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Thursday, July 30, 2015

A Happy Marathoner: A Podiatrist's Good Day's Work

This was a nice email from a patient that worked with me to be able to run the SF Half Marathon (from injury to 13.1 miles!!). This is the gratification both the patient and doctor feels in seeing this through from start to finish. Running a Full or Half Marathon for the first time is an amazing athletic feat and the runners are so full of pride. Congratulations to all the runners out there that 2015 has brought (or will bring) about their first full or half marathon. My patient below is excited about training for another 4 months from now!!!

Hi Richard,

I hope all is well with you. I thought sharing the good news with you as I just competed my first 1/2 marathon (13miles) and this is mainly due to your services providing me the right podiatric soles! So I am very happy of accomplishing this first challenge which seemed to be a bridge too far at the beginning!

Thanks again!

Saturday, July 25, 2015

Inverted Orthotic Technique Patent Request for the Kinetic Blake!!

After designing an orthotic device in 1981, it is fun now seeing it being used in various designs, etc. Here is a patent design for a product called the "Kinetic Blake"!!!

Insect Bite: Email Quite

I took my 2 year old to the park and she came back with what looked like a mosquito bite on her foot. I disinfected it with alcohol.She complained about it but I thought it would heal on its own.However a few days ago there was a bump where the mosquito had bitten her. This morning she woke up with what appears like a bruise.Her foot is swollen around the bite and has a blue and purple color spread all around her foot. She seems to be experiencing some discomfort. What should I do?

Dr Blake's comment: In this situation, with a spread of possible infection, I would definitely go to the ER. They will access things, and probably place her on antibiotics. Warm Water soaks for upwards of an hour can be helpful and drawing out an infection. You can repeat this every few hours. You can also use a damp warm face cloth against the skin, and then wrap this with saran wrap around the entire area. This is called a Koch Mason dressing. Check her temperature now and every few hours. If her pediatrician is available, let him or her know. Do not mask the pain with any medications for now. See what the ER docs have to say. I hope this helps her. Rich

Friday, July 24, 2015

Bunion and General Foot Strengthening Exercise

This exercise I teach for bunions, but it can be a next level exercise after conquering 30 reps of  the more simple metatarsal doming for foot strengthening. Remember to do these in the evening, and never through pain. 

Pronation Analysis through Running Warehouse

Excessive Pronation while you walk or run can be a cause of many injuries. This is a nice video on the evaluation of your amount of pronation. Because high arch, normal arch, and flat feet can all overly pronation, the wet foot test is interesting but can be misleading. To a lesser degree, the forefoot wear test can be influenced by the terrain you run, and your strike pattern (heel strike, midfoot strike, or forefoot strike). So, I believe the video tape method is the most reliable. Running Warehouse offers a free evaluation if you send them a clip from you phone or tablet. Hopefully, there is not too many strings attached. Happy Running!!!

Friday, July 17, 2015

7 Tips from Harvard for a Great Strengthening Program

Demonstration of Hip Abductor Strengthening

Strengthening your body is a life long goal. Here are 7 tips from  Harvard Medical that can prevent you for doing too much or not enough. Hope it helps. Rich

Thursday, July 16, 2015

Achilles Spurs: What should we do?

The image above shows clearly a painful achilles spur. Surgeons like to remove them, but it can be a long recovery. It is not a common surgery, so if it is being recommended, be a little cautious. Try wearing Achilles Gel Pads from Silpsos to see if it is more shoe irritation. Try to do the Plantar Fascial Wall Stretch 3 times daily to breakup scar tissue. Go to physical therapy to strengthen, stretch, and de-inflame. And, if necessary, wear a Removable Boot (cam walker) for 3 months to rest the area. 

FDA warns against any use of NSAIDS (July 2015)

From Google Images

The FDA just came out with more severe warnings against NSAIDS, like ibuprofen, aleve, and diclofenac. Since these drugs are common place in sports medicine practices, it will take some time to filter down to the athletes, coachs, and health care providers. Increase use of icing, contrast bathing, rest, topical sauves, etc, will be encouraged. 

Please see all of the tips at the end of the following blog post on reducing inflammation, even if an area does not appear swollen. 

More from Dr Blake: 

Over the years I have gradually shifted away from drugs and shots for anti-inflammatory measures after an acute injury. So you start with 4 days of straight icing after injury, then begin to add some heat. Yet, most of my patients are in the subacute or chronic states of their injuries at any given time. It is a time of gradual restrengthening and gradual return to full activity. How is the inflammation handled in this arena? Typically, I love (2) 10-15 minute ice packs daily and contrast baths at 4 minute hot to 1 minute cold ratio 3-5 times per week. The patient of course needs to try to control their activities so as not to keep the tissue inflamed and aggravated. NSAIDS (like advil and aleve) can be used  prn (as needed).  Never take the drug within 6 hours before exercise to mask pain. When the inflammation seems deep set and hard to more out (like a squatter!), consider topical anti-inflammatories like flector patches, voltaren gel, traumeel, arnica, compounding formulations, zyflamend, or biofreeze/mineral ice. You can also get an Rx for PT (consider 5 sessions of iontophoresis with dexamethasone or cupping) or acupuncture. 

Sunday, July 12, 2015

Having Fun after Sesamoid Surgery!!!

This is a young lady whom I helped online in an attempt to avoid surgery. It is crucial of course now that there is only one sesamoid left to wear some form of dancer's padding while she is participating in impact sports forever. So simple, but often forgotten. 

Hey!!  Yes sir, the surgery is finished (I had it on 
April 16th) and I am already back to everything.  I ran 4 miles this past Friday and I'm playing tennis later today... and I was able to wear some high heels for my birthday dinner yesterday :)  I am a very, very happy camper.  

The podiatrist said that the sesamoid wasn't necessarily fractured when he took it out, but he said that the cartilage all around it was worn down, and that everything was very inflamed.  It was the right call to do the surgery.  

I'm so thankful to have a new lease on life :)  It's the best feeling ever!  God bless you and your help throughout this long process.  It is people like you who make the world a better place, and you give people hope.  Thank you for being you.  

My best, 

Thursday, July 9, 2015

Ideal Running Form

Ideal Running Form: Slight Forward Lean of Trunk, Powerful Swing of the Arms, Foot not too far in front of body, and very little bounce up and down of the head
If you never have walked a Labyrinth you should. It is a mirror of our spiritual journeys. At times, we are so close to our Center, only to feel miles away minutes later. The correlaries to our own paths are worth reflecting on.

Wednesday, July 8, 2015

Another Video on Calmare Pain Therapy: CRPS and other forms of severe pain can benefit

Bisecting the Negative Cast for Orthotic Manufacturing

I apologize for most of my readers that this means little, but this bisection line on the back of a negative cast to me is crucial in designing orthotic devices. To complicate matters worse, the bisection line must be "tangent to the curve on the lateral side of the heel", whatever that means. I know what it means of course. But, when you are learning this stuff, it can be difficult, and sometimes impossible to learn. The lateral side of the heel is the opposite side from the level, and looks fairly straight. When you use Root Biomechanics, 1 degree changes are important, so a heel bisection 2 or 3 degrees off, can be disasterous. With the Inverted Orthotic Technique, with a rough estimate of 5 degrees of cast inversion to 1 degree foot correction, the exact bisection is not as crucial. 

Inverted Orthotic Technique for Severe Pronation: A Study Attempting to Document what it Actually Does

In 1981 I designed the Inverted Orthotic Technique, also called the Blake Inverted Orthosis. It is well accepted in the world for helping patients, as this study states, but what does it actually do to the running mechanics is hard. I wish I was around the design of these studies to individualize the amount of correction and the modifications necessary based on Strike patterns. But, I am happy it helps patients every day around the world.

Tuesday, July 7, 2015

Running Downhill: Go Gentle

 "Combined with previous biomechanics studies, our normal impact force data suggest that downhill running substantially increases the probability of overuse running injury." This is one of the summary statements from the article below. Having practiced Podiatry in San Francisco, with it's 46 official hills, I know the damage running downhill. Runners just have to be smart about them. Charge up the hills and slow down the down hills!! The force of running at impact is between 2-5 times body weight. Running fast and hard down hills can increase them force. Be kind to your body and you will run longer!!

Charge up the hills, and go gently down them

Hammertoe Correction: Post Op Return to Sports

Just want to say thank you for the amazing forum! It has been very helpful and informative.

I am currently a basketball player that's been dealing with hammertoes/corns for about 12 years now. Couldn't really deal with the discomfort and pain anymore so I decided to get the hammertoe/corn removal procedure done about 2 months ago on all 8 toes except my two big toes (yeah I know, brutal).

It has been exactly 2 months since the procedure and a month since PT and I can do slight running and jumping but with pain in my toes, which I do believe isn't a good sign. I consulted with my podiatrist and he told me that the pain was originating from the inflammation of my toes from the procedure. He recommended cortisone shots to eliminate problem.

Is the cause of my problem from a slow healing process or is it just the inflammation that's causing the pain? Are the cortisone shots a good idea? Will it better or worsen the problem? Are there any substitutes besides the injection? What would you recommend?

Dr Blake's comment: 
     You are still in the early stages of recovery so unless there was just one spot that was not improving, I would avoid cortisone right now. Of course, you need to be aware of Good vs Bad Pain so you can continue to stress the areas gradually and slowly. Rest typically does not help us. 

At this point, you need to get referred back to physical therapy at least once per week. They can help loosen the soft tissues, since you probably have a ton!! on scarring. Icing 2 or 3 times per day for 10 minutes is also very important to control the inflammation that will be part of the continued healing for the next 6 months. Scar tissue does not really get all better for 1 year post surgery, so some times it is a waiting game. See the link to a great review article.

You had 8 toes operated on which is alot of trauma. Do all your toes hurt, or it is really only 2 or 3? Try foam toe caps to protect the more sensitive toes. And shoes like Hoka One One that have a stable Rocker (less to bend). Or you can try shoes with a wider toe box like the New Balance 990s, etc. See what helps. You can see if a full length insert, like Sole or Powerstep can immobilize the toes without crowding. I hope this helps you some. Rich

Reducing Scar Formation: Great Review Article

Sunday, July 5, 2015

Anterior (Front) Ankle Pain: Lateral X-Rays can be Revealing

This is a lateral foot x-ray. The patient has front of the ankle pain. You can see a bone spur, is that the cause.

The bone spur is probably just a reflexion of considerable compression force in the front of the ankle. This ankle joint flexes to a point where bone hits bone. The soft tissue can get in the way. Removing the spur surgically will probably not help at all. The soft tissue is getting pinching as the tibia goes too far forward. Treatment is avoiding these positions in activities, like deep squats, heel lifts, calf strengthening, and anterior icing/anti-inflammatory.

Sun Flower field near Gilroy California

Measuring Shoe Size with iPads

My wife Patty and I on a hike near Half Moon Bay, Ca.

Slideshow on Diabetic Foot Problems and Treatments

Diabetic Nerve Pain: Consider a Vegan Diet

My wife Patty and I enjoying an anniversary meal at Acquerello in San Francisco.

Friday, July 3, 2015

Tip of the Iceberg: Blog Post for Podiatry Today

This is the second of my series of blog posts for Podiatry Today for my colleagues.

Heel or Knee Pain: Removing Hard Rearfoot Posts at times can help

Hard Plastic Rearfoot Posts give great stability, but can be too hard, especially with knee and heel pain. Here the left one has be ground off (It can always be put back on). 

This photo emphasizes the hardness of the post.

Here is a closer look at the ground off post.

I just love Graffiti Art that is all over San Francisco!! Here it is on Market Street seen on a walk today. 

Thursday, July 2, 2015

Accessory Navicular and Tarsal Tunnel: Email Advice

Accessory Navicular Problems: Further info from the initial blog post

Dr. Blake,

I am a 31-year old professional who currently works in an office in Massachusetts. Last year, however, I spent 9 months in Spain teaching English. I had no car and found myself doing lots of walking. I also gained about 15 pounds in the first couple of months there. I noticed after three months of walking in ballet flat style shoes a burning sensation in my right ankle. Long story short, here we are a year and a half later and I still have the pain. I weigh about 125 and am 5'2".
Dr Blake's comment: Tentative diagnosis is Tarsal Tunnel Syndrome. This is neuropathic pain, and needs to be treated with a nerve emphasis, some mechanical changes, and some anti-inflammatory measures.

I have seen a total of four doctors so far. I have done PT, tried custom orthotics (which I lost during my move back), tried a walking boot for 6 weeks, been on a couple strong NSAIDs, modified my activities, and tried ice and heat therapy at home on a sporadic basis.
Dr Blake's comment: This problem is helped with the mechanical support of the orthotic devices, especially if there is some varus wedge at the heel. Also, nerves love heat not ice, motion not lack of motion, no massage, and gentle stretching (like neural gliding). 

The orthotics caused more foot pain in other areas, so I am not sure they were made properly for my condition. The PT was done in Spain a year ago and consisted of 45 minutes of heat therapy, electric wave therapy, and massage every day for three weeks.

Six weeks in the boot this past winter was creating problems in my left knee and hip. They never gave me a leveler for the other side, but I did wear a high shoe which seemed okay.

Please help with your opinion! My current doctor who is an orthopedic surgeon and prescribed the boot is of the persuasion that PT and orthotics will not help the edema he sees on the MRI in my bones. I personally want to try a new PT routine and new orthotics before I resort to surgery, but that means I will have to move on to a new doctor yet again. Two doctors were in Spain and the other was here in the U.S. (podiatrist with a horrible bedside manner who said paying $400 for orthotics from his office was the only option).

I am so frustrated and feel like I have tried everything but I also think the timing and quality of the things I have tried could be reassessed and tried again. What do you think?
I don't want surgery if possible. It is my right foot and it will make me unable to drive.

Dr Blake's comment: Without a history of a fall or collision causing major injury, the need for surgery is typically small. Yes, starting again sounds the best. The bone edema could be residual for a stress fracture that has healed or is still healing, and the inflammation from the bone injury putting pressure on the nerves leading to the burning. Burning is classic nerve pain. You need to create your pain free environment however while you search out a new doctor. Typically sports medicine doctors, not necessarily podiatrists or orthopedists, are the best. If 6 months has passed from the first MRI, get another to assess the amount of healing. You may not feel any better until the bone edema is all healed. It is a reflection of bone trauma. Go back into the boot part of the day if you can not find another environment to keep the foot happy. See if warm water soaking works better than contrast bathes. If your skin can tolerate some massage, order NeuroEze online and massage 3 times per day, at least above and below the sore areas. Also do neural gliding 3 times per day, as long as it is comfortable. If warmth or contrast does not help, stay with ice packs. You can experiment with placing the ice pack over the area, or above it. Send me other info on what you have found works and does not work. Are you better in heels vs flats, barefoot vs shoes, etc? How long can you walk without limping? Send a photo of your foot with your finger pointing to the exact area. Hope this starts the forward progress. What exact diagnoses have you been given? Rich

Hi Dr. Blake,

Thank you so much for responding. I will do my best to answer your questions.
I have an accessory navicular in both feet (see photo of right foot with me pointing to general area of pain). I only realized they existed recently, because they never caused me any pain before, and I only present symptoms in the right foot. The pain changes places; sometimes it is under the arch, and other times there is a shooting pain up the post tibial tendon. Some days it feels like a rubber band about to snap with too much pressure, and other days it's that burning I described. I also have flat feet.
Dr Blake's comment: That definitely sounds more like an accessory navicular problem. Since it involves the posterior tibial tendon in the tarsal tunnel, you can get nerve pain or nerve symptoms being generated. 

It seems like switching shoes often helps. Barefoot is bad. I have spent more money on shoes in the past year than in my entire life! Dr. Scholl's inserts, MBT rocker bottom shoes (horrible for my condition), Clarks, sneakers, really expensive clogs, etc. The clogs (with a raised heel) are my favorite. However, I refuse to wear them in the summer as I still have some sense of fashion to maintain. I just bought some comfortable Clarks to get me through the summer that look like ballet flats but have a much better sole and support, with a wide toe. I'm also in love with Okabashi flip flops, and wear them around the house as much as possible.
Dr Blake's comment: If you can get comfortable, but stable orthotic devices, the design can be used in your sandals with a removable insole.

The MRI was done in January 2015 and we are now in May. My condition has not changed symptomatically since December 2013. My orthopedist believes that physical therapy will inflame the edema more, or be useless. He is also not a fan of orthotics, which I tend to agree with, because from what I've read online, they don't make your feet work hard enough and allow them to lazily conform to a mold. Some doctors believe they create dependency. What is your view on this?
Dr Blake's comment: I love orthotics for this problem. I believe you only need to do 2-3 minutes a day of strengthening to make up for any weakness from the bracing effect. And strengthening the posterior tibial tendon should be part of your program. You must understand, since you are still trying to get into a pain free environment for most activities, you are still technically in the Immobilization/Anti-Inflammatory Phase of Rehabilitation, so any assistive aid is very appropriate now (especially when some are suggesting surgery).

So you think I should try using the boot again even though it didn't cure the condition in 6 weeks, just for comfort, while I search for a sports medicine doctor? The boot does cause problems in the left hip and knee if I wear it too long, but I will certainly do anything to get better! I will also mention that I am developing a bunionette on the right foot from compensating, as well as from wearing winter boots with a tapered toe. Not too happy about this!
Dr Blake's comment: See the video on Tailor's Bunion care.

I am currently taking Meloxicam and it doesn't seem to be helping after a month. I was on Indomethacin for a few weeks, and while I believe it did help reduce inflammation temporarily, the side effects were awful. You are correct in stating the foot likes heat better than ice.
Dr Blake's comment: At this stage you have both inflammatory pain and nerve pain. And they can trade off on a daily or weekly basis what gives you the current symptoms. Try to see if you can distinguish the various types of pain, and what treatments help them. 

My life has changed completely and I cannot play tennis, do Zumba classes, or walk long distances anymore. It has affected my social life and career as I must ask co-workers, family and friends to coordinate activity around my pain. Sometimes I push myself when I'm alone because I need to get things done (cleaning, vacuuming, etc). but I suffer the following two days recovering.
Dr Blake's comment: This is why I would err on getting and learning all forms of immobilization: various taping, different orthotic designs, Aircast PTTD brace, removable boots, AFOs, shoes, and power lacing. Read the posts on posterior tibial tendon dysfunction to see all these avenues like the one below.

The reason I have hope for recovery is that I have had a couple sporadic days with absolutely no pain. I did not change anything activity-wise, so I have no idea what alleviated the symptoms. I hope I am being reasonable by avoiding surgery. I am very anxious about it, but I also don't want to avoid it forever if it's really the best option. It seems that the body can heal itself in many cases given the right conditions, and want to exhaust all options before going under the knife, being out of work, collecting disability, etc. I am a very active person and while I have rested the foot a great deal, I won't pretend it's been easy to slow down.
I'd like to lose 10 lbs. because I think being a little lighter will alleviate some pressure, but I am not even overweight and don't want to have to maintain a low weight my entire life just for this reason (I.e., what if I get pregnant someday)? I think the weight is a contributing factor, not a root cause. I am having a hard time losing weight with the condition, ironically.
Thank you again for your time, Dr. Blake. I sincerely appreciate it!

Dr Blake's comment: Good luck. Here is my typical checklist for accessory navicular issues (with tendinitis and tarsal tunnel symptoms just part of the overal syndrome).

The top 10 treatments for accessory navicular syndrome:

1.  An MRI is very important to discover what the source of pain actually is: stress fracture, joint inflammation, or tendinitis. There is a joint between the navicular and its accessory bone.
2. Use Kinesio Taping or tape or classic low dye taping techniques intially 24/7 and then for extended activities.
3.  Ice pack the sore area 10-15 minutes 3 times daily.
4.  Go into a removable boot (such as an Anklizer) for 2-3 months if needed to calm the foot down.
5.  Strengthen the posterior tibial tendon starting initially with active range of motion like ankle circles.
6.  Check out the Aircast Airlift PTTD brace to see if it is helpful for you and can get you out of the boot faster.
7.  Custom foot orthotics are a must for a 2 year period. They must produce a good force against the navicular, but it may take time finding the right orthotic guy/gal.
8.  You can use Sole OTC orthotic devices with medial longitudinal Hapads initially until a good protective orthotic device is made.
9.  Create a pain free environment as soon as possible (level 0-2).
10.  If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.

Wednesday, July 1, 2015

Podiatry and Humor make for Great Healing

Please enjoy!!! Rich

Water Brace for Ankle Rehabilitation: Posterior Tibial Tendon Injury

This patient of mine is currently recovering from a posterior tibial tendon injury. Her MRI showed inflammation without tears, so we are moving her along in the rehabilitation process. We had discussed no kicking in the water at this point due to the added stress on the tendon, and definitely no fins of any form.

Hi Rich,

I apologize again for being late this morning, after asking you to
be on time.  Thanks so much for your patience and understanding.

Re: swimming (no fins) being stressful on my ankles

1.  Would this, or something like it, allow me to swim w/out putting
that float thing betw my legs?

2.  Would it work for water aerobics?  Can I go to water aerobics in another month or 2?
   (it does involve some jumping, etc) What if I use one of those wrap-around-your-waist float things and my
    feet don't touch bottom?

3.  Were you saying that I should NEVER swim w/out that float thing?

I made an appt for a month from now.  Hope it's not too much trouble to respond to these ???s.

Thanks again!


Dr Blake's response after reviewing the link:

Thanks, that looks great. It will help the biofeedback loop telling your brain that you are protected and that you can swim, while you still must avoid excessive kicking in the pool. Still go easy and ice for 15 minutes after swimming whether it hurts or not. Your MRI was too good to have any permanent restriction on activity, but it will take you 6-9 months to get that injured posterior tibial tendon super strong. Yes, you can begin water aerobics in 2 months, just start with brace and no weight bearing for the first month. And we will see how it goes.Hope this goes well. Rich