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Tuesday, November 26, 2019

Part of Proper Shoe Fitting with Orthotic Devices

When I am fitting a wide orthotic device like an Inverted, I must place my fingers along the distal medial edge and make sure it is sitting on the base of the shoe. I do not want it to hang up on the edge, as that will tilt the whole orthotic device and jam up the first ray. 



If that is the case, you have two choices. You can narrow the entire orthotic plate from medially, and lose some of your correction. Or, you can take off the distal medial corner only, like in a first ray cut-out, which maintains the original support. 

Sunday, November 24, 2019

Shoe Wedging for Pronatory or Supinatory Problems

This post is a photo coverage of the common steps I use in shoe wedging for severe supination or pronation issues, that custom foot orthotics are not adequate enough.

This is a patient that had a complication in ankle fusion which left her right foot in varus foot (leaned to the outside) with terrible ramifications for her foot and the rest of her body.

First the midsole of the shoe is split with a 10 or 11 blade scalpel about 2 inches deep and within an inch of the toes.
Here the shoe is being stretched apart to make sure I got adequate cuts
I will then be using 1/4 inch Korex or grinding rubber that I purchase from JMS plastics in New Jersey to form my wedge.
The photo on the left shows the opening is separated as the glue dries. The photo on the right shoes both the shoe and wedge are glued and allowed 20 minutes to dry. The image below this is a closeup of the beveled wedge. 



There the wedge has been placed into the shoe and the excess removed



Superglue will used to seal any gaps 




Final product showed





Friday, November 22, 2019

Sesamoid Injury: Cortisone Shot or Not?

Hi Doctor Blake,

I stumbled upon your blog after lots of sesamoid research! And now I am asking for your help with my recovery... 

Long story short I’ve been off from dancing (just wearing special sneakers with dancer’s pads) for 7 weeks now for a micro fracture of my sesamoid. I just received an MRI with these results below (apologies if the translation from another language is weird):

Presence of bone edema of the entire medial sesamoid, with low T1 hypersignal T2 signal.  No fracture-separation of the bone, no sign of necrosis, and in particular no deformation of the bone surface.  Reactive joint effusion of the MTP 1. Light hallux valgus (confirm on radiography under load).  No sign of sesamoido-metatarsal osteoarthritis.  A little edema of hyperfunction of the plantar tissue in contact with the medial sesamoide.  No anomaly of the stabilizer of the sesamoid.  No abnormality of the hallux tendons.  Moreover no anomaly of other MTP and inter-capito-metatarsal spaces.  CONCLUSION: Appearance confirming medial sesamoiditis, without fracture or underlying necrosis.  Light hallux valgus (confirm on x-ray in charge)

I am seeing two different specialists in my country but now I have run into the problem of opposing medical solutions and I am not sure which to go with. 

One doctor recommends a cortisone injection and the other recommends oral anti-inflammatory medication. The doctor who recommended the oral medication told me that the cortisone injection is very dangerous for a sesamoid as it damages the foot’s natural padding, therefore exposing the sesamoid to further damage... 

The doctor who recommended the injection told me that the oral medication will not do anything to help the sesamoid and that all stories about sesamoid’s being made worse by injections are mainly myths and cannot be proven.

I am emailing to ask your advice on this debate? I am hesitant to get the injection because of all the mixed reviews online but it is a more “immediate” and localized option which is tempting. Do you have any feedback or success stories of oral medication? Or any thoughts on cortisone’s long term risks?

Any feedback you could offer would be greatly appreciated! 

My apologies for such a dense email, but your knowledge would be so helpful for me!

I thank you in advance for taking the time to read this email and I hope to hear from you soon.

Sincerely,

Here on this MRI image healthy bone is dark. The light tibial sesamoid indicates a healing response from the body. Hard to tell stress fracture (can not see) from bone bruise in these cases


Dr. Blake's comment: 

 I must side with the oral medications, which can not be taken before you dance (only after). Your MRI shows that the sesamoid has been slightly injured. Cortisone will mask pain for up to 3 days (short acting cortisone and not dangerous) to 9 months (long acting cortisone). Your dance career can not risk masking pain where the sesamoid injury worsens. You can ice twice daily and do contrast bathing every evening. You must float the sesamoid with Dr. Jill's dancer's pads of either one eighth or one fourth inch (3 to 6 millimeters). These can be bought on line and worn even walking around barefoot to protect the sesamoid. I have my patients get 2 lefts (both sizes) and 2 rights (both sizes) since the adhesive is on one side and at times you are wearing it on your foot, and at times you are putting it over or under inserts in shoes. Whatever you put on your injured foot, should be on the other foot for balance. I hope this helps. Rich 

Saturday, November 16, 2019

Thursday, November 7, 2019

Ankle Sprain with Significant Ankle Problems: Email Advice

Hello Dr. Blake,

You had helped me immensely through a long sesamoid recovery 7 years ago. In the end, I made it through to fully healed with no pain! For anyone with bad sesamoid injury, you can and will make it through the nightmare!  It can be done. 

Unfortunately I return with a new issue. 2 weeks ago I twisted my ankle stepping off a curb. I had some pain, though the majority of that pain went away in a few days. Then a few days later i was pushing my kids in the stroller up a steep hill (I’m new to the Bay Area) which put my ankles into intense dorsiflexion. I started getting pain the day after and was not able to dorsiflex, but Especially plantar flex without pain in my ankle (in the back). I was able to walk on it for the next week,  but had to limit dorsiflexion to avoid pain. After seeing a podiatrist, I was recommended to wear a boot (talk about PTSD from my sesmoid injury). The majority of my pain is on the lateral side, right behind and under the boney bump of the ankle (fibula). 

Nothing showed on x-ray, which I’m starting to realizing doesn’t mean all that much.  Today I got MRI results back and was hoping you could help to interpret and provide your thoughts? Photos attached.  I clearly have a talar dome issue (cartilage), though my Dr. seems to think that’s been there for a long time. For a long time I’ve always had some minor stiffness and pain in this ankle, but it always went away after a few minutes of getting ready in the morning. I’m assuming that what that is. But since that issue is more on the medial side (whereas my pain is lateral), is it possible that’s not the driver of most of my current pain? Or could a lot of this be due to that and I will need surgery?

My Dr believes the majority of the pain is from the sprains (ligaments) that need to heal. Though I see some remarks in my MRI about “stress reaction” which makes me think that there is possibly a stress fracture, but for some reason that didn’t make it into the MRI’s concluding remarks. What are your thoughts?

The Drs plan is to stay in the boot and revaluate after 4 weeks? I also know better and will do contrast bath.  

Does all these seem reasonable?  I “feel” like there is enough pain to possibly be a fracture, but can’t tell if it’s ligaments and soft tissue issue we’re dealing with here. How long of a healing process do you think I’m really facing?  I just want to set the expectation for myself, my work, and my family correctly. 

Thank you,


Dr. Blake’s comment: thanks for the update on your sesamoid. You have a fragile ankle, and someday you may have to have it cleaned out, possibly bone graphed or replaced. Someday! I see people all the time that sprain their ankles and wake up a sleeping giant, which you could have done. You have to treat the worse possible scenario to protect you, so you place it in a boot for awhile, gradually wean out into a brace, gradually increase all activities and follow how the ankle behaves. With the goal of walking around with 0-2 pain as our guide, you go one month at a time. Have you achieved 0-2 in the boot? Do not let anyone put cortisone into your joint as it can weaken it further. If you get a bone scan, and it lights up, you can call this a stress fracture and qualify for the bone stimulator. That may just strengthen the bone enough to have you dodge the surgical bullet. Separate from your injury, I would get surgical consult from several orthopedist or podiatrists on what they would do if this does not improve. Hope this helps. Rich

Wednesday, November 6, 2019

Great Article on Running: Forefoot Strike more Prone for Plantar Fasciiits

Here is the link to "Foot arch deformation and plantar fascia loading during running with rearfoot strike and forefoot strike: A dynamic finite element analysis": https://www.sciencedirect.com/science/article/pii/S0021929018308959

Posterior Tendon Tendon Taping: Leukotape


Leukotape with Coverall to protect the skin is the best tape for pronation control and posterior tibial tendon injuries. It starts just below the lateral ankle bone, goes under the heel and up the inside of the ankle 2/3 up the leg

Tuesday, November 5, 2019

Anti-Pronation Shoes Work, but only until the athlete fatigues

 2019 May 14;14(5):e0216818. doi: 10.1371/journal.pone.0216818. eCollection 2019.

Effects of anti-pronation shoes on lower limb kinematics and kinetics in female runners with pronated feet: The role of physical fatigue.


This is a great study showing how stability and motion control shoes work in controlling pronation only to the point the athlete fatigues. Shoes and proper training and strength work are all key ingredients to athletic success.

Plantar Fasciitis: Support the Foot Taping


My patients know I love Quick Tape from www.supportthefoot.com for my plantar fasciitis treatment. It is meant to stay on up to 7 days. My wife just wore it every day in our 500 mile trek across Northern Spain to prevent her right plantar fasciitis from ruining the trip. I feel it is diagnostic also, since other problems that are not plantar fasciitis can mimic the symptoms. If you use Quick tape, and your symptoms improve, you definitely have some plantar fasciitis. 

Sunday, November 3, 2019

Plantar Fasciitis: Success Email

Dr Blake,
Your patient with the left foot plantar fasciitis that is virtually gone with your 4 pronged approach.  😊
Dr. Blake’s comment: Simple first visit plantar fasciitis treatment is rolling ice massage for 5 minutes twice daily, plantar fascial wall stretches 3 times a day, Sole OTC inserts, and Quick Tape by supportthefoot.com. Works most of the time if it is pure plantar fasciitis. 

Got up the next day after tennis with oven baked Sole inserts and 0 pain. Just feeling a tiny 0.5/10 “this might return” sensation now that doesn’t limit my activities at all.

Found Quick TapeTM 3 pack on Amazon for $30 but only up to size 11, not my size 12.  I want to have them ready for use on day 1 of a flair.  Was I using regular size up to men’s size 11 from your office or is there a better source?
Dr. Blake’s comment: Use Quick Tape regular size on every one men’s 14 and smaller.

I’m stunned at how effective this has been. Thank you for this great combo treatment that isn’t on UpToDate or other reputable sources.

Look forward to celebrating over coffee, tea, meal and checking out the Sole fit at your convenience

Thanks,

Good Success Post Sesamoid Surgery