such as using the exogen bone stimulator twice a day instead of the recommended once a day.

I did not see a Dr. for my foot until 3-4 months after the injury. My Dr. put me in an immobilization shoe (which i alternated wearing with a carbon fiber insert in cuter shoes) for 2 months. I had a prolo shot, then arfter 2 months recieved my exogen machine and vitamin prescription. she was going to let me go back to work (with continued immobilization) and made it sound like the 2 fractured peices had mended together on one side.
I grew nervous and just got a 2nd opinion. When I looked at the x-ray...the tibial sesamoid looks like a pile of mush with no defined sides...YIKES!! He put me in a bigger CAM boot, prescribed a steriod, wants me off for another month as well as an MRI. Any suggestions you have for me?? How will a MRI help my treatment??
Thanks! ....Discouraged in Texas Tiffany


     Thank you so very much for the comment to my post on Sesamoid Injuries. Glad some of the fine tuning of the management is coming across like Exogen BID and the value of MRI in these injuries. You have had some interesting treatments like prolo shots and carbon fiber inserts which I seem to never use. If you can comment on them, I know people would be interested. Does the Cam Walker work better than the immobilization shoe, I assume it does so rarely use the shoe? X-rays are so misleading that I do not trust their role in any definitive way in making decisions. They are part of the picture only. 

     To say the sesamoid looked like mush does not sound appetizing, and I have only seen once. It may be the normal healing of the bone as it regroups and reorganizes. Sometimes osteoblastic activity (bone forming) looks a little chaotic at first, even when it is doing a good job. When you talk to the doctor, discuss CT scanning. CT Scanning just shows bone and will tell you if the bone is normal looking or disintegrated (thus the mush look). If disintegrated, surgery is normally done. You get an MRI in order to get another MRI and perhaps another MRI. MRIs shows what is injured (sesamoid, metatarsal, tendon, etc). MRIs for their true value in these circumstances need to be compared 3 to 6 months from now (the longer you can wait the better) to another MRI to check if things are looking better. They look better if they are healing. If the doctor is not going to consider surgery for the next 3 to 6 months anyway, because they want to see if you can heal this thing no matter what the X-rays show, then get your baseline MRI. If the doc is so concerned with the X-ray and honestly feels you should have surgery, get the CT scan first and discuss the findings together. Get an MRI if you agree to try to avoid surgery.

     Remember that steroids  and anti-inflammatory meds slow bone healing, use cautiously, or just ice is what I recommend. Make sure you develop a plan to protect the sesamoid with your doctor as you go from boot to shoes. This normally requires orthotics, spica taping, dancer's padding, some physical therapy, etc. The same treatment used to prevent surgery at this stage is used after surgery if needed. Hope this helps you Tiffany. Dr Rich Blake

Wednesday, April 25, 2012

History of Podiatric Biomechanics: Presentation by Dr Kevin Kirby

For those curious about foot mechanics, Dr Kevin Kirby, podiatrist in Sacramento, California, and all around great guy, presented this lecture on the history of modern day foot biomechanics in Belgium. I am honored to be part of this history.

Tuesday, April 24, 2012

Lemonade as a source of Healing

What a wonderful uplifting video!! I have 2 wonderful boys. I know for sure that they would have a lemonade stand for me if needed, as I would sacrifice my life for them. They have my back and I have their backs.

When we are trying to heal a temporary illness or a prolonged disease, we have to have someone who has our backs. It can be a spouse, a child, a friend, or a healthcare provider. These pillars of love and hope need to be cherished, and protected. They shine a light for us, they set up daily for their form of lemon aid stand.

Keeping Hands Cool While Working Out Prolongs The Exercise and Health Benefits

Read this interesting article on decreasing overheating during exercise and thus increasing the possible time you can exercise. Dr Rich Blake

Saturday, April 21, 2012

Diabetes Encouraged to Wear Compression Hose

Diabetics Should Wear Compression Socks: FL Podiatrist
Diabetes so dramatically affects the body’s circulatory system that the feet become far more vulnerable than they otherwise would be. What’s more, explains Boca Raton podiatrist Dr. Bret Ribotsky, “Because of the decreased circulation to the feet, diabetics can’t rely on their pain sensors to alert them that something might be wrong.” Therefore, any wound, skin irritation or other foot abnormality has the potential to mushroom into a dire situation if not caught early.
Dr. Bret Ribotsky

Diabetics should strongly consider wearing “compression” socks to aid their circulation (Dr. Ribotsky calls such footwear “bras for your feet”). They help prevent swelling in the feet, as well as the formation of varicose veins. Without the compression, edema and stretching of the skin can happen, and sometimes the skin tears, which can leave an ulceration that’s vulnerable to infection.
Source: Palm Beach Post [4/19/12]

Don't think I have ever heard compression hose being referred as "bras for the feet"!! Leave it to a guy to coin that one, although quite accurate! Dr Blake

Thursday, April 19, 2012

Lower Extremity Review Article on Plantar Fasciitis

This is a wonderful review article by Cary Groner for Lower Extremity Review on Plantar Fasciitis. The author was kind enough to give me a few quotes. I hope it is helpful to some plantar fasciitis sufferers. Dr Blake

Sunday, April 15, 2012

Bunion Pain while Running

Hi Dr. Blake,

      I started running last year and have since participated in a couple half marathons.  My bunions are quite painful during these long runs.  I tried doing shorter distances with the toe spacers, but found that I was "gripping" the spacers afraid they would move around in my sock.  Is there something else I can do to ease the pain?  They get swollen a few miles in and unfortunately, I'm more of a toe striker which doesn't help.

Marjorie, Here is an item you can buy at Footsmart that may help you. Rich

You can also get 1/4 inch adhesive felt from Moore Medical for proximal padding. Please see the blog. Rich

Developed a Stress Fracture: Consider Bone Density Screening

Bone Density Screening can begin can begin probably around 20 years old and normally tests the hip area and the lower back area. This image and graph is of one spot on the neck of the femur near the hip joint. The screening is calibrated by 2 methods for accuracy--- T scores and Z scores. Above the middle line for your age is normal density for age, height and weight. This patient score was right on the line, so borderline bone weakness. 

Before classifying a patient, 5 spots on the hip are used. The above image is a summation of these 5 spots indicating the bone density of the hip area is osteopenic (weakness) with a higher likelihood of fracture. I want my athletes well above the middle line. 
The lower back bone density screen uses 4 spots from L1 disc to L4. This is a different patient (my wife Pat) that is off the charts strong. I could not resist bragging!! Go Girl!!

The patient seen in the first two images had a low bone density at the hip and also a low bone density at the spine shown above. Compare her back bone density to my wife Pat's bone density. Pat works out 6 days a week and uses muscles in the low back doing her Pilates, Yoga, running, and spin classes. It is muscle contraction that pulls on the bones of the low back that give it strength.

Spica Taping with Buddy Taping of Metatarsal Pain

This was a YouTube comment to the video below that I received today. Glad people are being helped. Dr Blake

This video has helped me a TON!! I got some KT tape and applied it exactly as shown by Aphrodite here and my 2nd and 3rd metatarsal pain has COMPLETELY gone away!! :-)

I am so grateful for this video. I've gone from maxing out at 15 miles due to the pain to being able to run 26-30 miles. More than I ever thought I could do. Many thanks for creating this video!!

Post Operative Scar Treatment

Hi Dr. Blake :D

Here is my new email address.

If you can give me the  name of the medication I can buy at Walgreen for my ankle to help with the scar after my surgery. 

I'm trying my best to be more positive each day :D

Have a Nice Weekend to you and your family !

God Bless!!!

Regards from Joe :D

Mary, My best to you and Joe. I have attached the link to the product I suggested. Rich

Saturday, April 14, 2012

Sesamoid Injury: Finding Exercise While in a Removable Boot

HI Rich,
Happy Saturday. Is the stationary bike okay to do (with the boot on)? Not uncomfortable at all. It may be my savior- I'm getting really antsy! See you in 2 weeks (for an hour appt) w a consult Dr A (foot surgeon) right after. Also, will she look at my file, CT scan, and MRI before the appt so she's prepared to discuss? I know I'm a very demanding patient and I appreciate your help. Thanks again! 

Yes, although some patients can put on their normal shoe with orthotics. The goal is only that the joint is pain free and the boot, etc, does not alter your spinning motion from normal. You have to experiment with seat height, foot position on the pedal, and speed/resistance. See you soon. Rich

Orthotic Repairs: Fixing An Air Bubble

Hi Dr Blake,
I am generally happy with the new orthotics you recently made me. I still have the issue at the end of the day but I don’t think you can do anything about me getting older!
I do have one small problem that I would like your advice on. On the right orthotic the covering has pulled  away or was not glued down and there is a air bubble between the orthotic and covering. This air bubble moves around when I walk on it. The air bubble is about 2 ½ inches long and about a ½ inch wide. What would you suggest? Pete

Pete, First of all please see my blog regarding the daily foot strengthening exercises which may help the  end of the day soreness.

Secondly, I put the air bubble in on purpose to provide a cushion for being able to jump higher and dunk  the basketball.  If this is something you do not aspire to, please purchase a small tube of super glue or its knockoffs, and place in the areas of where the air bubble occur and the sides of the orthotic, of course on the plastic, and see if you can get it all glued down. Sorry if some of it sticks to your fingers.   Hope this helps, glad you are overall satisfied with the orthotics.  Rich

Achilles Tendinitis: Email Advice

Hi Dr. Blake,
I think the orthotics are working well.  If you wouldn't mind making me another pair (maybe with a longer pad this time), and mailing it to me.
Btw, I noticed that my left Achilles is a bit sore/tight so I started wearing my night splint at night, in addition to stretching.  Do you think that will be enough to prevent Achilles tendinitis?
Thanks for everything.

Beth, I will go ahead and design another pair. When you are dealing with any tendinitis, the acronym is BRISS--Biomechanics (what causes it and what can help it), Rest or Activity Modification (to avoid irritating daily), Icing, Stretching, and Strengthening. See the link below to give you the generalizations. You can also explore the blog for more specifics on each area. In summary, the treatment should be well rounded, and not just limited to stretching. Hope this helps, Rich. Please feel free to email with other thoughts. 

And here are 4 videos from my YouTube channel (drblakeshealingsole) which also may help.

Sunday, April 8, 2012

The Dangers of Pumping Gas and Cell Phones, etc. (when you should be out walking for your health anyway!)

Please send this information to ALL your family & friends, especially those who have kids in the car with them while pumping gas. If this were to happen, they may not be able to get the children out in time.
Shell Oil Comments - A MUST READ!
Safety Alert!
Here are some reasons why we don't allow cell phones in operating areas, propylene oxide handling and storage area, propane, gas and diesel refueling areas.

The Shell Oil Company recently issued a warning after three incidents in which mobile phones (cell phones) ignited fumes during fueling operations

In the first case, the phone was placed on the car's trunk lid during fueling; it rang and the ensuing fire destroyed the car and the gasoline pump.

In the second, an individual suffered severe burns to their face when fumes ignited as they answered a call while refueling their car!

And in the third, an individual suffered burns to the thigh and groin as fumes ignited when the phone, which was in their pocket, rang while they were fueling their car.

You should know that: Mobile Phones can ignite fuel or fumes

Mobile phones that light up when switched on or when they ring release enough energy to provide a spark for ignition

Mobile phones should not be used in filling stations, or when fueling lawn mowers, boat, etc.

Mobile phones should not be used, or should be turned off, around other materials that generate flammable or explosive fumes or dust, (I.e., solvents, chemicals, gases, grain dust, etc...)

TO sum it up, here are the Four Rules for Safe Refueling:
1) Turn off engine
2) Don't smoke
 3) Don't use your cell phone - leave it inside the vehicle or turn it off
4) Don't re-enter your vehicle during fueling

Bob Renkes of Petroleum Equipment Institute is working on a campaign to try and make people aware of fires as a result of 'static electricity' at gas pumps. His company has researched 150 cases of these fires.

His results were very surprising:

1) Out of 150 cases, almost all of them were women.

2) Almost all cases involved the person getting back in their vehicle while the nozzle was still pumping gas. When finished, they went back to pull the nozzle out and the fire started, as a result of static.

3) Most had on rubber-soled shoes.

4) Most men never get back in their vehicle until completely finished. This is why they are seldom involved in these types of fires.

5) Don't ever use cell phones when pumping gas

6) It is the vapors that come out of the gas that cause the fire, when connected with static charges.

7) There were 29 fires where the vehicle was re-entered and the nozzle was touched during refueling from a variety of makes and models. Some resulted in extensive damage to the vehicle, to the station, and to the customer.

8) Seventeen fires occurred before, during or immediately after the gas cap was removed and before fueling began.

Mr. Renkes stresses to NEVER get back into your vehicle while filling it with gas.
If you absolutely HAVE to get in your vehicle while the gas is pumping, make sure you get out, close the door TOUCHING THE METAL, before you ever pull the nozzle out. This way the static from your body will be discharged before you ever remove the nozzle.

As I mentioned earlier, The Petroleum Equipment Institute, along with several other companies now, are really trying to make the public aware of this danger.

I ask you to please send this information to ALL your family and friends, especially those who have kids in the car with them while pumping gas. If this were to happen to them, they may not be able to get the children out in time.
Turn off the phone when you drive into a service station, fill lawn mower etc.
Thanks for passing this along. I am sending it to everyone in my address book.

Neurogenic Foot Pain: The Role of The Straight Leg Testing

I treat a lot of foot pain with comes from the nervous system. Nerve pain, in contrast to muscle, tendon, or  bone pain, is the worse pain. Part of any workup for nerve pain in the foot will be an evaluation of the low back. This following video demonstrates the simple straight leg raise looking for signs of low back involvement in the presenting foot problem. 

Ankle dorsiflexion is one of the common variations of the straight leg test. Neck flexion and ankle eversion (pronation) are also common provocation tests. 

Foot Drop: Technique Being Used In the UK

For those suffering from foot drop, and it's terrible disability, a cure may already be here. 

Thursday, April 5, 2012

Use of Salicylic Acid Plasters for Warts and Corns Sometimes can be Too Strong

 This nice young man had a wart on the side of his foot.
He went to the pharmacy and picked up an OTC Wart Remover with Salicylic Acid.

The concentration was the normal 40%, but for him it was too strong. You can get it around
15% also.
He ignored the pain being produced thinking that was part of the treatment and left the
medicine on for several days.
It became so painful the 3rd night, that he had to remove the covering and found this
sore had developed.
He can into the office the next day.
Because it was a burn, I used Silvadene Cream (my gold standard). This is also OTC.

 He wore flipflops
for several days, and massaged the medicine into the wound three times daily.
After about 4 days he was fine, but realized he could have really done a much more
serious injury, with a much longer process.
The moral is to not ignore pain when applying anything, and at least, once a day looking at the
wound. I am amazed how he let this go that long. Oh, the quest to get rid of those nasty warts!!

Please see the write up from my national organization the APMA-- American Podiatric
Medical Association

Wednesday, April 4, 2012

Why do toenails become more curved as we Age?

I have both observed and been asked the question: Why do toenails become more curved as we age? The answer mainly lies in these 3 photos. It insures that we will have more problems with our toenails as we mature? I wonder what podiatrist I will see when I can not cut my own nails??

Here is a typical toenail that gets ingrown even with loose shoes and socks.

As you can see from the front view, the nail itself is not flat, but tremendously curved.

As we age our skin is more fragile and soft. When we walk, the  pressure on the bottom of the toe pushes the skin towards the growing nail. The added skin pressure on the side of the nail pushes in on the toenail and forces it downward. The nail physically can not grow flat due to the skin pressure, it is forced to grow downward or curved. Can you see how easy it is to get inflamed?


Bunion Pain: Xray Evaluation of the Swollen Tissue which causes Pain

Xray Evaluation of a Typical Bunion with almost 3/8 th inch soft tissue swelling at the bunion prominence.

Stage 4 Bunion Deformity with Red Inflamed Tissue

Patients can come in with red hot inflamed bunions. They may be so sore that they want surgery soon (even yesterday!!). When I get Standing AP Foot X-rays I show them the amount of soft tissue swelling between the bone and joint. I try to get them to do 5 minutes ice massage twice daily and physical therapy to reduce the overall swelling. 50% reduction of swelling, especially the 50% that is inflamed tissue, is common to achieve sometimes even with just the ice massage over the period of 4 weeks. As the symptoms die down, the immediate urge to have surgery passes, and I think the patients who still need surgery will make better decisions. For a lot of patients, as the pain resolves, and the bump reduces, and they learn all of the other steps to avoid surgery (see previous posts), surgery can be put off indefinitely. 

Tuesday, April 3, 2012

Gel Products: JMS Plastics

I purchase a lot of supplies from JMS Plastics in New Jersey. Recently they have added gel sheets and cutouts to help with cushioning and protecting sore areas. I just ordered 1 mm, 2 mm, and 3 mm sheets so I could get cut to my own specifications for patients. Perhaps it can help you. Got gel?

Crutches and Canes: Let Them Be Part of the Healing (in more than just the obvious ways)

Patient with custom made (herself) happy crutches
Canes from

Same cane from
When you are injured, the world can look dark. When you are told you need to use crutches or canes, decorate them to help with the healing, or order from fashionable canes. Of course, you have to be ready for the comments (so not for the shy of spirit, but great for the positive energy). We are big on positive energy here in California. Can obtain some from a variety of sources and this is one of them.

Monday, April 2, 2012

Fifth Metatarsal Fractures: Non Jones Type

These images are from a new patient I will see next week. She is almost 3 months post injury and her X-rays show a wide gap still. Here are all the thoughts that are meandering through my brain. 
Here is the standard Lateral view with quite a large gap noted 

A Jones Fracture to the Fifth Metatarsal is normally 1 inch closer to the toes. This AP view still shows some displacement.

This Oblique view makes the fracture clearer and you can see if goes into the joint of the 5th metatarsal cuboid. 

The fracture clearly goes across to the joint. 

     This 5th metatarsal avulsion fractures following some inversion twist of the foot are typically under treated. Because they do not have the stigma of a true Jones fracture (historically more serious), they can be less aggressively treated. Sometimes this is okay, and sometimes not. Again, the goal is to create a pain free environment, which I believe has happened. X-rays for foot fractures, since the healing normally takes place internally first, can not really reflect the strength of the bone. But, I do not like the gap and I do not like the fact that the joint is involved (possibly future arthritis). 

     So, what are all the steps we need to make happen? 

1) Establish a pain free environment if not already occurring

2) Make sure Bone Strength is good (questioning about VitD3 and Calcium, bone density, healthy diet)

3) Stabilize the fifth metatarsal with orthotic devices, accommodative padding, and kinesiotaping (there   are special techniques in orthotic devices for the outside of your foot)

4) Set workout goals that do not over stress this area

5) Avoid anti-inflammatories since they can slow down bone healing

6) Ice Pack 10 minutes twice daily, and contrast baths once daily to reduce inflammation

7) Due to the gap, seek approval for Exogen Bone stimulator

8) Have patient talk to a surgeon to find out what the process of fixing if the above does not work (well informed)

9) Advise on possible future arthritis

10) Only get future X-rays if treatment has plateaued (there are many cases of pain free non healing)


Source of Online Shoe Lifts for Short Leg

My patient Emily has nerve pain in her foot. It took awhile, but we came to realize since she had a short leg, the tilt at the base of her spine could be causing some of her pain. Emily first had xrays to document a 19mm short leg. Then she had insoles placed gradually into the short side up to 10 mm or 3/8th inch. She could really begin to feel a difference in her nerve pain. So she found this online source to place lifts in, and had 10 mm placed into the midsole. Once she had this done, and after a period of adjusting, I began to again add lifts to her short side within the shoe. This whole process has taken us several months. There is no magic rule that we have to correct for the entire 19 mm. She feels the best, and in my gait evaluation, looks the best at 13 mm. She is also doing Lidoderm patches on her foot where the most nerve pain exists, and will be adding Neuro Eze three times per day.

Possible Psoriasis Unusual Presentation

Here is the link to Web MD and all of the treatments for psoriasis.

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Sunday, April 1, 2012

Hallux Rigidus: Patient with Recent Surgery

Dr. Blake, I have had this condition for over 15 years.

 I started with orthotics and limited high heel use,

 then tried anti inflammatory meds, 

then no heels and limited activity based on irritation.

 I have also had acupuncture and cold laser with a 

chiropractor-both very effective. This whole time

 i have Taken glucosomine chondroitin as well because

 i figured it couldn't hurt. I'm now 42 and just broke down

 and had surgery, but just to clean up the joint.

 My podiatrist was pleased with the surgery and said

 I had one small spot without cartilage, but for the most part

 it cleaned up nicely. It has been 8 days and I am

 feeling like my recovery is going well.

 I found your website because I was looking for

 some exercises I can do to help with the recovery.

 My doctor was going to give me some when

 I get the stitches out this week, but I

 would love to have your opinion as well. I really want

 to get back into walking, running and playing tennis.

 I really like my doctor(after having seen several

 doctors over the years) and feel this was the

 right time for surgery (especially after

 reading your blogs!) before I was limited to

 joint replacement or fusion. However he is

 not requiring physical therapy, just exercises to

 do on my own. Should I see a physical therapist 

after my surgery? Thanks so much for putting

 this information out there!

Sesamoiditis: Great Advice from a Physical Therapist

Dear DR. Blake, I read your online article and it helped tremendously.

 This is what I have done to heal my sesamoditis.
 Thank You for sharing your knowledge.
 Sesamoditis WILL go away. This is what you MUST DO: I am Physical Therapist
 and very athletic person. I had sesamoditis for myself and I want to
 share my knowledge to help you. The pain was completely gone within 3 weeks.

 1. REST REST REST. If you are runner, dancer... take some time off and allow 
healing process.

 2. ICE MASSAGE (not ice pack). Use an ice cube to
 massage your foot for 10-15 minutes daily (before sleep).
 3. BUY/WEAR flat and stiff bottom shoes.
 Best are tennis and cross training shoes.
 ( NB, Nike).

 4. BUY/WEAR metatarsal sleeve to unweighted big toe area.
 I recommend: FlexaMed-Metatarsal-Sleeve.
 Walking will not be the most comfortable
 but your foot will adjust to it.
 Most important : you will walk !

 5. TAPE YOUR BIG TOE to immobilize joint, daily.

 6. Take CALCIUM supplements to allow faster bone healing.

 7. BUY BIOFREEZE pain reliever and massage your foot
 with it before sleep.

8. STRETCH: Gatrocenemius muscle 3 x 30 sec daily.

 9. BALANCE exercises ( as soon as you can do it)
 EX: Stand on one leg for 30 sec x 3. Also you can add: Hamstring, 
Quads stretch and Peronals muscle strengthening with thera- bend.
 (resist foot pointing down). Daily Active ROM : toes up and down
 and circles 
(do not go beyond pain tolerance). Also, you can add inserts with
 arch support to your shoes. It does help. 

Within 3 weeks you will be able to go back to your activities pain free.
 Remember REST, REST, REST. I hope this helps.