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Saturday, February 28, 2015

Shoe Lacing Tips: Great Source

Turf Toe Injury: Email Advice

Dear Dr. Blake,
Thank you for the wealth of information and encouragement you offer here!  Over the past five weeks and counting since I injured my foot, yours has been the blog I return to in my search for answers and hope that I can get back to my regular daily activities. Above any other online source, your blog has helped me maintain a sense of optimism and the feeling that I’m not alone in managing a catastrophic injury of my foot without the diagnostic team of doctors and physical therapists of a pro athlete.   I am an artist and until five weeks ago I stood at my easel to paint.  I had no idea how much I moved while I work, stepping back and forward and moving around my studio, but I realize now that my job is a physically demanding one, and I need to be on my feet.  I’m also general factotum around here and my husband has graciously picked up all the slack, but this scenario can’t hold forever.    I am a healthy, slim, reasonably fit, mid-forties woman with no underlying health conditions. I eat a primal plus dairy kind of diet with plenty of protein and fish and I supplement with vitamin D and vitamin C.  I’m on no prescription medicines.  I usually recover from injury very quickly and this has me stymied and frustrated.
I’ve tried to condense my saga to main points, but it’s still a long story.
Five and a half weeks ago:  Traumatic initial injury—hyperflexion of great toe as well as second third and fourth toes:  
I was running to answer my front door in sock feet when I tripped over my heavy tripod in its case on the floor in the front hall.  In the moment, my foot caught on the tripod and I hyperflexed my left big toe in particular, but also the second third and fourth toes.  I recovered somewhat and finished this awkward movement on the ball of my foot.  I knew then that I’d done something not good, but I shoved my foot in a winter boot and ran some errands (driving my manual transmission car with newly injured clutch foot) before returning home and taking a look at my now incredibly swollen and painfully bruised foot.
Initial symptoms: blue-black bruising on top of foot at bases and top surfaces of my three middle toes and dorsal side of great toe (which appeared somewhat flattened across the top—my other big toe curves up somewhat jauntily at the final joint).  Black blue bruising on the ball of my foot under the MTP joint.  Extensive swelling, especially of big toe and ball of foot under big toe and at bases of middle toes.
Pain, inability to bear weight on ball of foot—partly from swelling, partly from pain.  The most alarming swelling was the thickness of MTP joint preventing me from getting my foot into even the roomiest of my shoes.
My early attempt at self treatment:
Over the next few days I applied RICE—post-op shoe, compression with tensor bandages, elevation, and ice (applied as gel pack) as much as possible   I hobbled about with my weight on the outside of my left foot and a cane.  I thought this was a minor injury and that I would recover quickly.  I made several ill-advised trips in the car of over an hour wearing winter boots during this period.
Three and a half weeks ago:  First visit to family doctor; x-rays taken:
Two weeks later, with minimal improvement other than a lessening of the bruising and a small diminishment of swelling, I went to my family physician who looked at my foot, without physically manipulating it, and told me to keep doing what I was doing, sent me for an x-ray to rule out a fracture, and assured me that sprains often take several weeks to resolve.  She mentioned an Aircast in passing—in the event that something was broken and I found and purchased one the next day.
X-ray results were negative. 
My new attempts at treatment now in Aircast:
I began your contrast bathing protocol (keeping the contrast a little less contrast-y since I suffer occasional episodes of Raynauds).  I learned spica taping to immobilize my big toe—especially at night, I ordered insoles, dancer’s pads, podiatry felt, etc. and concocted a way to offload the swollen ball of my foot (suspecting some involvement of the sesamoids) and offloading the metatarsals.  It’s been quite an art to get things right, but I can be largely painfree in the boot for about an hour on my feet, after that things get very twingey as the swelling really sets in.  All this time I’d been weight bearing in the boot, climbing the stairs multiple times per day in my big old house with studio on the third floor, but using a cane when necessary.  I tried range of motion exercises especially in the warm water.   I attempted some of your rehabilitation foot exercises, but quickly realized I was not at that stage yet.  Otherwise I kept my foot elevated while sitting and sleeping.  The swelling is still alarming—even first thing in the morning.  Bruising remains under my foot and on my toes.
A week and a half ago: Return to family doctor to request further diagnostics:
After the fourth week of little improvement I returned to my family doctor who, not at all happy with the lack of progress or the swelling, referred me to a sports medicine doctor.
Several Days ago: visit sports medicine doctor; have more x-rays taken:
I visited the sports medicine doctor just after the five week mark.  He and his young resident doctor took a very thorough history and physically examined my foot—pressing on all of my bones to rule out breaks and manipulating my foot and toes, and asking me to move my toes freely and against resistance. The greatest pain was on tops and side of my big toe-especially the outside tip of my big toe and underneath the MTP joint.   I couldn’t  curl my toes at the final joint—neither my big toe, nor my second toe.  I can flex and extend my big toe slightly, but it’s very stiff and causes a little pain.  If I step down hard on the ball of my foot I feel a radiating tingly twinge of pain like an elbow pain.  The two doctors examined the initial x-rays and thought they saw a fracture across the joint of my big toe that might account for the lingering swelling and inability to move my toes.   They sent me for more x-rays at a different lab again both the new doc and the radiologist ruled out a fracture (sesamoids looked fine).  I spoke to the new doctor over the phone and he’s booked me for an ultrasound in about two weeks and an MRI in about four weeks.  In the meantime, he’s asked me to stay in the boot for another two weeks, wearing a tensor bandage and or tape at night and continue with the icing. 
Meanwhile I keep expecting to improve and I don’t improve:
My MTP joint looks huge compared to my other foot.  My foot swells alarmingly after standing for any period.  After showering, I have one purple, puffy foot and one normal, bony pink foot.  I wear Crocs flip flops in the shower and still can’t direct any weight to my big toe joint.  The rest of the time, except while sleeping or sitting with foot elevated, I’m in the boot.  Even after contrast bathing, elevation and gentle ankle motions to try to get rid of the swelling, my toes and foot become swollen, and skin shiny with pressure when I put my foot down again. I have residual bruising underfoot and across my toes  As I write this, I am in a graduated toeless thigh-high compression stocking with my foot slightly elevated, boot off, but the opening seems to hit my big toe at a vulnerable spot, so I’m not sure I’ll continue wearing it.  I am going to try 2.3% Voltaren on the most swollen areas of my foot and toe.
I’ve ordered a pair of Crocs clogs which should have a toe box deep enough to accommodate my giant toe joint when I transition out of the boot.  Other shoe choices will have to wait until I can get out and about.  We’re in a deep freeze with a mountain of snow and walking is not good even for the able bodied.
After all of this, can you give me any additional advice, hope, or questions to ask my sports medicine doctor when I return?
I’ve read your good/bad pain article but remain confused about whether I risk re-injury with range of motion and strengthening exercises.  Should I be attempting toe curls with so little movement possible, or could I make a tear in the ligament/tendon worse?  Can I try standing on one foot while in the boot or is that counterproductive?   Is swelling and bruising at this stage, so long after the initial injury a normal effect of injury?  I will try anything, ask anything, pursue any course to get better.  I’d appreciate any advice or remarks you can offer. 
History: Several years ago, I had a mild case of classic turf toe after hyperextending the same great toe while gardening on soft soil and feeling as though I was walking on a bunched up sock under my toe.  I recovered completely with RICE and buddy taping after about two weeks.  In the intervening time I’ve suffered no residual effects until now. 
Foot architecture:  I have a high arch and a long first metatarsal with Egyptian foot shape. 
Please forgive my long-windedness.
Thank you again for the excellent resource of your blog.
Silvia (name changed)

Dr Blake's response:
     Silvia, thank you so very much for the email, and sorry it took me a long time to answer. You have the classic symptoms of Stage 3 Turf Toe, with complete rupture of one of the main ligaments in your big toe joint (which gives you the constant thickness of the big toe joint, and unending swelling and bruising. The bruising is from repeated partial healing, and then re-tearing of the delicate ligaments). I am glad the x rays are fine, although the MRI may show some bone issues. Can you speed up the MRI so the soft tissue diagnosis can be made sooner? When the tear starts to heal, the tear begins to slowly not look like a tear, only scarring/fibrosis, and the MRI can be read incorrectly. Daily I would wear the boot and spica tape. In the evening, take the tape off so you can freely contrast and massage. The massage is very important to decrease the nerve hypersensitivity which can have a mind of its own. You should be able to have your dancer's padding inside the boot (sorry the image is so blurry).

Get some NeuroEze if you think any hypersensitivity is developing. Since some cases, and you may be one, of Turf Toe Injuries need surgery, the more you do not move it now and let things scar down, the better. 3 months in the boot and spica taping typically is needed, creating that pain free environment which allows 12 hours a day of walking/standing. Your immediate bruising, and the joint signs, and your inability to walk/stand more than 1 plus hours, means you have a serious injury. After the MRI, you can get more odds on the chance of needing or avoiding surgery. I hope this helps you. Rich

PS I am closing with my Top 10 for Hallux Rigidus, which seem to apply other then exercise that move the joint. 

The top 10 initial treatments for Hallux Limitus/Rigidus are:
  1. Create a pain free (0-2 pain level) environment with some form of immobilization and/or protected weight bearing.dreamstime_m_40381369.jpg
  2. 3 times daily use topical anti-inflammatory measures with icing twice and one session of contrast baths (you don’t have to tell anyone about your rubber ducky in in the bath!!). dreamstime_m_34958737.jpg
  3. Learn how to spica tape the big toe joint for times you want to immobilize (see my video at YouTube entitled drblakeshealingsole Spica Taping).spicataping3.jpg
  4. Learn how to make dancer’s pads for any shoe or boot to off weight the big toe joint. One eighth inch adhesive felt can be purchased from for this purpose. Dancer's Pad.jpg
  5. Learn if arch supports are necessary to transfer weight to the arch and middle of your foot. You can try the Red Sole inserts sold online or at stores like REI.Your Sole Inserts.jpg
  6. See if you can get xrays and an MRI to look at the health of the joint internally.
  7. Purchase a carbon graphite plate that can be used in some shoes under the insert to limit the joint motion for some activities.
  8. If you were started in a boot to obtain a pain free environment, purchase an Evenup to keep the spine level and avoid back issues. Removable Boot with Evenup3.jpg
  9. From the day you begin treatment, begin strengthening your feet, and lower extremities. Avoid pain, but this approach will lessen the deconditioning. This can be mean a lot of core work, some cardio on stationary bikes, and specific foot exercises approved by the health care provider (as long as they do not hurt is the general rule).dreamstime_m_40635691.jpg
  10. Use adhesive felt on the top of the foot (typically 2 layers of 1/8th inch or just ¼ inch) from next to the bump at the top of the big toe joint, but not over, in any shoe that it helps take pressure off.Bunion protection.jpg

Patient Response:
Dr. Blake,
My MRI will probably arrive in your mailbox this week. But meanwhile, I have great news. While the MRI has been making its way to you, a random conversation at our local woodworking club (which for some reason attracts many surgeons--they especially like bowl turning on the lathe) led to an appointment with a wonderful, but very busy, foot and ankle orthopedic surgeon, much beloved by patients in our region. He takes the patients other surgeons abandon, saves limbs and gets people back on their feet.
I just got back from my appointment with him at our local fracture clinic where he examined my foot (stealthily while making conversation) finding good movement in my joints (which I hadn't moved in weeks!), and said much the same thing that you've been saying all along: get the foot moving again!  He said (as you did) that the blood pooling, residual swelling, pain and stiffness are largely a result of non-weight bearing and immobilization.  He also said that too many patients are referred on the basis of x-rays. He said "treat the patient, not the x-ray" and said the only time he would consider fusing a joint is if there was a considerable lack of function.  He said even a poorly healed or even non-union fracture of the the small bones of the foot can often pose no significant problem for the patient even when they appear "like corn flakes on the x-ray".  Anyway, all this is to say that he advised me to start remobilizing right away (contrary to the advice of my sports medicine doctor who had asked me to remain non-weight bearing for three more weeks).  The surgeon said prolonging immobilization can cause weakness leading to secondary injuries.  I'm very eager to start rebuilding my leg muscles and foot strength and reclaiming my life.  I sincerely like my sports medicine doctor, but don't know why his advice was so different from yours and the surgeon's.  It's hard to contradict a doctor's advice as a layperson. I wish I hadn't remained non-weight bearing for so long out of fear of delaying the fracture healing.  In any case, I'm looking forward with optimism.

I just purchased a pair of Wolky sandals, a new brand to me.  The model called Jewel has three adjustable velcro straps (which is wonderful for someone with a very high arch like me), a fairly rigid sole with rocker front, and a removable cork foot bed into which I've put my own cobbled- together foot bed with strategic offloading padding. They are far more attractive than typical orthopedic shoes and your other patients might find them very helpful:
It feels wonderful to be transitioning to real shoes again. I believe I will be walking without pain or crutches very soon!
Thank you again for your support and very good advice.  Please feel free to use my case for your blog if you think any part of it will be helpful for others.  Your blog was such a great source of sensible, straightforward practical advice during dark days when was very easy to fall into worst case scenario speculation.  Thanks Dr. Blake!

Saturday, February 21, 2015

Dancer's Pads from Dr Jill Company for sesamoid protection

Dr Jill's Dancers Pad

    One of my sesamoid suffering patients brought Dr Jill's Dancers Pad to my attention. She loves it since it sticks comfortably to the foot and so she can wear in shoes/situations that may not work well with orthotic devices.

Friday, February 20, 2015

Sesamoid Injuries: Questions

This is my answers to a student studying the treatment of sesamoid fractures with my comments in red. 

Thank you so much! Below are some questions:
1. Which method would you recommend for the rehabilitation of the sesamoid bone in the foot? 
     I prefer to treatment conservatively with a removable boot for awhile, then orthotics that can off weight the area. The only other method would be surgery, which may be unnecessary, and I think the last resort. Lack of response to treatment, coupled with MRIs showing bone fragmentation will sway me towards surgery. Any treatment done, if surgery is eventually needed, will help greatly in the rehabilitation (like designing a good off weighting orthotic device). 
2. Why this method? 
     My personality which is conservative, and seeing patients still having bothers after surgery sometimes, knowing that surgery is not always the perfect fix. Any treatment should get the patient to no disability, and conservative treatment can do that the majority of time. 
3. Which method would you say is the worst? Why?
     Neither, because both have their pros and cons. The surgical treatment for a broken sesamoid is technically easy, and gets patients back on the road quicker than stubborn cases of conservative treatment. The con of surgery is that you are potentially removing a vital bone, and surgical complications can lead to some permanent problem. Conservative treatment avoids bone removal (leaving your anatomy intact) and avoids surgical complications. However, conservative therapy may take up to 2 years to complete (generally 6-9 months is normal), which would be difficult in a highly functional athlete, with no complete guarantee that it will not, in the end, require surgery. 
4. What is the most common way of injuring the sesamoid bone in the foot? 
     From the impact of sports
5. Have you ever heard of someone getting arthritis in their big toe from a certain treatment?
     The sesamoid is bottom part of the big toe joint. If the bone is fractured and irregular is can start arthritis forming on the under surface of the first metatarsal. When I x-ray and MRI or CT, I am always checking for signs of that. 
6. If you had to put your patient in orthotic devices, would it be a Morton's extension or a Dancer's pad (apologies if my terminology is off, while researching I realized some doctor's use different names)?
      The six basic designs for sesamoid injuries, which can be used in some combination, or with all of them are:
  1.  Enough arch support or varus wedging to shift the weight back into the arch and over to the 2nd and 3rd metatarsals as you move through your foot.
  2. Metatarsal arch support to shift weight laterally (towards the outside of the foot).
  3. Dancer's pads (aka Reverse Mortons) to shift the weight laterally as the weight goes onto the metatarsals at pushoff.
  4. Cushioning under the first metatarsal head
  5. Minimal heel lift not to shift too much weight forward
  6. Stiff forefoot area to minimize bend if needed (at least a design that does not encourage excessive big toe joint motion).  
7. What sort of side-effects could occur if one was to perform surgery to remove the bone(s)?
     I find that the crucial question is why did the patient get this in the first place. If the surgery does not correct that, and most of the time it can not, then removing the sesamoid puts the other at more risk. Losing one sesamoid is not the perfect scenario, but you are still highly functional. If you lost both sesamoids, you have not protection for the first metatarsal head. Removing the medial sesamoid does make you more at risk for bunions, but if you start wearing toe separators and yoga toes, and start doing abductor hallucis strengthening, you can minimize that. Typically when you injure something, there is an obvious cause, and several still important less obvious causes. After surgery, you have to know what the causes were and prevent them in the future. I find this area is addressed the best while the doctors are trying to avoid surgery in the first place, learning why it happened helps with designing treatments. Only some of the causes are: poor running or walking styles, poor shoe selection, inadequate fat pad, high arches, plantar prominent first metatarsals, training techniques, improper cleat placements, poor bone health, transient Vit D or Calcium inadequate intake, over pronation, stiff foot that does not adapt to ground, etc. I am sure I have left out quite a few. 
8. It was brought to my attention that some people are born with their sesamoid already in two pieces, do they experience the same problems of someone who has broken their sesamoid experiences?
     Yes, even when the sesamoids are congenitally in two or more pieces, they can still fracture or bruise these small bones. I feel having the bone in multiple pieces greatly confuses the diagnosis. It is too easy to say they are congenitally that way, so they must not be injured. These separated pieces can develop fractures, but they are even more prone to sprains between the bones. These sprains are impossible to fully diagnose, and seem to cause lingering pain more than from a fracture. So, when I see the bone in more than one piece, and the pain matches a stress fracture level, I am more worried that they are going to have a difficult time healing (at least quickly). I sure hope all these answers help you and other reading. Dr Rich Blake

Thursday, February 19, 2015

Sesamoid Fracture: Email Advice

Hi Dr. Blake,

My name is Martha (name changed), I am a Southern California/NYC resident. I am a professional actor performing in a show until a stress fracture of the inner sesamoid on my left foot caused me to have to take a break from the show. 

I injured the foot back in November of last year, and have now been off of the foot and not bearing any weight for 2 weeks, prior to that I was pretty active doing the show 9 times a week. I am currently in an air boot and crutches, as well as using a magnet for healing several times a day, calcium supplements and am waiting for a bone stimulator to be approved. 

I wanted your advice on how to best heal and about how long I will be out of the show. In the show we mostly do pedestrian dancing, walking, running, etc. I want to heal as fast as possible as this show means a lot to me, and I desperately want to go back soon. I have several questions for you, if you have the time to answer them! 

1. How can I best heal, besides what I am doing? 
Dr Blake's comment: Basically creating a pain free environment (0-2 pain level) with protected weight bearing (removable boot, orthotics, dancer's pads, stiff sole shoes, etc), anti-inflammatory measures of icing and contrast bathing, bone healing measures (like Vit D3, Calcium, zinc, bone stimulator), lower extremity strengthening including cardio (typically orchestrated with a PT), and gradually increasing weight bearing. 
2. What is the likelihood of healing vs. surgery? 
Dr Blake's comment: I would need to see MRI imaging. With sesamoid injuries, you typically get a baseline MRI and then 3-6 months get another to see how much healing is occurring. If you have a disc, you can mail to Dr Rich Blake, 900 Hyde Street, San Francisco, CA, 94109 and I will try to let you know what it says. Without that information, it is hard to tell. Only 10% of my sesamoid fractures require surgery, but as you read in the various blog posts, there are so many variables. If you have had sesamoid pain for 3-4 months, and you are not responding, you are considered a surgical candidate. I know many of the professional athletes (and you fit that category) get surgery much earlier in the game to get them back onto the playing field faster. It is really a judgement call case by case. What makes sense for you. And what are your risks.
3. What is the timeline for going back to the show (assuming I have custom orthotics?  
Dr Blake's comment: Too many ifs, ands, and buts!!! As you go from Immobilization to Restrengthening to Return to Activity, you have to keep pain free (0-2). You have to be 2 weeks in the removable boot with no crutches walking fine, before you can start to wean out of the boot. The weaning process can take 2-6 weeks, so you have to have the boot with you at all times, and you have to keep the pain between 0-2. What helps you wean out of the boot the fastest----anti-inflammation measures of icing and contrast bathing, keeping your core strength, spica taping, dancer's pads, cloughy wedges, orthotics, shoes that protect and cushion.  
4. Even after my foot has healed will it feel "normal" again? Or should I expect some pain? (I read the article on good vs bad pain, is it safe to assume the good type of pain will be typical? 
Dr Blake's comment: Patients who heal from sesamoid fractures have no pain and are fully functional. That process from you to no pain can take up to 2 years, hopefully shorter. The healed sesamoid can remain strong, but sensitive due to bone swelling and nerve hypersensitivity. The patients who remain sensitive can not ignore the symptoms, so have to tape, ice, avoid barefoot, etc for longer periods, even if they are back to full activity. Read the post on the Magic 80% Rule. When you are 80% better, you can be fully functional, but you still have 20% of the symptoms to deal with. Good luck. Rich

Thank you so very much. It is difficult finding a doctor who specializes in this injury that accept workers comp. Your blog gave me much relief. I look forward to hearing from you. Again, thank you so much. 

Fondly, Martha

Sunday, February 15, 2015

HOKA ONE ONE: Maximalistic Running Shoes probably here to stay

I have recommended Hoka One One Running Shoes for great shock absorption for walking and running. They are stable, take a little time to get used to, but can minimize the impact shock that can destroy knees. For those long distance runners with Hoka One One and Hannaford Orthotics (previously prescribed) their impact shock is almost nada, nilch, zero, zip!! Yes, we are talking about another version of runner's high. 

Saturday, February 7, 2015

Iliotibial Band Syndrome: General Thoughts

The top 10 treatments of IT Band Syndrome are:

  1. Develop an appropriate stretch that you can do to reduce the pain, then do that stretch 5 times daily. Go to Youtube and type drblakeshealingsole iliotibial band stretches.dreamstime_m_48700943.jpg
This is a yoga version of Iliotibial band stretching to stretch the lateral side of the hip and knee. It can be done also standing upright and also leaning against a wall.

This version of iliotibial band stretching can be done laying all the way done and then draping your leg over the other with a gentle pull from your opposite hand.

  1. Gradually strengthen the hip abductors with limited range of motion. I prefer theraband progressive resistive exercises. Keep your knee straight as you do them.  dreamstime_m_120661.jpg
Whether you are doing these standing or side lying, and especially if you add resistance, please you limited motion (max 3 inches away from other heel, starting 1-2 inches in front of and across the other foot). Too far away from mid line irritates the hip and is not in the functional range we need.

Here with the resistance bands you walk slowly sideways in one direction, then the other, building up time. I would use a longer theraband so you did not have to have your knees so bent.

3. Ice pack for 10-15 minutes or ice massage 5 minutes 3 times daily.

4. Use activity modification, typically you can run until you get initial symptoms, stop stretch walk several minutes, and begin running again. Repeat as needed with 20 minute ice pack afterwards.

5. Physical therapy to stretch, decrease inflammation, strengthen, and look for biomechanical faults.

6. Correct any biomechanical faults that may be causing like over pronation, over supination, or short leg syndrome.

7. If symptoms are mainly at the tibial attachment at Gerdy’s Tubercle, get a baseline x ray.

8. If symptoms do not respond at the hip greater trochanter, consider a cortisone injection for trochanteric bursitis.

9. Massage, either professionally or self, should be limited to the area above the knee and below the hip to avoid the bony prominences. This includes when you stretch/massage with the ethafoam roller.dreamstime_m_8846383.jpg
10. Taping of the leg has begun to prove helpful at times.
Not this type of taping!!
More like this type (there are many versions)

11. Like any tendinitis, BRISS is initiated. But, if symptoms linger, you have to think deeper, and consider xrays, nerve testing, MRIs, etc.

Music to Relax when dealing with Chronic Pain

Cognitive Behavioral Therapy and Nerve Pain

Calming down the nervous system is a great chore. This article discusses the possible benefits of Cognitive Behavioral Therapy.

Friday, February 6, 2015

Patella (kneecap) Problems: General Thoughts

  1. Patellar Tracking Problems (kneecap)

Probably the most common knee complaint that a podiatrist will be called into treatment involves the kneecap.
  • Also called Runner's Knee, Biker's Knee, Dancer's Knee

  • Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc…

  • Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation illustrated by the young women with her right knee below

  • All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO with short arc single leg press and quad sets, and
  • Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.   

Bauerfiend GenuTrain Knee Brace for Patellar Tracking Issues

Here is some advice I emailed a patient inquiring about knee pain and flat feet:
Dear Dr Blake:
I am in a conundrum.  Spend out of pocket to see a podiatrist or spend out of pocket to see a PT.I am Flat footed.

In 1990, my right knee hyper-bent with 150 lbs of backpack weighing me down with my right foot stuck in snow as the left foot slipped downward.
Current symptoms:
- Clicking knee cap
- Kneeling on carpet, great pain until the knee cap pops into place from pressure upwards
- Grinding knee upon flexing
- Pain on the inside of the rt knee and lower left quandrant of patella
- Pain and tightness from right side of knee up to the hip
- Pain behind my knee at the back (anterior)
- Extreme pain in knee and hip when rising up from a kneeling position
Wonder what he did??

- Pain and tightness on the inside of my thigh at the knee
- Feeling of being swollen in the knee itself
- Walking in running shoes with support is OK at best
- Walking in dress type shoes with no support results in pain after 25 yards or so
- When I use to take spin classes, the instructor noted an outward or inward? movement of my leg/knee and asked me to keep it straight, which I could not.

I have sat at a desk for 8hr/day for the last two years ~ the first desk job in my life and this may be part of the problem.
I am self pay ~ no health insurance.
What would the cost range be for a diagnosis by you, treatment and possibly orthotics?
How long would it take, should we work together, to know if your regiment for me is working?
At what point would it be wise to pony up for an MRI?  Do I need one?
I am 53, and until recently, in good shape if not great shape.  I need help!
Best always and Happy New Year!
Robert, Thank you for the email. This is definitely a question about timing of treatments when both can be very helpful.
  With that much knee pain, you are really in the immobilization/anti-inflammatory phase. Orthotics would be part of a restrengthening/return to activity phase. The immobilization is anything that creates a pain free environment, from braces, to shoes, to activity changes, and yes, to orthotics if that is what it takes.
   I would tend to have a PT cool your knee down first, and then add orthotics when you are ready to increase your activity again. Orthotics can play a role when you are throwing everything into the treatment arena but the kitchen sink (an approach used with unlimited funding).
This is why the kitchen sink is not included
Definitely, cool the knee down with PT and Icing. The icing for the knee must be 30 minutes 3 times a day. Yes, 30 minutes is normally needed to get deep into the knee.   Try to stay away from anti-inflam meds since they can slow bone healing. Get an MRI, around $500 self pay, if your symptoms plateau (look at it one month at a time). Try to create a pain free environment over the next month, which may mean staying in your most stable shoes. You can also try Sole over the counter Arch Supports (get one of the soft athletic versions). These are easy to adjust. You have already established a relationship between your feet and knees, but see if you can get them calmed down, less fragile, over the next several months.

    The top 10 initial treatments of Patella problems are:
  1. Create a pain free environment.
  2. Ice 30 minutes 3 times daily
  3. Start Quadriceps strengthening painlessly on day one
  4. Stretch the quadriceps and hamstrings 3 times daily, although avoid knee flexion over 45 degrees.dreamstime_m_15225478.jpgToo much knee flexion for kneecap pain
  5. Knee Brace for Patellar stabilization like Bauerfiend Genutrain Knee Brace
  6. McConnell knee taping with Leukotape and underwrap or KT taping.dreamstime_m_36278072.jpg
  7. Core Strengthening for external hip rotators, including gluts, iliopsoas and piriformis muscles.dreamstime_m_17645150.jpg
  8. OTC or Custom inserts to stabilize any overpronation tendencies, or just varus cant. Goal is to get the knee to function in the center and not internally rotated.
  9. Use activity modification to get cardio without irritating the knee. Consider raising the seat in cycling to prevent too much flexion (over 45 degrees the patella starts pushing hard on the femur). dreamstime_m_18879601.jpg
  10.  If it is a running injury, shoes are crucial for stability. Have a good running shoe store help you pick out a great stability or motion control shoe for you.
Your shoe selection should help avoid the heel valgus seen here where the heel rotates outward driving the knee inward too far.

Anatomy of the Foot and Ankle Video

Thank you!!

Tuesday, February 3, 2015

Power Lacing Question

Hi Dr. Blake,

I just watched your YouTube video on power lacing and I was wondering why you need to skip the 3rd hole?  Is that necessary?  It looks really strange on my shoes because the 3rd hole is actually an extra strip of material, so the strip sticks out when not laced.

Anyways - thanks for your time!  I appreciate it!  


Dr Blake's response:

     No, you only need to skip the 3rd lace if you do not have enough length to the laces. If you have adequate length, by all means, use all the eyelets. Rich