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Friday, February 28, 2014

Friday's Patient Problem of the Week: Toe Injury (Should they be checked???)

It is common knowledge, or better said "myth", that toe injuries do not have to be x-rayed because there is nothing to do anyway. It is a common misconception, and many times the wrong misconception. When I see a toe injury, I do not always take an x-ray, even when the patient feels it may be broken. I check toe position, where the pain is, joint movement, and swelling/black and blue patterns. A podiatrist typically is skilled in recognizing with that sixth sense if an x-ray is needed. In this case, the patient felt she probably did not need an x-ray, but left me a phone message to run it by me. I recommended an x-ray due to the discomfort she was having and left the order at our front desk. After she got the x-ray (I work within a hospital), she emailed me and I checked to find the first 3 images noting a dislocated 5th toe. In this type of medial dislocation, if she had tried the standard buddy taping to the fourth toe, she would have dislocated the toe further. The first 3 views below are done at the same time, only from different angles. She was immediately sent to our podiatric surgeon, Dr Remy Ardizzone, who placed the toe in the right place under local anesthesia in the office (called "closed reduction"). This is well documented in the last 2 images. Good Job!!!

Thursday, February 27, 2014

Thursday's Biomechanics of the Week: Orthotic Devices: A Cure for many Problems

I am honored and humbled by the comments below. I love biomechanics. I thank this nice patient from sending in this compliment. Orthotic devices can do so much to help patients. I make my own orthotic devices, not only because I love that work, but I love to experiment. I love to see the process from start to finish-- from taking the impression cast to dispensing the devices. 

Dear Dr Blake: Recently I saw a podiatrist at Kaiser to just learn more about what their podiatry department has to offer. The podiatrist I saw told me that he followed your career and that you are the best orthotics person in the country.  We, your other followers, already know that of course!  But this is also to say again thank you for your dedication and helpfulness to your patients.
I am trying to work with my flexible hammer toes.  Will come in for visit as my old orthotics are getting worn out. Thanks.


Dr Blake's comment:

     Foot orthotic devices can be used for many functions. It is the attempt to understand what you are trying to accomplish, and what the limitations are in the devices you prescribe, that experimentation is often needed. Health care providers that prescribe and dispense orthotic devices are trained to know how to work with these inserts. The common checklist that is worked off of in prescribing is:

  • Amount of Pronation Control Needed
  • Amount of Supination Control Needed
  • Amount of Motion Needed
  • Amount of Shock Absorption Needed
  • Amount of Limb Length Shortness Correction Needed
  • Amount of Metatarsal Arch Needed
  • Amount of Flexibility/Rigidity Needed
  • Amount of Foot vs Leg/Knee Correction Needed
This is a terribly complex equation at times. And, at times, each foot need very different support. And, at times, corrections are contradictory (i e. the need of flexibility and rigidity at the same time for different reasons). As I exam my patients, it is often after I give them an initial orthotic device, and get their feedback, that it is apparent  that major changes are needed. What I thought was important initially was incorrect or just must take the back burner to a more important issue. This is the Art of Biomechanics that I live in, and love. 

When you are making orthotic devices, you need to know how to work with your lab to have 3 or 4 levels of change in each of the categories above. That will make you successful with 95% of your patients needs. For Example, your initial "standard" orthotic device has a certain amount of shock absorption qualities. But, could you improve on that shock absorption in 3 more layers of complexity: more motion, more cushion, more support. Yes, the better the foot contacts the orthotic device, the better the plastic absorbs the stress away from the body and on to the device. The vertical ground reactive force gets transferred less up the leg and more out the end of the shoe. We can go on and on about all the modifications to biomechanical support that can be made to improve someone quality of life. I hope this gets everyone thinking in these terms. "We are truly limited by our Imagination in this field", and sometimes I have a good imagination.

Wednesday, February 26, 2014

Wednesday's Article of the Week: Cipro and Tendon Injuries

Every cold season I have one patient at least who tears a tendon in their foot or ankle while on, or just coming off, Cipro. I tell my patients to be very conservative in their workouts up to 2 weeks after they have stopped the antibiotics.

Tuesday, February 25, 2014

Tuesday's Question of the Week: How to deal with Metatarsal Pain

Hey Dr. Blake!  Hope 2014 has been good for you so far.

So I was doing really well with my recovery (after another foot injury),  but I may have tried to do too much too soon. I have a new issue with my RIGHT foot (first injury was on this foot) and something going on with my LEFT foot now too! I attached a pics (RIGHT foot is BLUE marker, LEFT foot is red marker). 

RIGHT: Big X is new pain (the dot is the old, original injury). New pain feels like a sharp electric shock on one particular nerve every time I put pressure on the area (i.e taking a step, pressing on it). It's a tiny bit swollen. I don't feel any pain when there's no pressure on it. It started one day when I took a step. Nothing happened at that moment, no quick move or anything that I would connect to an injury. It was very faint at first. Then as time went on, it felt "stronger."  In the weeks BEFORE I felt it, I was recovering from the first injury (blue dot). I was increasing my walking time/distance, experimenting with shoes other than sneakers (some high heels) around the house. The foot felt great, but weak. Then this new "zinging" little pain thing!! I tried to ignore it but I can't, hurts too much. After much experimentation and remodels, I have rigged a gel insert to support the area all around the Blue X. Problem is, my old injury (blue dot) is starting to hurt again, maybe from wearing this new rigged padding. I attached a pic of the rigged padding. 
Dr Blake's comment: yes, you must have the original area "dot" within the hole also.

On my LEFT foot: attached pic to show you where it's bothering me. It feels sore. And very rarely, a few "zings" too. I've been wearing a pad for this too. Pic attached. This came on very slowly, then one day just felt too sore to walk on it without padding. My left foot took a beating throughout the whole time my right foot was useless (from beginning August until October) 

The pain of all this new stuff in NOTHING compared to the first injury. However, I still can't walk properly so I can't ignore it. I had been doing the ankle and foot rehab at least 3x per week until last week when my right foot hurt more than normal. I would like to know what you think. I may be in your area of Cali soon and if I am, I hope to come see you. Until then, we have email and attachments :) 
Dr Blake's comment: When making an accommodation or float for the bottom of the foot, always go with the horseshoe concept like with right foot. The hole technique can make the swelling much worse as the swelling does into the hole and has no room to escape. 


Hey Sam, Definitely try to get the pad on the right to float the small blue dot also. Definitely sounds like you pinched a nerve, and try to ice 3 times daily for 10 minutes for the next 10 days. Try to use the same horseshoe pattern on the left, the donut holes can make the swelling worse since the swelling is trapped in the hole. Rich

Monday, February 24, 2014

Monday's Images of the Week: AFO (Ankle Foot Orthosis) for Posterior Tibial Tendon Dysfunction

This is one of the best AFOs (ankle foot orthoses) I have seen for posterior tibial tendon dysfunction. It is hinged so it allows for some or no ankle motion (basted on how much pain!). The leg part is placed in a varus position for better pronation control. The plastic is wrapped around the arch for superb support. I looked high and high for a manufacturer and could not find one. If you are suffering from PTTD, show this to the brace guy/gal and see if they can do something like this. The foot bed part is pretty standard. 

This following link gives you an idea of the brace world, but does not show this exact brace. Rich

Sunday, February 23, 2014

Sunday's Video of the Week: Peripheral Neuropathy

If you are beginning to get symptoms of peripheral neuropathy, this is a wonderful video on the common causes that must be investigated. Peripheral neuropathy involves the feet and/or hands initially, and then spread upwards. These video discusses the diligent evaluation of the common causes of this problem. Many feel it is a sensitivity of the nervous system to common environmental excesses that irritate the nerves. Peripheral neuropathy will present 1/3rd of the time as pain alone, 1/3rd of the time as only numbness, and the remaining 1/3rd of the time a mixture of pain and numbness.

The video reviews common peripheral nerve irritants as areas to investigate and reverse. These irritants include:
 deficiency in B12 vitamin,
 deficiency in folic acid and thyamine,
 chemical exposures,
 high glucose levels,
 chronic infections (including lyme disease),
  alcohol toxicity (more than 1 drink per day??), and
  mechanical causes at the foot/ankle/knee/hip/low back.
So many times it is a combination of low grade irritants that lead to symptoms. This is the challenge of trying to diagnosis. But as a patient, these are some of the secrets to easing/treating. 

Saturday, February 22, 2014

Saturday's Exercise of the Week: Soleus Roll for Achilles Tendinitis

Achilles Tendon Injuries are very common. This is a wonderful video to help work out the muscle tension in the soleus muscle just above the tendon itself. There are many versions with massage sticks, foam rollers, and tennis balls, so please feel free to experiment. I personally like the wine bottle with warm water roll to get heat into the tissues while you massage, then an ice pack for 10 minutes after if you have mucho inflammatio!! Have no idea what I just said. Good luck. Dr Rich Blake

Friday, February 21, 2014

Friday's Patient Problem of the Week: Peripheral Neuropathy

Hi Doctor Blake,

My name is Sophie.  I live in Chicago, IL.  I am 30 years old.  And when I turned about 25, I began seeing symptoms of peripheral neuropathy.  I have burning, numbness, tingling, and pins in needles in my feet and legs.  Decreased sensation to temperature in my legs.  It's all of an unknown cause.  So it's very scary.  I do not have diabetes and have been tested for dozens of other illnesses, all of which come back with clean test results.  Which is great.  I have read a lot of your blog.  I need a doctor of your caliber to see on a regular basis.  Do you know of anyone in the Chicago-area that operates their practice like you do?  It seems so important to you to look at the big picture, spend LOTS of time listening and advocating for your patients.
Just curious if you had a referral in my area.  I'll continue to research, read your blog and stay hopeful!
Dr Blake's comment: I am sure someone on this member list of the American Academy of Podiatric Sports Medicine shares my philosophy. Here is the link. Unfortunately, I do not know someone directly. You could also call the William Scholl College of Podiatric Medicine in Chicago and see whom specializes in peripheral neuropathy.

Many thanks,
Sophie (name changed)

Sophie, I am attaching various links from my blog on aspects on this complex problem and I am so sorry my response to your email has been so slow. Read through these posts and see if anything makes sense, and send me more of your thoughts also. The basics that you need to do on a daily basis that are listed below are:

  1. Neural Flossing three times a day
  2. Apply Neuro Eze or similiar topical 4 times daily
  3. Do pelvic/core strengthening to stabilize your lower spine AMAP
  4. Take daily supplements that help with nerve sensitivity
  5. Make sure your bone density is great.
  6. Perform weight bearing exercise daily to stimulate the nervous system
  7. Make sure you are not Gluten intolerant or another cause of nerve inflammation
  8. Experiment with mediation, accupuncture, biofeedback, chiropractic which all have success stories with peripheral neuropathy

Thursday, February 20, 2014

Thursday's Orthotic Discussion of the Week: Why I love my oldie moldies!!!

This wonderful young lady has very severe pain around her big toe joint. My initial orthotic devices just did not give her enough support. So, back to the lab as they say. You can se how I marked to dramatically increase the support under the medial arch and first metatarsal. 

Here I also set the metatarsal arch longer and higher. The goal is to increase the pressure on the 2nd and 3rd metatarsals and off weight the first metatarsal/bunion area.

Another view of the opposite foot where the markings tell the lab to remove more arch plaster, thus making an orthotic device with a higher medial arch. 

An average view of my lab with several pairs of Inverted Orthotics being made. 

Orthotic devices are made from negative casts of plaster of paris. Then, these casts are poured to make positive casts. Then, the prescribing health care provider tell the lab how to make the positive cast to correct what is wrong with the patient. This is quite a skill. You can see each of these molds are individually made to uniquely represent a corrected foot. I love my molds that have unlimited possibilities!!!!!!!

Wednesday, February 19, 2014

Wednesday's Article of the Week: Walking Poles Benefits for Hiking

If you are a hiker, consider walking poles to help ease the stress on your spine and lower extremities. My patients have greatly benefited from these, and they greatly reduce the stress on all weight bearing muscles and joints.

This study confirms what hikers have felt, but realize these studies are very hard to do (and some contradict others). RPE stands for Rated Perceived Exertion and HR is Heart Rate.

Tuesday, February 18, 2014

Tuesday's Patient Question of the Week: Mysterious Ankle Pain from an old Ankle Fracture area

Hi Dr. Blake,

I realize this and the last email may have to fall to wayside of priorities of interest for you or patients and understandingly so. I have not received any recent x-rays or mri's to lead to any truly definitive idea of what is going on here with this pain that arose abruptly one morning as a sharp stabbing in the frontward area of my left (outside) ankle. The same ankle that was fractured roughly 18 years ago which was found out by an MRI about 12 years after the accident. The MRI did show several bits of bone fragment floating around in the vicinity of my ankle.
Dr Blake's comment: Definitely old bad ankle sprains with or without fractures can resurface 15-20 years later. The thought is that the original injury caused some small micro trauma to the cartilage which slowly degenerates leading to arthritic pain. 

The ankle has as I explained been tempermental with occasional swelling front and back of it and often if doing a lot of outward toe pointing as in pilates or wearing a boot or shoe that crosses the area it will become irritated and sometime "catch" with a sharp pain to follow that usually mellows out rather quickly.
Dr Blake's comment: Catching in the ankle can be a sign of a loose bone fragment (called a loose body) that is moving and occasionally getting in the way. This may require surgery to remove. It can also be a sign of some ankle weakness and overall wobble, so that the joint line (synovium) occasionally gets caught between two bones. This soft tissue impingement requires icing, some PT, and a lot of strengthening. The muscles/tendon must stabilize the joint which may have compromised ligaments. Prolotherapy, sugar water injections, into the ankle ligaments to irritate and scar is being used more in an attempt to avoid surgery. 

 Well that morning about two weeks ago I awoke with that catched feeling and stood up to walk it off and to no avail. It seemed almost stuck. No moving it side to side but point toe straight out or up seemed okay. It hurt at rest as well. And swelled. The doctor did no xray and dismissed as a sprain. I applied the RICE method, arnica, epsoms, and braced it a bit. After a week it started to work it self out. More range of motion each day. Then  a few days ago a little "pop" occurred while sitting on the sofa and adjusting in a pulled up leg position and voila! Any and all pain was dismissed?
Dr Blake's comment: This is classic for a bone fragment. It can be mainly cartilage so unfortunately may not show up in any test. That being said, xrays, CT scans, and MRIs may be taken to get more information. The catching can actually be from the ankle joint, or the smaller subtalar joint beyond, so have no surgical intervention unless the two joints are looked at thoroughly. If you have another episode that again limits side to side motion, try a diagnostic local anesthetic block into the subtalar joint to see if it is involved. 

I find this interesting is all and unique but perhaps it's easily explained by someone like yourself who is so steeped in this practice of feet! ;) I've been unable to pinpoint anything as the real cause other than walking in poor footwear for too long the day before the pain began and perhaps that is all the answer I need. Proper footwear!

Thanks for your ear ;)

Dr Blake's comment: I hope my comments are helpful to you. It is important that you begin to strengthen your ankle on a daily basis so by next year you have tripled the strength in your ankle. The video below is the one to start with. Good luck and thanks for your patience with my response. Rich

Monday, February 17, 2014

Monday's Image of the Week: Perfect Compressive Support Hose: Thigh High and Open Toe

Here is my ideal compression hose for foot and ankle swelling. They go above the knee and are open toed. This avoids so many problems with toenails. Also, below the knee compression hose actually cut off circulation in my estimate over 50% of the time. If you are wearing below knee support hose, check to make sure the upper end is not leaving an indent in your skin!!! This is a sign that they are actually causing a swelling problem, not helping one!!

Sunday, February 16, 2014

Sunday's Video of the Week on Gait Evaluation: The Key to the Movement Analysis of the Human Body

Key Points Presented:

  1. Walking is done with complete symmetry and reproducible timing.
  2. Analysis of Gait is important in treating all spine and lower extremity problems.
  3. Before we know how to recognize what is a problem in gait, we must know what is considered normal gait. 
  4. A normal gait cycle is from Heel Strike of one Foot to the next Heel Strike of the same foot.
  5. The normal gait cycle is divided into the Stance and Swing Phases.
  6. The Stance Phase (foot is on ground) is 60% of a normal step, and the Swing Phase (foot off the ground) occupies the remaining 40%. 
  7. Double Stance or Double Support is when both feet are on the ground at the same time.
  8. In Running, there is no double support phase. When both feet are off the ground, it is called the Double Float phase.
  9. The Critical Incidents in the Stance Phase to watch are Heel Strike, Foot Flat, Heel Off, and Toe Off.
  10. The Periods of the Stance Phase of Gait are Heel Strike Period (heel strike to foot flat), Midstance Period (foot flat to heel off), and the Push Off Phase (heel off to toe off). 
  11. The Critical Incidents in the Swing Phases are Toe Off, Toe Clearance, and Heel Strike.
  12. The Periods of the Swing Phase of Gait are Acceleration or Initial Swing (toe off to toe clearance), Mid Swing (toe clearance to heel decent), and Deceleration (heel decent to heel strike). 
  13. Heel Strike: Knee very straight with stabilization contraction of the hamstrings just prior, and contraction of the quadriceps just following (to avoid falling forward). 
  14. Midstance: From foot flat to heel off, the two limbs are vertical and passing each other.
  15. My Mantra in Gait Analysis: Heel Off of one foot should occur just prior to heel contact of the opposite foot.
  16. Just prior to toe off in the Push Off Phase, the iliopsoas muscle contracts flex the hip. This leads to knee flexion which allows the foot to clear the ground.
  17. During this Push Off Phase, the foot dorsiflexors are contracting to have the toes clear the ground.
  18. Midswing is where the swing leg is passing, and going in front off, the support leg.
  19. Deceleration of the Swing Leg to slow it down for Heel Strike is caused by Hamstring and Glut contractions.
  20. Other Components of Gait to observe that are important are: Pelvic Tilt, Pelvic Rotation, Lateral Shift, Width of Base, Stride Length, and Step Length.
  21. Pelvic Tilt, Pelvic Rotation, and Lateral Shift all help to conserve energy by accomplishing a smooth motion. 
  22. The Width of Base is normally 2 to 4 inches in double support.
  23. The Stride Length is the length from heel strike of one foot to heel strike of the same foot.
  24. The Step Length is the length from heel strike of one foot to heel strike of the opposite foot.
  25. Normal Gait: Stride and Step Lengths of both feet are equal.
  26. Abnormal Gait is also called a Limp and has many causes. 
  27. During the stance phase of gait, pain, muscle weakness, and joint abnormalities produce there many effects causing abnormal gait patterns.
  28. Antalgic Gait due to pain shortens the support phase and increases the swing phase of that extremity.
  29. Quadriceps Weakness shows up at Heel Strike with knees bent not straight.
  30. Foot Flat Gait is where following heel strike the foot dorsiflexors are weak and allow the foot to slap hard down against the ground. 
  31. Back Knee Gait is hyper-extension of the knee during midstance due to limited ankle dorsifexion (fixed or tight muscles called Equinus) or weakness in the quadriceps.
  32. Abductory Lurch or Gluteus Medius Gait (trunk 1 inch shift to one side) where the weight shifts excessively over the painful hip or away from the weakness. This is seen predominantly by trunk lean.
  33. Trendelenberg Gait used when no pain involved and the weight shits to one side due to a collapse downward of the hip during swing phase. This is seen predominantly by hip sway.
  34. Gluteus Maximus Gait is seen by posterior thrust of the trunk due to glut max weakness.
  35. Flat Foot or Calcaneal Gait where the foot is rigid and no toe off is seen. The foot is just lifted off the ground. This is also seen in Calf Muscle Weakness that limits proper push off.
  36. Swing Phase Abnormalities are Steppage Gait or Drop Foot Gait. With weak ankle dorsiflexors, the hip flexors are recruited to lift the foot off the ground with abnormal hip flexion.
  37. Hip Hike Gait with weak ankle dorsiflexors the hip is raised to allow toe clearance. 
  38. Circumduction Gait like Hip Hike Gait allows the toes to clear the floor by throwing the leg out to the side.
  39. Abnormal Pelvic Rotation due to Hip Flexor Weakness to throw the pelvis forward when the hip flexors can not achieve that forward progression.
  40. Wide Based Gait to add stability.

Friday, February 14, 2014

Friday's Patient Problem of the Week: Ankle Swelling from Psoriatic Arthritis

This was a comment on my You Tube Channel. 
Dear Dr Blake:
I have a small circle of swelling that my doc said was over the posterior tibial tendon right in the posterior arch towards the edge of my foot. He said it doesn't feel like a fibroma and my MRI was normal, but three months later, I still have it, same size. Went to a second doctor for a second opinion and he said it was edema. I've had it for three months now. MRI was apparently normal and so was my Xray. I'm doing electrical stim and physical therapy for flexor hallucis longus tendonitis and peroneal tendonitis. I also just found out I have psoriatic arthritis. They're starting me on methotrexate and prednisone soon.

 Crazy how these autoimmune problems like to go after my feet! Anyways, do you know how to break up some of the scar tissue or swelling or whatever it is in that area?
Dr Blake's comment: Any inflammation of the ankle joint tends to collect fluid on either side in the back or front (depends where the loosest part of the ankle joint sac is). I am glad the MRI showed no damage, and I share your frustration with the swelling. Your therapist would be the best at telling where to massage and not irritate the nerves in the area. However to work on the swelling, see if the therapist will give you a version of Tubigrip. See the video below on RICE for ankle sprains and try to develop some easy home program. 

 Are there any gels I can put on it? 

Dr Blake's comment: I love ice packs and contrast bathing the best to do on some regular basis that fits into your routine. The most common prescribed anti-inflammatory gel is 1% Voltaren Gel that your doctor must authorize. Even though it is topical, you do get drugs into your system and that may not be a good idea if you are taking other drugs. One doctor should be in charge of all your drugs, and one pharmacist involved with all your drugs. 

I'm surprised neither of my doctors had any advice on this as it's killing me every time I put on a shoe because it rubs on the little swollen area. With peroneal tendon orthotics, it's really hard to find shoes that don't either rub the peroneal tendons or this little bump the wrong way other than crocs, which are tough to go to classes in the winter in! 
Dr Blake's comment: This is different since you do have pain with pressure. Silipos sells various gel sleeves that may be a great help to you in taking the pressure off the shoe.

Also, do you know if methotrexate helps with tendonitis pain at all? I don't know a whole lot about all these meds or conditions because I was just diagnosed at 25 friggin years of age, but I'm having a hard time balancing a doc who's very optimistic about the tendonitis/arthritis treatment with an ortho guy who keeps telling me sometimes tendonitis just "never gets better." Scary thought, especially since even walking is really painful right now! any help or advice appreciated!
Dr Blake's comment: Please see the link below. It describes the positive affect of methotrexate on tendinitis.

Also, all of my patients with psoriatic arthritis seem to do just fine. You have to manage the disease well, and as early as possible, and expect a long life. Here is one link that seems to back that up.

Thursday, February 13, 2014

Thursday's Biomechanics Discussion of the Week: Possible Left Posterior Tibial Tendon Rupture

Boy, there are many hours of discussion here but I will stick to the obvious. This video shows a collapsed left arch probably following a posterior tibial tendon rupture. The posterior tibial tendon can no longer support the arch, so there she goes. Even though the patient is shown demonstrating the ability to do a double toe raise, I seriously doubt the patient could do a single leg toe raise. This helps in the diagnosis of posterior tibial rupture. The pronation force is so great, I would go right to a 35 degree inverted orthotic device on the left side only, and a more normal device on the right. 35 degrees is my highest starting point. 

Here an Inverted Orthotic Positive Device is being made for the right side. See how the high point of the arch under the first cuneiform, not the first metatarsal base. This is crucial at not blocking first ray range of motion.

This is opposite of our video where the left is flatter. Here is a pair of orthotic devices designed to correct more for the right side with an Inverted Orthotic, over the more traditional Root Balanced Technique on the left. 

Wednesday, February 12, 2014

Wednesday's Article of the Week: Exercise Decreases Nerve Pain

I have many patients with nerve pain. They must honor the pain at times and push through the pain at other times. This article discusses the positive role of exercise in reducing nerve pain. Exercise is crucial for health, and especially true when a patient is suffering. It is important for the medical profession to continue to work towards restoring function with exercise, while balancing the tightrope of pain management. 

Tuesday, February 11, 2014

Tuesday's Question of the Week: Hallux Rigidus

Hi, Dr. Blake, 
It is almost a year later since I first wrote you, and I wanted to update you.  I went to a podiatrist who said I had to have surgery and gave me a cortizone shot which did absolutely nothing. I then managed to get in to see a podiatrist whom works with our local celebrity Orthopedist in Birmingham, Alabama. He took xrays (nobody has even suggested taking an MRI) and pronounced surgery the only option... total fusion. I wouldn't be able to do anything for 11 weeks....WHAAA??? It's my right foot so (unless I purchase a British car) no driving. I can't remember how much of the 11 weeks I'd be almost completely immobile because the whole conversation sent my mind reeling.
Dr Blake's comment: Typically, you are totally off your foot 10-12 weeks with a fusion of any joint, since it takes time for the fusion to take. You can use Roll ABouts and Crutches, but no weight bearing. Then, you start the 3 months of gradual to full weight weightbearing with some physical therapy. So, 6 months after surgery, you typically are close to where you were before only with no pain in the big toe joint. 

I have tried contrasting baths which has offered lessening of pain somewhat, but not much. I am definitely pronating and the old hips and knees are sure to suffer. I have also gained at least 10 pounds in a year due to lack of movement. I will definitely increase my Vitamin D intake and head out into the sunshine, but wondered what else I can do.
a) Do you know a physician/podiatrist/witch doctor in this area that won't immediately head for the default setting of fusion?
Dr Blake's comment: Try going to the AAPSM website and look for podiatrists in your area. Typically these are podiatrists who are sports minded and less surgically minded. At least a starting point!!

b) Where can I get the best (and hopefully not too $$$$) orthotics? 
Dr Blake's comment: AliedOSI labs in Indianapolis, Indiana. They are a big national orthotic lab. Talk Kathy Dubois and mention my name and your need to locate someone near you. I think this is a good starting point. She is wonderful!!

Kathy Dubois
Territory Consultant

c) Is there otc pain med (gel) that would help? (what in the world is Blumjk..must I go to Norway to get it?) 
Dr Blake's comment: See if you can get Voltaren 1% Gel prescribed which you apply 3 times a day, along with Icing 10 minutes 2 times per day. There are many compounding creams/lotions that may help more, but you have to experiment and they tend to be costly. 
d) Should and where can I order a boot to calm ornery toe joint down?
Dr Blake's comment: Definitely, these boots need to be part of your wardrobe when the joint gets flared up. As soon as it does, go to the boot to calm things down. Wear 3 days longer than you think you need to. My current favorite is from Ovation Medical.

The idea of a fusion sounds insane and having read a lot from your blog; it sounds like the surgery is just the BEGINNING of more problems.
Dr Blake's comment: I am not as sour on big toe joint fusions as I use to be, but the patient must be very carefully selected and informed on all the choices/possibilities. There is no going back, so that bothers me. It completely, and suddenly, eliminates all big toe joint ROM and that bothers me. It is the sudden loss that I find the body has a hard time dealing with, not the gradual loss as you naturally go from Hallux Limitus to Hallux Rigidus. That being said, we are adaptable creatures. We can do this, but it can be a great challenge. I have never seen a study, although it probably exists, to look at the common body compensations and resultant problems after big toe joint fusion. Fuse if it must be fused, but make sure every i is dotted and t crossed before making that decision. 

The last doc said I have only 10% movement in my toe (and only 60% in my left foot...EEGAD, et tu, Brute?!?!) 
Dr Blake's comment: I just love you and your humor. Good for you, because you have to be able to laugh at the situation, yourself, and anything else that tickles your fancy!! If you have only 10%, or 6-8 degrees, fusing the toe is less traumatic to your body than if you had 30 or 40 degrees. 

The pain is obviously pretty severe because coming from a physician's family, we, of course, never ever seek medical advice unless we are at death's door. 
Dr Blake's comment: Amen!!! 

From the first orthopedic visit over three years ago, where the doc said take Moebic and then return for surgery when I can no longer stand it (NO mention of boot, orthotics, otc gels...said there was nothing I could do.) ,to the podiatrist who loves cortizone and surgery to the Sports Med guy who insists on total fusion; I'd say I wish I had sought help earlier, but it looks like everyone would have opted for a "wait and see...and suffer" approach anyway.

I do not want this surgery, Dr. Blake. If there is anyone in the Alabama or Georgia area (how bout the entire Southeast) you could recommend, I would gladly limp over.
Dr Blake's comment: Please look up Drs Perry Julian and Edward Lopez. Let me know what they say. Good Luck. Rich

Thank you so much for this blog. It's giving people hope and probably years of surgery/pain free feet!

Jane (name changed)

Monday, February 10, 2014

Monday's Image of the Week: Wear Pattern of Shoe Insert

Have you ever seen anything this strange? When I started having forefoot pain I took out an old pair of insoles and saw this. My pain is actually centered right at the spot on my right foot where the wear spot is at the base of the 2nd metatarsal. It just doesn't seem possible to have that right foot pattern.
Sandi (name changed)

Dr Blake's comment:

Hey Sandi,

 You are very centered on both feet with equal medial and lateral wear. When you are centered, which is correct biomechanics for pushoff, your weight goes through the 2nd metatarsal. You definitely have a greater pushoff on the right than the left, so more force is being exerted at the toes. You see this is in right handed patients doing sports that emphasize lateral movements (like tennis or basketball). Try to make an accommodation with old inserts to float the 2nd metatarsal as seen in some of my videos. Ice twice daily for 10 minutes also. Rich

PS. The greater pressure on the right, even though considered normal pattern of weight distribution, could indicate that one leg is longer than the other, but that could be mindless wondering!!

Sunday, February 9, 2014

Sunday's Video of the Week: Piriformis Syndrome Stretches combined with Neural Flossing

Piriformis syndrome is quite common in the athletes our Sports Center treat. I have another few posts on this syndrome. Since the piriformis muscle/tendon is an external rotator of the hip, and since excessive foot pronation can cause excessive internal rotation of the hip, podiatrists are called on to design orthotic devices to correct that. If the hip internally rotates too much, the external hip rotators must overwork to stabilize the hip, and the piriformis may strain, swelling, tighten and irritate the sciatic nerve. Here is a wonderful video on combining piriformis stretching with neural flossing (see my other posts on neural flossing). Do these gently at first to see if they have any negative reaction. Or, review with your physical therapist on some modification that is tailored to you. But, sufferers of piriformis syndrome will be helped with some version of these wonderful exercises. Good luck! As you can tell from another post on neural flossing, I personally prefer spine neutral stretches with the patient laying on the back.

Also check out this incredible video about the San Francisco Fog!!

Saturday, February 8, 2014

Saturday's Exercise of the Week: Hamstring Stretching of both the Lower Part and the Upper Part

"I wish I had a dollar" as the old saying goes "for everytime a patient with hamstring injury is doing stretching, but does not know the difference between upper and lower hamstring stretching". This is especially important when the hamstring injury is in the upper part by the buttock. 

Friday, February 7, 2014

Friday's Patient Problem of the Week: Fractured Tibial Sesamoid: Successful early progress

Hi Dr. Blake,
I had contacted you back in May or June for some advice regarding a fractured left tibial sesamoid. Following your advice, I got an MRI, which ruled out necrosis (yay!) so I continued on with conservative treatments. I have been using a bone growth stimulator nightly for about 8 months.  I was in a removable boot from March to August and then went to rocker sole shoes with an orthopedic insert. I did PT to strengthen my ankle and foot after coming out of the boot and have recently started to work on your walk to run program. I'm up to 7 minutes walking/3 minutes running x 3, and while it's taking me about twice as long at each level, I am making progress. I got a follow up MRI this week and it showed no more swelling around the bone and bony bridging of the fracture.

So, I'm just writing to report a case of going the conservative (extremely patient) route working. It's been tough, but it's worth it to me to keep the bone and hopefully one day be back to full activity without pain.

Thanks so much for your advice!

Dr Blake's comment: You are welcome. I am so happy for you. Please continue to ice for 10 minutes 2 times a day, and continue the bone stimulator for 2 months longer than you think you need to. Glad the Walk/Run Program is safely returning you to activity!!!

Thursday, February 6, 2014

Thursday's Orthotic Discussion of the Week: First Toe Stability aid with Budin Splints

I love Budin Splints to stabilize the 2nd metatarsal phalangeal joint. In this images, I am failing at my goal. I need to get the 2nd metatarsal down more, so that when the patient stands, the second acts as a stabilizing force against the first. If the second can be brought down with a tighter fit, or my changing to a double Budin Splint, I will have achieved a more stable first ray. The more stable this medial column, the more stability and comfort there will be in the body.

Wednesday, February 5, 2014

Wednesday's Article of the Week: Peripheral Neuropathy and Gluten Sensitivity

There are so many causes of peripheral neuropathy that podiatrists see affecting the foot. The classic causes are diabetes, osteoporosis, alcohol, Vitamin B deficiencies, but we all know that there are many other causes. This article abstract documents the potential relationship of gluten sensitivity to peripheral neuropathy. Gluten is in wheat. It makes sense that anything that increases our overall inflammation could lead to neural inflammation and therefore, peripheral neuropathy. 

Podiatrists finally win the Fashion Game: Nothing Else Needs to be said!!!!!!

Does Dr Blake have his pulse on fashion or what!!!!!!!!

Tuesday, February 4, 2014

Tuesday's Question of the Week: What % of Alcohol in the Shots for Morton's Neuromas

Dr. Blake,
Thanks, what do you think of the alcohol injections for Morton's Neuromas? Do they work?

Sam (name changed)

Dr. Blake (this sent one month later when I did not respond), 
I am looking to try the alcohol sclerosing for my MN. It will be a 0.25ml ultrasound guided injection with 4% alcohol. The podiatrist is looking to do 5-7 shots at 2 weeks apart. 

What is your take on the alcohol shots and are there any side effects or concerns?

Thanks again Sam

Dr Blake's response:

Sam, I typically try alcohol shots only after failure with the cortisone shots, orthotics, daily icing, etc. I like to get an MRI before doing the shots if possible. If the MRI shows a large neuroma, I only get 30% or less success with the alcohol shots. When you are considering the alcohol shots, you have to consider that you may need up to 3 sets of 5 shots. It is alot of shots. A back specialist should also be ruling out referred pain from the back, neck, or peripheral neuropathy. Rich

Dr. Blake,

Thanks for the information. I think my podiatrist in Arizona ordered the 4% solution and wants to start them and space out the shots every 2 weeks with a limit of 7 shots total. Is it necessary to wait 2 weeks between shots? You do them weekly with no adverse results. Why do some wait 2 weeks?

Does the higher alcohol content (6-8%) have better results?


Dr Blake's response: 

Sam, I mix my own, so typically now make 6% for the first series of 5 once per week. Based on the patient's feedback, I have been recently going with the second series of 5 (when needed) to 8%. Have not seen any problems (even post MRI imaging), but the shots are always irritative when given. Try to ice for 20 minutes post shot, and then another time that evening. And based on the article below from London, I am going to increase my percentage higher. But, not sure how much.  Rich

Dr. Blake,

The alcohol solution is on back-order here in Arizona (1-2 month wait). How do you make your own? It's basically diluted alcohol, right?


Dr Blake's response:

Use a 10 ml vial of 0.5% Sensorcaine (or equivalent) without epinephrine and withdraw 0.6 ml and discard. Take a 1 ml vial of denatured alcohol and draw up 0.6 ml. Inject this 0.6 ml back into the 0.5% Sensorcaine for your 6% alcohol soluation. Change amount based on % required. Rich

Monday, February 3, 2014

Monday's Image of the Week: Windowing Kinesiotape to off weight sore points

There are many times I use Kinesiotape or Rocktape to circumferencial wrap the arch area. In this case, the patient was recovering from a 5th metatarsal base fracture. The patient was weaned off of the removable cast and now in orthotic devices and circumferencial wrapping to stabilize the 5th metatarsal base as activity was being increased. The kinesiotape was important for stability but irritative to the sore area due to the pressure. This was resolved by when first putting on the tape cutting a window in the tape even before the backing was removed. Then apply the windowed area over the sore spot first before applying it to the rest of the arch area. In this way, you can have your wrap for stability without irritating the underlying area. 

Sunday, February 2, 2014

Sunday's Video of the Week: Foot Problems from Cervical Spine Myelopathy (Neck)

I am struggling with a patient who has nerve problems in her foot. Her problems have arisen from many areas, but the clonus (involuntary muscle contractions) with unusual gait disturbances set her apart. She has neck issues also which I assumed were separate from the foot, however I knew they were adding to the overall neural tension in her body. One of her recent consults suggested Cervical Spine Myelopathy as a cause of her foot issues (or at least an aggravating factor). No one has suggested this before to my knowledge. But, it makes sense. She is probably reading this, and we need to have more discussions. Not sure how to prove the foot to neck correlation, but the symptoms and objective findings of clonus/babinski, etc, are all there. If not for my patient, other patients with difficult to diagnosis foot problems, with unusual nerve symptoms, and with neck problems, may have this correlation of foot to neck.