Total Pageviews



Sunday, June 28, 2020

New Series: How I Approach Problems: Plantar Fasciitis

     This is a new series of blog posts on various injuries entitled "How I Approach Problems". I will be going through common injuries to start and then the areas that proven more complex challenges. I hope my thought process will help you if you are treating this injury or have this injury or injured area.
                                                           Plantar Fasciitis

So, you have made (or been given) the diagnosis of plantar fasciitis (inflammation of the thick ligament under your arch that runs from your heel to your toes).

It is typically at its attachment at the heel where it is palpably sore on examination. If the soreness is somewhere else than its attachment, then the diagnosis should be in question. Since rare cases occur elsewhere, and if you are certain, the next diagnostic test will actually be the treatment to be prescribed. Plantar fasciitis should respond to this treatment.

The next test of the diagnosis is in the symptoms. Plantar fasciitis progressively gets sore over weeks and months. If the onset of pain is sudden, and the pain is under the heel bone, it is not plantar fasciitis. My next “How I Approach Problems” will be on sudden onset heel pain which is definitely not plantar fasciitis.

Plantar fasciitis also is always the worst in the morning when you get out of bed. Even though you should never use always in medicine, this is a pretty accurate rule. If the pain is not worse in the morning, it probably is something else. Again, we should see how it responds to treatment for plantar fasciitis.

Plantar fasciitis should have little to no soft tissue swelling. The patient typically can not feel heel swelling, but a doctor or therapist should. If there is significant swelling between the two sides of the body, it is probably not plantar fasciitis. Again, one of my next posts on “How I Approach Problems” will be on heel pain with swelling.

Plantar fasciitis should respond to typical treatments of ice massage, plantar fascial stretching, and taping. It can take a few months, but you should feel better and better each month. I love patients to continue doing activities that they can keep in the 0-2 pain range, even if it hurts more after. You do not run again until you are at the base line pain.

Treatment #1: Freeze a sport water bottle after filling 1/2 full of water. Roll over the painful area for 5 minutes 2-3 times a day with a towel on the floor as you sit and roll.

Treatment #2: I love the 2 achilles and 1 plantar fascial stretches described in the video below. These are typically done 3 times a day, especially before and after exercise like running.

Treatment #3: Tape the arch to immobilize the pull of the plantar fascia. I have replaced the time-consuming, but wonderful, low dye taping with Quick Tape from Support the Foot. This is typically left on 5-7 days at a time.

Plantar fasciitis always gets a lot better with this regimen. If there is little to no improvement, I doubt the patient (you) have plantar fasciitis at all. Next blog post will go over the decision making of no treatment response. If the patient gets 50% or so improvement but plateaus, we typically have to increase the treatment. Tomorrow I will discuss this scenario with partial success with plantar fascial treatment or no treatment success.

Plantar fascial treatment should allow full, but modified, activities. A non-response to treatment for plantar fasciitis, typically means that there is no plantar fasciitis but it can take a month of treatment to know that. A partial response to plantar fascial treatment typically means more specialized treatment is needed with inserts and PT.

Wednesday, June 24, 2020

Problems with Removable Boots and Swelling

Hi. Dr. Blake,

I wanted to get your take on my situation. I started having pain which turned to swelling at the end of Feb. 
I have very high arches (I have custom orthotics) but had not started wearing them yet. I went to a podiatrist who said that I needed to wear a boot. 
I wore the boot for about 4 weeks but still had some swelling. 
She suggested doing a MRI. During the time I was wearing the boot she said it was okay to walk around in the boot and so I was going for short walks with my son. 
I ended up seeing another podiatrist via tele med. He suggested Physical therapy. 
I did physical therapy for about 4-5 weeks. The PT hurt my foot and after the first visit I had swelling after I thought my foot was better from the boot. 
I continued the exercises and it felt like my foot was finally getting a little better but then he had me do some twisting balancing exercises that again really hurt my foot and made me think I re-injured it.
 He sent me back to the second podiatrist who did an MRI. 
He said I had a lot of inflammation and a small tear needed to wear the boot again, stop all PT and take  MEDROL or do a cortisone shot. 
I opted against cortisone, am wearing the boot but finding that my foot is swelling up again even though I am not walking and laying off it. 
I was also icing. I feel like the icing and the boot are hurting it. Is this possible? Maybe it's not getting blood flow.
 Before I got the MRI I was wearing my Dansko shoes at home and my sneakers and walking around an it felt better. I am really confused.
 Any sugggesitons?

Dr. Blake's comment: First of all, swelling can be inflammatory (typically painful), part of the healing/reparative process of an injury and chronic since it can last months and months after an injury (typically not painful), and related to venous insufficiency (veins having trouble removing fluid from feet and generally also not painful). 
So, when you say swelling, I need to know if this swelling hurts or not. 
Chronic symptoms, over 3 months, start to strain the venous return and swelling can get harder to drain out of your foot. You may need compressive socks or, at least, some period daily of elevation. Boots can begin to work against you and trap in the swelling due to the immobilization and Velcro strap restriction of the venous return. 
Icing controls inflammation, but usually does not get rid of it. Contrast bathing can be the best at removing inflammation and swelling produced by that inflammation. 
So, recommendations: Are we sure the tear needs to be protected? That is the million dollar question here. Inflammation is better served by contrast bathing not ice, no boot, some elevation, motion that does not cause more than 0-2 pain. I sure hope this rambling helps you. Rich 

Monday, June 22, 2020

Posterior Tibial Tendon Dysfunction (left side only)

Left Posterior Tibial Tendon Dysfunction with Arch Collapse and Heel Valgus

Here the actual degrees of Valgus is measured

I am designing him the first of three orthotic devices. The first orthotic will correct 7 degrees, the second orthotic up to 10, and the third orthotic up to 13-14. This is utilizing the Inverted Orthotic Technique based on heel valgus measurements. 

The Subtleties of Testing

There are many subtleties in tests ordered by doctors. This can be from brain scans to simple routine blood work. In my practice, foot X-rays and MRIs are a commonplace as the socks in my drawers. However, there can be subtleties in reading these well represented by this x-ray. While the report documented normality, the subtle signs of mid foot arthritis abound. Plenty of spurs and bone irregularities mark the painful area. For this reason, I always want to see the X-rays, and actually prefer to read them before I review the report. Many times I only get the report faxed to me and have to have the patient go out of their way in retrieving the CD of the actual images. I think it is worth it!!

Floating a Sore Spot on the Bottom of the Foot

 From the Image above you can tell where the patient is hurting. She took this image right after icing and was amazed at the color changed in the sore area. My schema is of the padding that I actually applied to the shoe insert that give her great relief. This is one of many patients whom the shelter in place has allowed for more walking, but that increased walking has brought out that some problems. She will continue to ice 5 minutes 2-3 times a day, and tape her 2/3 or 3/4 in a downward position. Another post covers that type of taping with KT tape or Rock Tape. 

Saturday, June 20, 2020

Vasli Dananberg Orthotic for Plantar Fasciitis and Functional Hallux Limitus

Hi dr Blake
I am 56 year old woman with plantar fasciosis of 2 years now since oct 2019 functional hallux limitus. In general have you found Vasalyi dananberg orthotic helpful if both  plantar fasciosis and hallux limitus Present .none of my sports med, ortho, podiatrists that I have seen  are familiar with it. Does it have any liabilities in your opinion. I read your blog am -doing the toe mobilizations and bought a toe spacer ( siliipos one)
Thank you

Dr. Blake’s comment: I am in favor of this design overall. The arch is deceit and the release of the first metatarsal to push off great. It will work less and less as the pronation syndrome gets higher, but a good place to start for sure. Rich 

Friday, June 19, 2020

Hallux Limitus/Hallux Rigidus: Conservative Thoughts

Let us start the discussion on avoiding surgery for Hallux Rigidus as our first option. Let's try conservative care for awhile. Here is my original Blog Post way back in 2010 on this subject.
Here are 2 PTs discussing mobilization of the joint. I typically do not recommend putting a rigid hard device under the toe that hurts initially, and I typically avoid the standard dorsiflexion and plantarflexion motions, but it is okay to see how it feels.

Sore on the Bottom of the Foot

Here is a patient from today's clinic. Yes, I am back after so much time off. Now, let's not blow it and forget our masks and social distancing!! I know I sound like your parents!!

     It is so important to off load sore areas on the bottom of the foot. This patient had a deep seated callus under the fifth metatarsal which I tried to dig out. Then I attempted off loading with my 1/8 inch adhesive felt. Thick moleskin also works, and you may have to layer to get the right thickness. 

Thursday, June 18, 2020

The Inverted Foot: What to Do?

I treat many patients that are inverted aka varus aka supinated. This is a great foot for me to help. Even though the exact numbers do not mean much, this is a patient with 10 degrees of genu varum (bow legs) with 10 degrees of tibial Varum. You can tell this patient likes to walk on the outside of their feet, however the compression forces are at the inside (medial) aspect of the ankle and knee. 
     As the patient stands they are inverted to the ground. You will want to perform the block test or have them rotate internally with the leg to see if there heels get to vertical. This patient easily had the range of motion to get to vertical. 

     Treatment wise you may decide on holding the patient inverted (say in the case of lateral meniscus injury or sesamoid injury) although allowing pronation for shock absorption, or getting the patient back to near a vertical position (say in a lateral ankle instability patient trying to avoid surgery, or chronic medial meniscus pain trying to avoid knee replacement. I will talk more on the inverted foot in the next few days. Rich