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Sunday, October 16, 2016

Common Running Injuries and Their Treatment

This hour long video could help many runners with some self help ideas. Dr Kevin Kirby is a podiatrist in Sacramento, California, always known for his brilliant ideas and innovations. 

Wednesday, October 12, 2016

Lecture on Shoes and Socks at California School of Podiatric Medicine

Shoes and Socks Lecture
October 12th, 2016
Samuel Merritt University
California School of Podiatric Medicine
My partner Dr Jane Denton examining shoes

This lecture is mainly for self study, since the blog posts and videos can take a long while to study. Yet, Dr Blake would like to spend the next 2 hours giving the students a glance at the ever-changing topic. Dr Blake will skip some of the videos during class time for time concerns. 

What are the objectives?
  1. Introduce the anatomy of an athletic and dress shoe (what is a vamp, etc.?)
  2. Explain the 3 types of socks used in a podiatry practice (athletic, compression, speciality).
  3. Explain how to modify shoes for fit and stability (What is skip lacing, or power lacing, or dancer's padding, etc.?)
  4. Introduce podiatry students to various shoes specific for certain sports (what are the 3 traditional types of running shoes?)

1.   Introduction---Shoes and socks are some of the great Podiatry tools that are used in helping patients. The individualization of these factors can greatly benefit your patients. To start out, let us look at a video of the anatomy of the running shoe. Some of the red questions will be used in developing your midterm quizzes. Some of the links are for self study alone.

                      What can go wrong with flex grooves in the wrong place?
               What is more dense--outer-sole or mid-sole?

And now, even more on the anatomy of the shoe.

                                   What popular shoe company has a narrow last?
                        What part of the shoe is the Vamp?
                        Where is the saddle of the shoe?
                         How many irons equal one inch?
                         What is a toe spring?  
                         What are 3 common tests done to shoes?

I think another crucial TEAM effort is the marriage of podiatry and the shoe store. In San Francisco, I am lucky to have the extraordinary help in fitting from 3 stores: Shoes and Feet, Fleet Feet, and On The Run. I have also heard wonderful recommendations on A Runner's Mind and See Jane Run. However, it can get a little too easy just recommending a store, when the doctor should also be giving some direction. 

2.   Socks---A) athletic (know about Merino Wool and NuWool)

     There has been an explosion in the world of socks and shoes. Podiatrists need to have several recommendations for their patients since they get incredible benefit from this knowledge.
                        What socks advertised have Merino wool?
                 What socks have left and right requirements?
                  What socks have embedded arch support (name 3)?
                  What socks from Heat Holders are 7x warmer than                           most?
                  What socks have silver embedded (for anti-bacterial)?
                             What are the two best wools for Hiking?
                    What is the sock with the 5 separate toes?

                    B) compression  (look into 110% and Juzo)

I love Juzo for the thigh high and open toe. Juzo comes 12-20 mmHg pressure in OTC, but also medical grade (20-30 and 30-40).

This following video talks about putting on support hose.

             What is the pressure in typical medical grade support hose?
What is the Juzo slippee used for?

Athletes are using compression socks to their advantage. Check out 110%.

Why are compression and ice used together in controlling swelling?

                    C) particular purpose---arch support

                                                           heel or metatarsal cushion 

(BeyondSock from Thorlo)
See the nice video attached.
                                                           plantar fasciitis
What is the name of 4 plantar fasciitis socks?

3. General Shoe Modifications in Podiatry

What are 2 ways to stop heel slippage?
What eyelet is skipped in power lacing?
Why is Sole easier to work with then Superfeet?
What can you do to make a full length lift more flexible?
When designing lifts, why does Dr Blake prefer full length over heel lifts?
4. General Rule on Shoes---Always Think Bio-mechanics 
                                             Always Think Injury (or history of injuries)

     A) Stable (everybody, pronators, supinators)
     B) Cushion  (where??)
     C) Flexibility
     D) Rocker
     E) Stiffness (usually talking about forefoot)

     F) Width
     G) Toe Box Room (can there be too much?)
     H) Durability?
     I)   Price?
     H) What do we put into Shoes?
     I)   How much do people's feet grow?
            What is the length change from 20 to 70 yo?
     J)   Power Lacing (another name is "Runner's Lacing")
What are two other names for Power Lacing from the video?

     K)   General Shoe Buying Rules
            Buy within 2 hours of the store closing
            Thumb width longer than longest toe
            Fit for the longer foot
            Go to a Speciality store whenever possible for fitting
            If the shoe is uncomfortable in the store, then it probably                          will never break in
            Buy with the socks you will be wearing.
            You should feel low in the shoe.
            If you wear orthotic devices, bring them to try.
            The shoe should always fit snug around the midfoot

5. Types of Shoes  (that have a removable shoe bed)
     A)   Running

What are the 3 general types of running shoes?
What has a straighter last--cushion or stability shoes?
     B)   Court
What are the 3 crucial components of the good basketball shoe mentioned in this video?

What is the phrase "feeling low in the shoe"?
     C)   Ballet
What are 3 ballet shoe companies?

     D)    Dress
As Podiatrists, we are interested in dress shoes with removable inserts to remove and put our orthotic devices. 

     E)   Walking (I love to have patients walk in running shoes)--more cushion and stability than walking shoes
     F)   Hiking
What are the 2 parts of a hiking shoe that helps in stability?
     G)     Soccer
What would have the longest cleats: Indoor or soft ground?
     H)     Ski Boots

What boot line is for narrow feet?

What is the best time to fit a ski boot?
When putting on a ski boot, what is buckled first?

And finally, the last word on what is in!!

What shoe line has the distinctive yellow stitching?
What shoe line started mainly as a skate boarding shoe?
What shoe line had the "Pump Shoe"?

Monday, October 10, 2016

Inverted Orthotic Technique: Email Questions

Dear Dr. Blake,

sorry for my bad english,
 I'm an Italian podiatrist; I very interested about inverted technique. I have some questions to ask:
- Is it right to think Fettig modification only with inverted technique? and then, is it only used to correct a forefoot valgus associated with rearfoot varus? if no, when and how?
- Denton and Feehery modification are similar, when apply one or the other?
- In your daily treatment, do you often use these modification?
Thanks for your patience!

Dr Blake's response:

     Thank you for the kind email. I am happy to teach you. Please feel free to take the information I give you and ask any more. I will combine with this posting.  My wife and I hopefully will go to Rome next year on vacation. The Fettig Modification is a modification of the Inverted Technique only and used for the many patients with both a pronation tendency and a supination tendency. The Fettig can only be used in forefoot valgus (everted) feet, as it uses the forefoot valgus correction to be an anti-supination instrument. When the inverted technique controls rear foot pronation, the Fettig can grab that lateral column and slow down or stop mid stance to propulsive phase supination. The supination tendency can come from many causes one of which is rear foot varus, another unstable lateral column, or weak peroneals, or chronic ankle sprains, etc. The Denton modification, her sister lives in Rome, is an extrinsic lateral arch fill that wonderfully fills up the lateral arch  and helps block a supination tendency. The Feehery is an intrinsic raising of the cuboid and lateral anterior calcaneus that does the same, but you cut into the cast. Like the Kirby skive laterally, you have to learn when to violate the cast and when not to. I make orthotic devices as a process typically only violating the cast on the second modification when needed. This is the same general principle I typically use for the Kirby skive.
     Let us say that you have a patient with pronation and supination tendencies. They pronate mainly at contact, but due to chronic ankle instability, love to misstep and supinate at times (typically also at contact). For the pronation, you estimate they need a 30 degree inverted correction. For the supination tendency, they have a forefoot valgus/plantar flexed first ray we can use. So, you order a Fettig. You can also typically add a high lateral heel cup and lateral phalange, a Denton modification, and a full topcover to a forefoot valgus extension under the 4th and 5th metatarsal heads. 
     Let us say that you suspect initially, or you see at dispense, that the patient is not as controlled laterally as you would like. Your next orthotic device will be a lateral Kirby skive to the above cast, a Feehery cuboid skive, or both. And you  can also add more height to the lateral heel cup, and more height to the lateral phalange, along with a bigger forefoot valgus forefoot extension. The possibilities are endless. Please ask other questions. Rich

PS I use the Denton routinely (almost daily) and the Fettig modification 1-2 times per year. I probably use the Feehery once every other month. I relie a lot on stable shoes, lateral phalanges, forefoot valgus extensions.

Sunday, October 9, 2016

Recovery from Sesamoid Avascular Necrosis:Can he avoid surgery?

Hi Rich

I hope fall's arrival is treating you and your family well.  I noticed that on a video or two you are wearing cornell gear.  I graduated from cornell in 1984 and my daughter graduated with both her BA and MS. 
Dr Blake's comment: What a wonderful school!! I actually went to Cal Berkeley, but my oldest son Steve went to Cornell. He loved it, and really blossomed as a young man.  

wanted to give you and update.  It has been 6.5 months since my injury and Since labor day, I have resumed partial weight bearing, after 12 weeks NWB (bc of avascular necrosis).  Have had PT since july and ongoing.  Progress has been slow, prob 75 to 80% weight bearing, but can't seem to do more than that without getting pain beyond (0-2) and getting some swelling on the big toe joint.  Feel stalled for past 2 weeks.  Still in walking boot 80% of the time and using crutches to control weight bearing 100 percent  of time.
Dr Blake's comment: Of course, the daily routine of pain level is fine. You can not push it. You should be bone stimulator daily, ice pack twice daily, contrast bathing in evening, massage 2 minutes 3 times a day with the palm of your hand, 1500 mg calcium, 400 units or more Vit D, 1/2 inch adhesive felt in boot as dancer's padding off weight, and a soft orthotic with 1/2 to 1 size larger shoe in the wings. 

  Since injury, I Have seen 2 ortho foot and ankle MD's who counsel patience and slow rehab, and the diagnosing podiatrist (Ivan Herstik, MD, do you know him?  affiliated with NY School do Pediatric Medicine, says he has done over 100 of  these  with many good outcomes ) who feels I have maxed out on conservative measures and recommends surgery.  He feels risk of arthritis and other factors could limit my mobility in the  future even more if I do not get the medial sesamoid excised as I am only 54.
Dr Blake's comment: No, I don't. I would see one of the podiatrists in New York for their opinion that I know: Dr Karen Langone, Dr David Davidson, Dr Robert Conenello, and Dr Joseph D'Amico. Arthritis can be watched for as joint limitation and plantar changes of the first metatarsal. With all the followup MRIs, typically every 6 months, it is hard to imagine missing the development of arthritis. It is still with you in the discussion of "preventative surgery" and I do not have a great feel of those 2 words used together. 

I am going to get custom orthotics from a well regarded pedorhist next week or so. I may also try aqua therapy at Burke Rehab.  Still getting once a week acupuncture and exogen (5-10 min 3-5 times a week, cannot tolerate more as it sometimes causes more swelling and pain if I do too much) and contrast foot bathing 1-2 times a day.   My thinking is that if I cannot walk with minimal assistance (cane) and keep pain level manageable by Thanksgiving (only 6 weeks away), then I will likely get surgery.  My QOL has been low to nonexistent since april.  thanks goodness I have supportive family to help.

Any advice or reflections would be helpful
Dr Blake's comment: I try to tell the patients I am treating to give me a year. If their quality of life is still too hampered, and usually we have now 2-3 MRIs by then which do not show enough improvement, then surgery is needed. But, it is rare to have the surgery, but only 1 out of 20 get significant AVN. If you haven't gotten, please get a CT Scan in the next month, because it is the best test for AVN and for arthritis. The protocol for sesamoids that alot of docs use is 3-4 months to heal, and if not, remove. I have many patients that healed fine in that time, and some taking several years. Vital to the surgery is the manufacture of good off weight bearing orthotics for the year post op. It is also vital to the avoidance of surgery. 

By the way, for my Left foot sesamoiditis, I am finding zero drop or low drop sneakers helpful.  Altra shoes in particular.  Tried Hoka Bondi but the early stage rocker design was too much (although super max cushion ) and seemed to aggravate the sesamoiditis , maybe because toe was curved toward in that early stage rocker design?  they recommended constant 2 which has later stage rocker and is a more stable cushioned shoe, but I will wait to try until I see how I am doing over ext 1.5 months
Dr Blake's comment: I love the Hokas for sesamoids, and typically the Hokas with orthotic with dancer's pads with spica taping can work. But not for everyone, and the subtle differences in Hokas can make a difference for sure. Good luck and thank you for your kind words. 

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Saturday, October 8, 2016

Orthotic Arch Height

Dr Huppin discusses a simple, but very important, concept in arch height. I am amazed at how many times I find not correction in this area. However, it is not that simple, since many corrections for supination tend to correct laterally (outside of the foot) and not medially. You should never feel that the shoe and ortho combination makes you unstable to the outside. If your dealing with metatarsal or heel pain, you desperately need weight transfer to the arch. Very crucial say with plantar fasciitis or sesamoid injuries.