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Saturday, February 29, 2020

Peroneal Strengthening with Resistance Bands

Article on the Statistics of Coronavirus, Flu, and Diabetes

Speech from President Kennedy on the much needed Universal Health Care

Good vs Bad Pain: Very Important Lesson to Learn when You Are Injured

Dilemma of Good vs Bad Pain

For the athlete dealing with a painful situation, coming to a useful understanding of what is good and bad pain becomes crucial to speedy rehabilitation. Good pain is discomfort that is appropriate to work through, or to feel afterwards. Bad pain is discomfort that must be stopped; it is the breeding ground for setbacks and flare-ups.
Varying pain thresholds in athletes can greatly complicate matters. Some athletes with a high pain threshold can train through a more serious injury believing that they are doing no harm, only to find that the injury has greatly worsened. In this case, their body’s own feedback mechanisms have let them down. Something in their head is yelling: “No pain, no gain!” and probably in several languages. They can participate at very high levels with pain, hoping they can work through it. Sometimes they can, but many times they cannot, and the injury gets worse. Most of these athletes need the outside help of coaches and personal trainers, doctors and physical therapists, to help set some limits. Their own “self-preservation” mechanism is not working properly. Evolution to better body awareness can occur with good coaching. There is hope for this group. For other athletes, including myself, with low pain thresholds, all pain is bad and cannot be tolerated. This group may actually learn to accept some pain as okay. They can also evolve.

Besides varying pain thresholds, there are many physiological reasons that the exact same injury can hurt a lot more for one athlete than another. The closer the injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt, especially with deep swelling that cannot escape the joints, bones, ligaments, or tendons. If the injury is on the outside of your foot, and you walk/run on the outside of your foot, you will hurt more than another patient who walks/runs on the inside or the middle of their foot. The weaker the area is before you are injured, the more you will hurt after the injury, since it will take longer to get the area strong. These factors are just a few.

Remember, injuries first heal, and then double heal. Some bones, like your metatarsals, may get approximately twice as thick during the total healing process. This is why tendon and ligament injuries can heal with scar tissue that leaves the tissue twice as thick. So, even when an injury is completely healed, more healing may occur for several more months, possibly producing noticeable symptoms to the athlete. Healing always produces some level of pain with swelling, muscle tightness for protection, scar tissue breakdown, etc. This can be good pain. So, how do we make some sense of this?

Four Golden Foot Rules that may give us some focus:
Golden Rule of Foot: Never push through pain that is sharp and produces limping.
Golden Rule of Foot: Never mask pain with pre-activity drugs, including ibuprofen,
                                         aspirin, etc., and even icing.
Golden Rule of Foot: 80% of healing occurs in 20% of the overall time, with the
                                    remaining 20% taking 80% of the total time.
Golden Rule of Foot: Good pain normally dwells in the 0 to 2 pain level (scale 0 to 10).

Let us focus on these four rules. When an athlete asks if they can participate in their activity, there is no breaking of the rule of sharp pain and limping. Good pain may be at the start of a workout, then eases up. If the pain comes back in the middle of a workout, this is bad pain (as you have hit the threshold of tissue strength) and it is best to stop. Participating in a team activity that is semi-dependent on you is tough as you ease yourself back into activity. But you must be clear from the start of the activity that you may need to stop if pain develops. Ask your co-participants to tell you if you are limping. Sometimes they see it before you feel it. Limping throws the entire body off, risking other injuries. Sharp pain normally produces limping, but limping can also occur as you transfer weight to avoid pain or if a body part is too stiff to bend properly.

Drugs, as simple as aspirin, ibuprofen, etc., can mask little to significant pain. Never take these drugs before participation, only after, if allowed. In general, taking medication six hours before an event is permitted. Many of the anti-inflammatory drugs (NSAIDs) also inhibit bone healing, so are contra-indicated in bone injuries entirely.

Healing can take a long time to completely occur with any injury. The job of the doctor, therapist, and patient is to try not to repeatedly get in the way of the healing process. But even with our best efforts, we tend to take two steps forward, one step back, then two forward, then three back, and so on. I am happy to say in following injuries for more years than most of my readers have existed on this earth, injuries do heal. People do forget what ankle they sprained in 2004, and what heel got plantar fasciitis in 2007. Yet, most healing occurs in 20% of the time, with the remaining 10-20% healing occurring in 80% of the time. When you are 80% better, level 1 or 2 pain may still exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, and occasional flare-ups, to get rid of the last 20% of symptoms. It is considered the realm of good pain, but it can wear thin on our nerves and patience.

Good pain is pain/discomfort/soreness/tenderness/dolor that does not have to interfere with activity. Listen to your body. Does the pain cause limping? Is the pain sharp in intensity? Does the pain come on in the middle of an activity? Does the pain come on after an activity and then hurt for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 2 range, no matter what your pain threshold is. Good pain is normally gone the next day, so there are no residuals. Good pain does not cause limping, and is not sharp, although a temporary sharp twinge lasting seconds is typically okay. Dealing with good pain is not the perfect scenario for my patients, but it is your daily reminder to keep icing, stretching, strengthening, and listening to your body. Good pain can be a good guide to allow you to work an injury to complete healing. It can be your training guide and friend.
But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more de-conditioned you become, and the longer the return to activity process will actually take. So, it is better to try to discover the difference between good and bad pain. The better you become, the better decisions you will make in your athletic life, and the longer you will be an athlete. The better you become, the better prepared you will be for the next injury. An important medical decision may be made based on your knowledge of good and bad pain. If all pain is bad, you will have a less active life and may seek surgical intervention as a quick and sometimes unnecessary fix. If you still believe “No pain, no gain,” I cannot wait to see you at our sports medicine clinic as a regular customer, but I will try to convince you otherwise in the long run. Learn about your body through this process. It has prevented three surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletic injuries. Good Luck!!

This is an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

What Sports is All About!!!

Low Dye Taping for Plantar Fasciitis: New Video on Self Application

Tuesday, February 25, 2020

Kinesiotape has many great qualities, but does not help Ankle Stability

     I use Kinesiotape and Rocktape in my office all the time. The study above documents that these flexible tapes are not strong enough for ankle stability, even those I have found them useful to helping activate weak muscles and biofeedback functions. The ankle motion is too strong. However using Kinesiotape on less stressful joints (big toe joint, MPJs, midfoot, and at muscle attachments) is very helpful.

Monday, February 24, 2020

Posterior Tibial Tendon Braces

Hi Dr. Blake,

I sprained my ankle about 8 weeks ago.  I had very little pain, swelling, and bruising and was walking on it the next day.  I then realized that I had lost significant range of motion in my foot which concerned me, so I took it easy for about three weeks, only walking as needed but not walking for exercise.  A month after the injury I was still concerned about the limited range of motion ( up, down and side to side).  I was also concerned about my inability to raise my heel off the ground when standing only on that leg.  I had watched a lot of youtube videos about sprained ankles and that didn't seem to be a symptom.  

So, after a month I went to a podiatrist who confirmed that I had a grade one sprain of the ATF.  I told him I was concerned that I couldn't raise my heel when standing on that one leg, but he didn't say anything about that.  Now, eight weeks after the injury, my foot is basically pain free although it still appears slightly swollen and bruised on the ATF side.  I can now raise my heel off the ground easily when seated (not weight bearing) but can only raise it an inch or two off the ground when standing on that one leg.  At least it is improving slowly.  

I just did some research online and learned that my symptom is likely due to PTTD.  That may also explain why I have been having a feeling of pulling under my foot (sometimes when I walk) basically where the back of my arch meets the underside of my heel.  It looks like that is right about where the PTT wraps under the foot.  

I have been wearing the blue powerstep insoles but am thinking about switching to the red ones that offer even more arch support to hopefully take more pressure off the PTT.  Also, I found a couple PTTD braces online, and I was wondering if I should get one of them to wear for a while.  Wondering if you would recommend one of those and if so, which one and for how long?  Here are the ones I found-

I already have an ASO brace and could use that, but I'd rather get whatever is best for this.

Thank you for your help!!  I really appreciate it.

Dr. Blake's comment: 

The above Bioskin brace was touted as a good one for his Stage 1 PTTD by one of my patients. Aircast and Richie's are for advanced cases which I hope you are not. See my video also of posterior tibial taping with leukotape, a good alternative to braces usually. Rich

Sesamoid AVN: Email Correspondence

For anyone that might read through this with similar problems - I am the patient in this email correspondence. As I write this comment I'm 6-months further along - it's Jan 2020. I'll update again in another few months. I spent about 6-weeks non weight bearing on my left foot and then another couple of weeks after that in one of those big boots you can walk in. I spent 3-months through to November contrast bathing every night and I've been using an Exogen bone stimulator on my left foot every night for the last 5 months. After the boot I transitioned into New Balance Fresh Foam More shoes with some home made orthotics to off-weight the sesamoids.

For whatever reason over the summer my right "good" foot also became painful in that big toe region and I freaked out and ended up getting that MRI'd as well. It continues to be sore in that same sesamoid big toe joint area but the MRI showed up pretty benign. I've continued to exercise throughout although being pretty conservative with my activities. I haven't tried pushing it too hard yet but I'm curious to see how my feet handle more aggressive activities.

My current status is a pretty much constant low level discomfort and stiffness feeling in both feet in that sesamoid/big toe joint area when I'm walking. It ebbs and flows a little bit but I haven't had severe flare-ups at all in the last 6-months. I've done a little walking bare foot, played with my kids fine, swim regularly even pushing off walls, bike rides, done a couple of short hikes, and worn dress shoes for work on occasion. It's not perfect and I haven't done any running or played soccer at all - the background level of things doesn't really feel much different to when I was diagnosed with these issues 6-months ago - but it was really the flare-ups and not being able to walk without hobbling that was the most debilitating. 

I'm not willing to take any more aggressive steps like surgery at this point. Especially considering my right foot acted up as well and there's not really any way to pinpoint exactly what the problem is with that. I was taking a lot of anti-inflammatory meds to be able to function before I got formally diagnosed with this issue last summer. I'm not taking any now and so I at least feel like I'm establishing a good background level of functionality. It's concerning to me that the background level of pain and discomfort hasn't really improved or changed at all in the last 6-months but at the same time I'm working on finding the balance with how highly I can function activity-wise. My next step is to get some custom orthotics and further define what kinds of footwear can help me diversify into increased and more aggressive activities.

Saturday, February 8, 2020

Sesamoid Fracture: Email Advice

Dear Dr. Blake,

I came across your blog and since sesamoid injuries are so tricky, I thought I would reach out to you. It looks like you have been in the field for awhile and hopefully, you can give me the best course of action.

I was diagnosed with a medial sesamoid fracture on my right foot 7 months ago, about two months after running 1/2 marathon. I’ve been a runner all my life and have done a number of races. Im aware not to overdue things and had a running schedule designed by my PT to do a mix of runs and cross training so I was surprised to have sustained a stress fracture. I’m 39years old. 

I went into a boot for 5 weeks, and then slowly weaned out of the boot for a few more weeks. I was still having pain with walking, so  got another scan that showed delayed union, some healing but not fully healed. I went back into the boot for 3-4 weeks, and then has been walking in sneakers with orthotics. I was doing great until 2 weeks ago when the pain came back. An MRI showed edema, persistent fracture, a cystic intraosseus cyst  (which was on prior imaging as well), chondral loss, and partial ligamental tear of MCL. Full results below.

I saw a surgeon who has had good results with sesamoidectomies although I’ve heard that surgery could lead to further complications. I also have hallux valgus on my right greater than my left foot. Does surgery sound reasonable at this stage? If so, what should that entail, removal of the sesamoid only? Or would you recommend more immobilization? Drain the cyst? Steroid injections? I am desperate and would really appreciate any thoughts you have. I can send photos of MRI if that is helpful. I also had CT done back in Nov. Thank you so, so much.

1. Undisplaced fracture of the medial sesamoid bone with persistent
diffuse bone marrow oedema appears similar to the previous study.
Fracture line is still visible on MRI but the degree of fracture
healing would be best assessed by CT if clinically indicated.
2. Cystic intraosseous lesion within the medial first metatarsal head
likely represents an intraosseous ganglion cyst related to the
proximal medial collateral ligament origin. This has decreased in
size due to bony ingrowth proximally but there is persistent
moderate bone marrow oedema within the medial head of the first
metatarsal similar to the previous study.
3. Persistent increased T2 signal and thickening of the proximal
fibres of the medial collateral ligament likely due to a partial
4. Unchanged full-thickness chondral loss first metatarsal-medial
sesamoid articulation.
5. Full-thickness chondral loss medial aspect of the first metatarsal
head at the first MTP joint.

Dr. Blake's comment:  thanks for reaching out. You had quite the injury involving at least 3 structures. If you can send me the images, I can get a better read than the report alone or some random images. My mailing address is Dr. Rich Blake, 900 Hyde Street, San Francisco, California, 94109. There is never a charge for this service, just part of running this blog. What I would recommend if this was me to rest the toe bend this next year. I know that sound alot, and of course you have to evaluate things monthly. You have alot to try to heal, and I think you should give yourself the time to try to heal. You abnormally loaded the big toe joint at some point injuring the medial sesamoid, first metatarsal head, and medial collateral ligament. If surgery was to be done, they would remove the medial sesamoid, perform microfracture surgery on the first met head, and sew up the medial collateral ligament. You would be off your foot for months on crutches and scooters, and this would be bad for the ligament should needs motion. And you would still need the shoe, orthotic, dancer's pads, spica taping, etc to protect the joint for a year post surgery. 
     So, my suggestion, start using Exogen 5000 bone stimulator twice daily, get into some bike shoes with the embedded cleats or other stiff soled shoes, learn to spica tape, and design dancer's padding. Massage with oils or gels the area twice daily to de-sensitize. Do icing for 5 minutes twice daily and contrast bathing for deep bone flush each evening. All of this work is within the blog at various parts. The spica taping is actually very helpful when the ligaments are involved. 
     As the year goes on, you may be on the fast side of healing, and the restriction of shoes can be lessened. Make sure you have good bone health by getting a Vitamin D blood test, and a bone density scan. There has been many surprises on these. Hope this helps. Rich

Friday, February 7, 2020

Hallux Varus: Splinting Possibility

Dear Dr. Blake,

I came across an article from Podiatry today regarding non surgical solutions for patients who had a failed hallux valgus surgery in the past, this is my situation - I am a 55 year old woman - that is active and busy at work.  I live in NYC, otherwise I would make an appointment to see you. I am suffering from this condition  after my bunions surgery went wrong. I am really looking for some kind of orthotics to help me with basic things as walking - since my big toe is always going to the outside - is there something else than taping it together that you can recommend?

Please I really appreciate your help and will be really thankful with any ideas/tips about it.

Thank you!

Dr. Blake's comment: For walking, get 1/4 inch adhesive felt from Alimed and place it along the medial side of the big toe to gently push towards the 2nd toe.

A local brace shop should be able to use multiform, also from Alimed, to fashion a sleeping brace. Depending on how tight your tissues are, they can slowly move the first and 2nd toes closer. A sheet is cut out about 8 inches long and 4 inches wide. My little video here shows the way they would wrap the multiform. A sock will have to be worn with it.

You also need to strengthen the right muscles. So, metatarsal doming must be done with the toes taped together along with single leg balancing. Hope this helps. Rich
PS you can always go to PT and have them make sure you are do the right exercises, but also increase the mobility of the lateral and medial capsules of the joint to allow it to be pulled back.