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Monday, August 31, 2020

Thank You Dr. Jane Denton for the Denton Modification

     Today is the last day I am practicing Podiatry with Dr. Jane Denton. She says she is around for September some, but nothing is fixed. So, after asking her advice for 38 years and using her brilliant orthotic modification for lateral stability for almost 35 years, I am finally saying thank you publicly. 
     Dr. Denton's modification has improved the stability for thousands of my thankful patients. A patient of mine last week told me that the difference in a good vs great professional is only in subtleties. The Denton modification is subtle, but powerful. It has been the difference in making my orthotic devices, and overall treatment, a success in both pronators and supinators alike. It is a vital part of the Inverted Orthotic Technique for severe pronators, and a crucial element of every orthotic device designed for supinators. I am attaching a video of the orthotic components crucial for supinators, and a photo of the Denton modification.
     So, Dr Jane Denton, I personally, and the world of podiatry, thanks you anytime the Denton modification is applied to an orthotic device. It always makes a difference, sometimes big and sometimes small, but it is always helpful in treating my patients. I will miss you. Rich 

Here is the Denton applied before ground down even with the floor or base of the shoe. 

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Friday, August 28, 2020

Designing Orthotic Devices with Temporary felt support to predict Pain Relief

 The red is the outline of the orthotic device I am making for this patient. The pink is the placement of support the patient will have as a front section to the orthotic device. The patient experimented for several weeks to find the most comfortable placement utilizing the 1/8 inch adhesive felt I gave her. This will save us a lot of time in making her orthotic devices comfortable. 

Thursday, August 20, 2020

Recent Interview for Spanish Podiatry on Biomechanics I Enjoyed Doing

Here I present during a Spanish interview 3 biomechanical cases with the thought process. Rich

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Wednesday, August 19, 2020

Inverted Orthotic Technique: The Reason the Device Works Still A Mystery??

As most of you know, I inverted an orthotic device almost 40 years ago that has been very successful. It has been the only orthotic device documented to help children outgrow their flat feet for instant. Yet, it is hard for researchers to grasp why. It is meant to change motion while walking or running into less pronation. Yet, studies have had a hard time studying this. The YouTube link below and the Podiatry Arena thread following is a wonderful example of this decision. The article they are referring to was on 11 symptomatic runners who when switched from standard orthotic devices to Inverted Orthotic Devices got better. But when studied, they could not find out why. I am actually learning a ton from these discussions and have my own theories. First of all, the study was done using the outside of the heel area of the shoe to represent the heel of the foot and this can be totally off. Secondly, the Inverted Orthotic Device is made for each foot individually, with different degrees for the right and left foot. And, when the foot does not respond, a redo is done to get it as perfect as possible. This was not done with the research. All patients, both right and left feet, got the same orthotic correction. In my mind, as a research project it was a failure from the beginning. This being said, it is my life's work, and I will continue to help it along as I can.

Technique in Performing Biomechanical Tests are Crucial: Article on Achilles Evaluation

It is great that 43 years after I was taught how to properly examination the tightness of the achilles tendon, that the below article documents it is still ideal. The article also warns us about being sloppy with our examination techniques as errors can occur. Rich

Dr. Bruce Williams on Pressure Mapping

I am excited about adding pressure mapping to my practice over the next month for my patients. I will continue to treat my patients the same, and begin to collect data from them with an in-shoe pressure device. It will take me awhile to learn how my patients will benefit, but I respect Dr. Williams who was interviewed and he feels after the learning curve of a few months, the impact will be apparent. Rich

Great Article on Nerve Pain and Making the Diagnosis in Athletes

I have just starting treating a patient with 2 years of pain unable to get anywhere in treatment. She sent me this article this morning that I read from a physical therapist on nerve pain. I would have to say I agree with so much of this article, and although I am not sure yet if it applies totally to my patient, is a good discussion of the 3rd source of pain in my patient. The 3 sources of pain, each demanding separate treatments at times, are: mechanical sources (like your foot pronates too much or your hip muscles are not strong enough), inflammatory (where swelling in the tissues causes pain from injury or systemic causes), and finally nerve pain (which can be local like Morton's neuroma, referred pain from the spine, or combination of local and up-the-chain problems). 
The one aspect not discussed, and also may apply to my patient, is nerve overload with chronic symptoms. This basically means that there was a mechanical injury, that even with complete heeling, can leave you with nerve hypersensitivity, which now months later is the reason that you do not feel any better. This nerve hypersensivity can also need nerve treatments over mechanical ones. 
So, as I try to sort this all out for my patient, the body will continue giving us clues which can help if we listen. Rich

Sunday, August 16, 2020

Stage II PTTD: Email Advice

Dr. Blake --

Thanks so much for your blog, it's great.  I had a few questions I was hoping you might be willing to help me with.  Feel free to share on the blog so long as I am anonymized.

I'm in my mid-40s, am very overpronated in both feet, and have long-term PTTD in my right foot.  I used to be an active runner (many half-marathons, one full) prior to these problems.  Here's the details (all about right foot):

*  Started having ankle and arch pain (in retrospect, classic PTTD pain) in 2009.  Podiatrist believed pain related to accessory navicular.  Kidner procedure performed, hard orthotics prescribed.
Dr. Blake's comment: For the reader's benefit, the posterior tibial tendon is the most powerful tendon to support the arch. 10% of people have that tendon weakened by having an extra bone at its attachment into the navicular. This extra bone is called os navicularis, accessory navicular, or os tibial externum. The posterior tibial tendon is weakened when some of the tendon does not attach where it should to support the arch, it attaches into this extra bone. It would be like 30-40% of the achilles tendon not attaching into the heel bone, but just hanging out up the leg somewhere. 

* Generally pain-free until mid-2016.  Mild flare-ups occasionally.  Podiatrist recommended that I give up running, so I did.  I walk a lot for exercise (and still do), probably 15-20 miles per week.  I wore orthotics religiously, but my footwear was not the greatest (I loved wearing Chuck Taylors with orthotics, podiatrist said that was fine as long as I wore orthotics).

* Got new podiatrist in mid-2016.  Asked if I could try running again.  He said okay.  Started running in neutral New Balances with orthotics.  No issues for a week, then on a run felt sharp pain inside of foot and ankle.  Wore boot for a while and it got a bit better, but pain continued off-and-on for a year.
Dr. Blake's comment: With Neutral shoes, you need a lot of support from the orthotics, with stability shoes, you need less. Hard to know what did it, as it could have just been weak. You are not commenting on strengthening, but post Kidner you should be on life long posterior tibial strengthening. Simple maintenance 3 days a week. I have attached my video of the exercises. 

* MRI in 2017 showed partial PTTD tear.  Podiatrist (who is also foot/ankle surgeon) says surgery may be needed if no improvement.  Got second and third opinions in Dec. 2017/Jan. 2018 from good surgeons (including Clifford Jeng at Mercy Medical in Baltimore).  All had same general take: PTTD stage 2, surgery likely needed, FDL/MDCO.  In this timeframe, I also tried UCBLs and a Richie Brace, which I could not tolerate very well (painful).

* I have small kids, so I told doctors that I'd like to grin and bear it if I could and push off surgery until kids were older if possible.  All said fine, and who knows, it could improve on its own.
Dr. Blake's comment: That is very unlikely, but Stage 2 is not a surgical stage. See if you can get some version of the Inverted Technique for PTTD, or at least varus wedge your current orthotics. Get the Aircast PTTD Airlift Brace and learn to tape like the video below. 

* The very good news: it did improve on its own.  Been basically pain-free for almost 2 years now. 
Dr. Blake's comment: I am humbly happy I was wrong!!LOL
 Dr. Jeng recommended Brooks Beasts to me, which have been great.  I wear them or Brooks Addictions (their similar overpronation product for walking) religiously, with orthotics.  I wear a Bioskin trilok brace on right foot if I can't wear the Brooks (e.g., dress shoes).
Dr. Blake's comment: I am glad you bring this up. The Brooks Beast is an orthotic in a shoe, so when you add another orthotic, you have amazing support. The Brooks Ariel is the women's version of the Beast. 

I had a few questions,if you are willing and have time to respond.

*  As long as things continue okay, can I avoid surgery?  Dr. Jeng implied this when he told me that he doesn't do surgery on feet that don't hurt.  (Interestingly, he said that the overpronation on my left foot is as bad as the right, but it's completely asymptomatic -- this happens all the time, he said.)
Dr. Blake's comment: Usually this condition is bilateral, with one side many years in front of the other. It is a degenerative process so no one can guarantee that you remain asymptomatic. With your history, you stay in good shoes, keep strong, tape and brace when you are in over load (backpacking trip), ice when needed, and stay away from activities that put severe demands on your tendon (like downhill skiing is better then snow boarding, or running flats are better than rocky hill trails). I have many patients in Stage 2 for the last 30 years and doing great, and some progressed over 10-20 years and needed surgery. I think the flareup you had was a good lesson for you. Never treat flareups as anything but another episode that you have to rehab from. That is the mind set you have to have. 

* Any chance I can run again, trying your walk-run program? 
Dr. Blake's comment: I love to have my patients run, and the walk run program is perfect. You run every other or even every third day. You run with the Brooks Beasts, with orthotics, on level ground. I would personally not start this until you are at 2 sets of 25 Level 6 resistance bands (which will take you 6 months to get to and then maintain 3 days a week). Running is so nature to our bodies, and thus innately safe, but we can do anything too much. 

 I very much would like to run again, I miss it.  I'd wear Beasts, orthotics, and the Tri-Lok.  I am willing to risk a small chance of recurrence (10%, say), but don't want to roll the dice with a more substantial chance.  Doctors I have seen have told me not to, though I get sense some of them don't understand runners.  So, I would take your advice to not chance it (if that is your perspective) very seriously.  I'd very much like to run again, but if I am really rolling the dice on a recurrence or worse if I run again, I understand that.  (I have also been told that it's very unlikely I could ever run after FDL/MDCO anyway.)
Dr. Blake's comment: To my above comment, do the posterior tibial taping also to hedge your bet. 

* If it was not too risky to run again, are Beasts/orthotics,Tri-Lok a good strategy? SEE ABOVE

* Are you aware of any business-type shoes that might work for someone like me?  I know they probably don't sell dress shoes with support like Beasts, but something in the ballpark would be nice so I don't have to wear a brace when I have to wear business shoes.
Dr. Blake's Comment: You can take a sturdy pair of Men's dress shoes (Wright, Allen Edmond, etc) and apply a 1/8th inch varus wedge to the out sole by a cobbler. Works like a charm for PTTD
Dr. Blake's comment: Of course, they blend it in. Good luck. Rich 
I very much appreciate any thoughts you may have.  I of course will take them in the spirit offered and not as specific medical advice, because you are not my doctor and haven't seen me in person.

Thanks again for your blog and doing this for folks!


Friday, August 14, 2020

Foot Nerve Pain: Email Advice

Good afternoon,

I recently read a blog of yours pertaining to a sesamoid injury. Her questions and your answers were exactly what I am going through. It brought me to tears to finally read someone discussing my EXACT symptoms that I have been dealing with for 4.5 months. I have a few questions and some information of what I have done/currently doing.

1. I stepped on glass back in March. A small shard of glass entered my toe and came out perfectly in contact within a couple of hours. I hit a nerve in my toe apparently (or so I think) as I had immediate pain in my toe that was not in the area that the glass had entered. Due to Covid it took a while for me to get in to a doctor. For 2.5 weeks I taped my toe and walked on the ball of my foot or outside of my foot and lifted my big toe constantly. All of this was done by walking barefoot on my hardwood floors. 

2. I continued to have a change in gait for many weeks to come and continued to walk on the hardwood floors putting additional pressure on my ball of foot by lifting my toe. 

3. I have seen a total of 6 doctors, I go to PT 2x per week for ultrasound and ASTYM and strengthening, and I also do virtual meetings with Caroline Jordan out in California. I have had a few xrays done as well as an MRI. The MRI only showed some inflammation directly above the sesamoid bones.
Dr. Blake's comment: For my reader's sake, Caroline Jordan worked with another great podiatrist, Dr. Arlene Hoffman, also in San Francisco, and chronicled her healing and exercise program for a sesamoid injury. Here is a link to one of the YouTube videos.
4. I had lots of nerve pain initially with my injury. So much so that I wanted to always keep my foot elevated to help with the inflammation and keep any additional pressure off my nerves. I could barely walk into the other room or have a sheet touch my foot:

5. I now wear a Hoka bondi outside and Fresh Foam More shoes indoors. I only go barefoot in the shower. I have nerve like pain only in my sesamoid area (poking, pinching, burning) and into my big toe sometimes as well but less often then months prior. I do get a small bubble in the webbed area between my first and second toe as well as in my second joint in my big toe. My foot is sensitive to the temperate changes in the shower. I really don’t look forward to showering for this reason. I’m using ice about 10 mins a day. I take turmeric, liquid fish oil, and vitamin D supplement (after reading your blog).  I will soon be getting custom orthotics made. 

What exercises or stretches should I be doing?
Dr. Blake's comment: The treatment should be nerve focused. Nerve love motion, ice 5 minutes only, and warm compresses more. Nerves therefore love neural flossing or simple range of motion of the toe and ankle, but no prolonged stretches. Nerves do not like pressure, so make sure that the orthotics off weight the area. Nerves love massage, if it is non painful, so use Neuro Eze or Neuro One to massage 3-4 times a day. Both over the counter products. 

Is nerve pain normal with sesamoiditis?
Dr. Blake's comment: The nerves are superhighways to your brain, that is why they unconsciously force us into mega protection mode. You injured the nerve twice that runs from your toe to your sesamoid (same nerve I suspect). First, you traumatized with glass, and secondly, you traumatized it by either holding your big toe in the air, or walking on the nerve under the sesamoid. Luckily you should have been walking slow enough not to injure the sesamoid badly (alittle maybe??)

Are there any sandals that are okay to wear for short periods of time?
Dr. Blake's comment: Oofos sandals would be my best bet now due to the softness. 

I know healing time periods vary, but does there seem to be an average amount of time?
Dr. Blake's comment: The mantra I use is "Look at a nerve funny, and it hurts for nine months". You are 5 months along, and you are improving. The reason you wrote (I read between lines sometimes) is that you do not want to have a setback and start over again. 

What can I do for the nerve pain in the mean time as I heal?
Dr. Blake's comment: Start with the above, and when they are all in place, you can add other nerve treatments if your symptoms warrant: flossing, massage with topical, warm or ice, off weight with orthotics or gel pads, soft sandals, and no prolonged pressure or stretching. Keep me in the loop, and I will try to answer. Rich 

Thank you so very much for posting! This has been one of the most emotional times in my life and have felt quite alone until coming across blogs posted by kind people such as yourself. 

Kind regards

Tuesday, August 11, 2020

Foot Nerve Pain: Where does it come from?

Hi Dr. Blake,

I have enjoyed reading your blog and felt inclined to send in a question regarding my foot pain.

I developed a lot of pain right under my big toe in my left foot (not in the ball of the foot, but the underside of the toe itself) about a year and a half ago. The pain had first started cropping up with rock climbing and got progressively worse over time. I got a cortisone shot from a podiatrist that did not help at all and I could barely walk (was in a boot/using a knee scooter) for several months. I ended up having 2 more cortisone shots in that toe over the course of the next year (the 2nd two shots did help, they were from a different doctor than the first time and spaced 4 months apart). I had improved to the point that I was able to do my day to day activities, but still could only walk for about 10 minutes at a time without causing a flare up of pain. 
Dr. Blake's comment: Do you know what he was injecting? Ligament, joint, nerve?

At the one year mark, my right big toe started experiencing the same symptoms and the bulk of the pain simply switched over to my right foot. My left toe stopped bothering me and my right toe became the problem.
Dr. Blake's comment: The only explanation was a nerve problem from your back. The position of your toe in rock climbing put to much tension on the local nerve. This same nerve, typically originating from L3/L4 or L4/L5 nerve roots in the back, was painful due to double crush. This means the nerve is being irritated at the foot and back combined. A slight change in your spine would make the symptoms jump to the other foot. That can could be from limping or protecting for a year, or a primary back problem. 

I limped around and tried to manage it with anti-inflamatories for 3 months before deciding to get a cortisone shot in my right big toe. As soon as I got the shot, I had a TON of pain in the ball of my foot closer to my 3rd and 4th toes (probably an inch below the base of my toes). The doctor I was seeing at the time diagnosed it as a morton's neuroma.
Dr. Blake's comment: Cortisone is for inflammation, which many times there is none. Cortisone if injected into the nerve, a superhighway in your foot and leg, can cause pain in many nerves. Morton's neuromas take many years to develop. 

The big toe pain either went away from the cortisone shot or was masked temporarily, and this new pain in the ball of my foot became the main problem. It pretty much made it so that I could not walk for more than 1-2 minutes here and there to get around my house. It also became painful to drive. I felt some relief by using a metatarsal pad to offload the area, but was still in pain. After 2 months, the big toe pain started returning and it would just depend on the day what would hurt more, the toe or the ball of my foot. My guess is that whatever help the cortisone was giving had worn off. 
Dr. Blake's comment: Yes, but cortisone is not a predictable way of helping nerve pain, so please limit. 

I began seeing a new doctor who ordered an MRI. The MRI showed a "stress reaction" in my big toe, but did not show much for the ball of the foot problem. My new doctor advised me to take a vitamin D supplement and to immobilize the toe for a month in a walking boot. After the month was up, my big toe felt a lot better, but I still had pain in the ball of my foot. 
Dr. Blake's comment: It is hard to know if the boot helped the stress reaction, or just not moving the toe helped you not to irritate the nerve. Did you ever have an MRI of the left? 
The new doctor diagnosed it as "metatarsalgia". He said it was possible that it could be a neuroma, but it was unclear from my symptoms. He gave me a steroid injection from the top of my foot down in the 3rd-4th webspace. This definitely helped and the ball of my foot feel much better. HOWEVER, I now have a similar pain in the ball of my left foot (sort of below 3rd and 4th toe or 4th-5th...hard to pinpoint). I again am unsure if this new pain is metatarsalgia, morton's neuroma or something else. It is worse some days than others. Offloading with a metatarsal pad helps. My doctor has prescribed 6-8 weeks of physical therapy so I am planning to try that next. 
Dr. Blake's comment: You are making me a little dizzy!! LOL Only irritable nerves behave like this. Has your back or any other part of your spine, up to your neck, been an issue in the past? 

My questions for you are: 
What advice do you have to finally kick this pain? I feel like I'm playing a game of whack a mole....when one problem improves another one always seems to pop up!
Dr. Blake's comment: The problem with this is probably not finding the true source of the nerve issues. All of the pain would have to be primarily from the low back or higher. That would make the foot nerves sensitive, and as you favor one problem you then set off the other side. At least, this is the most common cause. I do like the "mole game" analogy. Research in your area PTs that are in the national neurologic physical therapy association as these peripheral nerves are not so mysterious to them. I am glad the cortisone is calming things down locally. 

Do you think my ball of foot pain is morton's neuroma? 
Dr. Blake's comment: No! You can have morton's neuromas that have never bothered you, and normally never will, unless something like this happens. Morton's neuroma has a surgical side that I would avoid thinking about. Typically, it is merely a local neuritis that the cortisone great for. So, I would call this neuritis over neuroma from now on. Yes, I am opinionated!!
Nerve problems present 1/3 of the time as pain (you, unfortunately). 1/3 of the time as a mixture of pain and numbness. And, 1/3 of the time as numbness with funny feels of transient burning, bugs crawling around, tingling, vibration. The more pain involved, the more treatment, even though these scenarios present with the same pathology. Sad!

What do you think is the best way to heal the ball of foot pain that I have described?
Dr. Blake's comment: So, I would use 5 minute ice soaks, if tolerated, several times daily. I would get a pair of Hoka One One shoes or other stiff shoes that your toes do not bend alot. I would have the advice of a PT and Physiatrist about your back and peripheral nerve sensations. If someone agrees that you trust, then trying to calm the nerves down with topical medications like Neuro Eze, Lidoderm patches, TENS units, oral medications. Sometimes we are icing the back, and using warm water soaks for the foot. Find what predictably helps some, and stick with it for 3-6 months to slow down this roller coaster. The met pads seem to help for one so that should be part of your treatment. Come up with 5-7 times over the next month that have some positive affect. I hope this helps some. Rich 

Thanks so much!

Monday, August 10, 2020

Why Do I Watch Someone Walk?

My whole practice of Podiatry has gait evaluation as its foundation. I found this wonderful video last night on the components of gait, when things are right and when things are wrong. The happiness of a Podiatrist is somehow tied to the number of hours spent watching patients year after year walking and running. The happiness comes from truly helping patients with shoe selection, inserts, gait re-training, muscle stretching and strengthening, etc, all tied to injuries and preventing the same injury reoccurring year after year. Gait Evaluation can point to the Root of the problem, or at least one of its components.

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Sunday, August 9, 2020

Shin Splint Discussion: Part III

This is Part III of a discussion on Shin Splints. The links to Part I and II are attached. Here we will talk about treatments when the pain is all in the leg. Even though this discussion is geared for the podiatrist, patients can get a favor of what is important in their treatment.

Common Mechanical Changes for Shin Splints

  1. Strengthening of Involved Muscle Group

  2. Stretching of the Involved Muscle Group

  3. Reducing the Suspected Pronation or Supination Tendencies

  4. Stretching the Achilles Complex

  5. Strengthening the Achilles Complex

  6. Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment Issues Involved

  7. Training Decisions

  8. Consideration of Bone Involvement

Strengthening of Involved Muscle Group is crucial in all 4 types of Shin Splints.

What is important is good muscle testing principles and you will need to learn

how to differentiate the muscles in each group. It is well taught how to

differentiate testing of the gastrocnemius (knee straight) and soleus

(knee bent) in the posterior group with the other groups *equally

challenging. It is important to know if it is the posterior tibial,

flexor hallucis longus,or flexor digitorum longus giving the medial ankle

pain. Or, if it is the peroneus longus or brevis that hurts when testing against

resistance the lateral compartment. Or, if it is the anterior tibial or another

one of the extensors producing the anterior shin splint. 

Stretching of the Involved Muscle Group is typically only done for the

anterior or posterior muscle/tendon groups. You should know the general

rules for stretching,but remember stretching should never hurt or the tightness

actually gets worse. I recommend stretching an involved group 3 times a day

so I can get to 100 stretches within a month for my next followup visit

generally. It typically takes stretching 3 times a day to gain.

Reducing the Suspected Pronation or Supination Tendencies with varus

or valgus wedges, taping, arch supports, shoe changes, custom orthotics,

and strengthening exercises occurs when youthink the pronation or supination

observed in gait or activity is related to the type of shin splint. 

Stretching the Achilles Complex is vital to most sports injuries when

there is equinus forces. However, it is so important to be able to reliably

measure for this equinus because over stretching a normal or hyper flexible

achilles tendon will do more harm than good. Tight achilles has been known

to be involved in all 4 shin splint types. 

Strengthening the Achilles Complex is vital when the achilles is weak.

The acid test for normal achilles strength is 25 single leg heel raises with

the knee straight (gastrocnemius) and 12 single leg heel raises with the knee

bent (soleus). These are typically done in the evening. 

Custom Orthotic Devices particularly for Forefoot to Rearfoot Alignment

Issues Involved is your classic Root design. Doctors not trained in Root

biomechanics tend to use more metatarsal pads and anterior orthotic bars and

posts, and combinations of all may be needed. Not only is forefoot support great

for the correction of pronation or supination tendencies, the metatarsal support

provided can be crucial for long flexor or extensor produced medial or anterior

shin splints. 

Training Decisions for shin splints is universally to lighten the load on the

injured tissue. And for those athletes who seek treatment, the chance of a

stress fracture is high. The runner must cross train with biking as the

mainstay alternative. Since both hill work and speed work are more stressful,

slow distance training is the first goal to accomplish. Each sport involved

will have different strategies at lightening the stress first, and then

gradually re-introducing these same stresses. 

Consideration of Bone Involvement is very important in shin splints.

There are yearly reported cases of compound fractures in runners ignoring

the shin splint symptoms only to have the stress fracture become a through

and through fracture. I have had 27 year olds with shin splints have the bone

density of 80 year olds. It is important to remember Shin Splints can be bone

pain primarily, and verifying the patient has good bone health is crucial. 

Heel Bursitis: Email Advice

Hi Dr Blake, 
I'm a former patient from years back who is active and actively working on improving my feet as well as the rest of my 61 year-old self.  

I have what I thought originally was plantar fasciitis in the L foot after some heavy lifting / carrying,  clearing out some old furniture for our "bulky waste pickup" over the July 4th weekend.  The following week the soreness came on, and I took it a little easy on the running.  Then it would feel better, so I would do a longer run (only 3+ miles though) and then it would be sore again.  

I'm wearing zero-drop shoes (Altra) exclusively now with splayed toe box so my  feet can get back to their natural shape. I love them for many reasons, but I realize they are not ideal for a sore heel.  
Dr. Blake's comment: This is very true, zero drop shoes make the knee slightly more stable, and take some pressure off the front of the foot, but add stress to the heels, ankles, achilles, and shins. I like my runners to alternate between shoe types to vary the stresses. We have wonderful choices for this option now. Rich 

An active tissue release chiropractor I see prodded around the foot and released a lot of tight hamstring and calf. He has confirmed that it's NOT the plantar fascia, so I'm left hoping for bursitis. I really don't think it's a stress fracture; I don't do a lot of any one thing.  I was running daily (1.75 daily, 3-4 mi on the weekend), and am able to continue floor Pilates, Zumba 3x weekly, and strength work 2x weekly. 

Dr. Blake's comment: First, here is a link to my video on heel pain. Secondly, running every day at our age is not advisable and may be the whole reason you are hurt. I always find that it takes 3 things (or more) to team up to produce an overuse injury: daily running (so no adequate recovery time), tight achilles which weakens the achilles and prolongs the time your heel is on the ground, zero drop shoes also increasing your time the heel was on the ground thus stressed, and doing something that irritated the heel in your cleaning project perhaps. 

I have not been to a podiatrist yet, as my Health Insurance encourages us to deal with some of these things at home.  I'm also off arch supports since I'm working hard to strengthen my feet.  But I would come in to see you in a New York minute. 

Apart from icing, contrast bathing and not running for a while, any additional suggestions for suspected heel bursitis?  I am playing with offloading using 1/8" adhesive padding in a donut shape around the sore spot and will (grudgingly) get some shoes with a little heel elevation to take the weight off if it doesn't start improving.  I am getting fretful with no running! 
Dr. Blake's comment: Heel bursitis hurts the most when you try to walk on your heels barefoot, and no pain at all walking on your toes. Heel pain is tricky with heel pads, some work and some do not. You are trying to cushion the heel, and transfer the weight forward. Some heel cushion do that and some just increase the heel pressure. I personally do not like the donut idea, as I am afraid the hole will allow the swelling to collect which it sometimes does. But, you have to experiment which what makes it feel better. Run every other day. Walk for several blocks first to warm up the tissue and then run a mile (or even a half mile) as rest does not help. You of course can not have pain during, and no limping. Ice after the run. Can you get some cardio some other way? Bike? Elliptical? Ocean swimming (avoid sharks)? To break down the bursitis, freeze water in a sport bottle. Initially fill half way as it expands when frozen. Put a towel on the ground to protect your floors and massage the heel area only, not the arch, for 5 minutes progressively pushing harder. This is done sitting and is the most useful thing for the home for heel bursitis. Straight ice packs, without the massage, just controls inflammation, but will not get rid of it. I like some sort of OTC arch support of course to transfer weight off the heel--a temporary help while you reduce the bursitis until you do not need it. Rich 

Many thanks for your book (which is on my Kindle) and your blog. I'm a big fan. 
Dr. Blake's comment: Thank you, and I honored to help!!


Saturday, August 8, 2020

Healing from An Injury: The Physical Stress Theory

As many of you know, I love sports medicine. Helping patients through an injury is very rewarding, and very challenging. I am constantly learning. I just heard a great talk by Dr. Javier Pascual, Spain, and he recommended the below article as a must for rehabilitation. It is going to take awhile due to its length, but a first review it seems excellent. In podiatry, we are either decreasing stresses to help an injury recover faster, or we are improving stability of the patient, or just making sure that they are maintaining a healthy life. As I read through this article, I will use this post to add the key points.

Key Points brought out by Mueller and Maluf when presenting the Physical Stress Theory include:

Shin Splint Discussion: Part II

This is Part II of a discussion on Shin Splints. The link to Part I is attached.

One of the number one causes of shin splints that do not seem to improve is undiagnosed stress fractures. The young inexperienced cross country runners (or other athletes) who are not responded to shin splint treatment should be worked up for tibial (anterior or medial shin splints) stress fractures or fibular (lateral shin splints) stress fractures. This is still a version of the same process of overload. The overload in shin splints goes to the weakest link in the chain: the bone and a fracture occurs, the periosteum of the bone (which is the classic shin splint), the muscle belly, or the tendon.

The five most common types of stress fractures which are mistaken for shin splints are: posterior tibial (posterior or medial shin splints), distal tibia (medial shin splints), anterior tibial (anterior shin splints), fibula (lateral shin splints), or proximal tibial (either medial or anterior shin splints). Of course, if you do make the diagnosis a stress fracture, always think about the overall bone health. Did this bone break not only due to the mechanical overload of hills, pronation, supination, tight muscles, etc, but is the bone actually healthy? An unhealthy bone becomes the weak link in the chain. 

I mentally use the Rule of 3 in overuse injuries. The Rule of 3 means look for at least 3 legitimate reasons why a certain structure started hurting. Overuse picks on the weakest link in the chain, and many times a structure is weak because of 3-5 factors working against it. For example, since we are talking about stress fractures, remember that 40 years ago they were thought only to be related to impact shock. Then, article after article came out regarding stress fractures related to muscle contraction or bony torque. And, recently, the role of overall bone health has been more publicized. Therefore, if we use the common example of lateral shin splints actually being undiagnosed fibular stress fractures, the common rule of 3 includes:

  • Inadequate bone health with eating problems or low Vitamin D

  • Excessive supination causing excessive peroneal strain or simply increased lateral body weight

  • Weak Peroneal Tendons increasing the strain or pull on the fibula

  • Old lateral ankle sprains increasing the supination moments of force

With shin splints, the game for me is trying to figure out what muscle group is involved and what could be the cause of the overuse of that muscle/tendon. If we take the extensors as a group, they give us anterior shin splints. What causes general overload of the extensor group? The extensor group is again overloaded with a very tight achilles tendon complex which makes it work  harder to flex the ankle joint. Also running hills makes you use the extensors differently than what you are used to, especially eccentrically as you run downhills as they avoid foot slap. Typically our bodies will get used to the activity, so shin splints are usually from new activities or changes in some routine. When shin splints occur in a seasoned runner for example, I think bone over tendon, therefore I want to rule out a stress fracture first. And, to add an extra twist, there are 4 individual extensor tendons. The anterior tibial tendon can cause a shin splint particularly if the foot pronates too much. The anterior tibial is straining to decelerate contact phase pronation. The peroneus tertius and extensor digitorum longus get painful with over supination especially in midstance or propulsion. While the extensor hallucis longus is fairly neutral to the subtalar joint, it can overload in functional hallux limitus as it tries to lift the big toe off the ground, or in painful big toe joints (perhaps hallux rigidus) as protection. 

The lateral shin splint syndrome is commonly caused by over firing of the peroneals to protect the lateral ankle. Common causes of normal lateral or foot overload are: laterally worn shoes, running on banked road (foot held supinated), shoes laterally unstable (70% of all supination problems are not in supinators structurally), and foot types like pes cavus that overly supinate. One of the exceptions to this concerns the function of peroneus longus tendon to raise the medial arch by plantar flexing the first metatarsal. Here lateral shin splints can develop from over pronation when the peroneus longus is strained. 

The posterior shin splint is typically the soleus fibers or a tibial stress fracture. The pain is deep to the calf muscle belly, so given the name shin splint since it does not seem to be a calf strain. The stress fracture may never show up on xray, and not seem serious enough to get a conclusive MRI or Tc99 bone scan. 

In Part III of our discussion on Shin Splints, I will talk about general mechanical treatments

Friday, August 7, 2020

Modifying Boot with Metatarsal Fracture

Oblique Fracture at the Head of the Fifth Metatarsal Left Foot

2 one quarter inch felt layers to place in Removable Boot 
to off weight the 5th metatarsal fracture. It goes under the 
lining of the boot

Shin Splints Discussion: PART I

                         Shin Splints 


     I love shin splints for the academic challenge to figure out

what is wrong and what muscle/tendon is involved. Since shin splints are so common at the start of cross country season, it is easy to get a little lazy with treatment since most get better. You have to take the approach that the athlete will not get better without your treatment, and that should inspire you. I breakdown shin splints into medial, lateral, anterior, and posterior. The muscles and tendons involved are summarized below for each. This discussion of shin splints will be broken down into 3 parts, today PART I.

Medial Shin Splints

Involves the posterior tibial tendon, flexor hallucis longus tendon, or the flexor digitorum longus tendon

Lateral Shin Splints

Involves the peroneus longus tendon or the peroneus brevis tendon

Anterior Shin Splints

Involves the anterior tibial muscle, extensor hallucis longus tendon, extensor digitorum longus tendon, or the peroneus tertius tendon

Posterior Shin Splints

Involves the gastrocnemius muscle or the soleus muscle

Common Location Anterior Shin Splints

Common Location Medial Shin Splints

Shin splints actually can be defined as pain between the ankle and the knee. There are a lot of structures that can be involved which are important when treating these symptoms. When we treat shin splints, we can simply use activity modification, some ice, general leg strengthening, cross training, and most patients will do fine. However, if will treat it will a little more zest, we can prevent it from reoccurring. This can mean an athletic will have a longer running career. For the patient who does not respond to simple measures, they could have compartment syndrome or tibial/fibular stress fractures. Muscle testing sometimes helps, but most cases of shin splints are related to the muscle fatiguing when tiring. This is hard to test in the office when the patient is rested, although I do normally have patients workout hard, or workout to the threshold of pain, before their appointment last in the day. One muscle testing principles is to test the muscle in two basic positions: patient has advantage and examiner has advantage. You can pick up subtle weaknesses this way. 

A thorough understanding of shin splints starts with you defining it as one of these 4 types and then delving into the function of the muscles and how the patient may have overused that muscle or muscle group. Today, this blog post, will focus on medial shin splints.

If the patient presents with medial shin splints, the muscles involved are posterior tibial, flexor digitorum longus, and flexor hallucis longus. We then have to look for overuse in one of its functions. So, what do these muscles do actually? These tendons have many functions, but let us look at what they do at the ankle. Since they all arise from the deep compartment, they are ankle plantar flexors and ankle invertors. What is the primary ankle plantar flexor? That is the achilles tendon, but anything that makes the achilles tendon weak can cause you to overuse one of the 3 muscles causing medial shin splints as they try to help the achilles perform its job. Typical weakness in the achilles is simply fatigue from the new sport they are engaging in, or just adding hills to their running program can fatigue the achilles. But, an over stretched achilles or excessive tight achilles, is considered weak by force length physics. With the recent craze of zero drop shoes, I have also seen more achilles and anterior or medial shin splints. 

The ankle inverter function is probably the more common cause of medial shin splints. What taxes the inversion strength of these muscles? Excessive pronation can cause these 3 muscles to fatigue and strain as they attempt to decelerate the pronation. As the arch collapses in pronation, the medial 3 are strained, but especially the posterior tibial and peroneus longus (a cause of lateral shin splints). 

So, what are some of the causes of excessive pronation? Running itself with landing on the lateral side of the heel will cause 2-4 times more pronation than walking in many runners. Another one of the common causes of severe foot pronation is achilles tightness called equinus. This tightness can be the cause of posterior shin splints, but also anterior and medial shin splints. This is why a complete understanding of achilles strength and flexibility is crucial. If the achilles is tight, it is harder for the anterior (extensors) to dorsiflex the foot (thus causing anterior shin splints). If the achilles is tight, the foot can pronate and the arch collapses (medial shin splints), both putting strain on the functions of the deep posterior compartment. If the achilles is tight, the forefoot is forcibly loaded by ground reactive force, making it difficult to bend the toes in propulsion. Stress is placed on the long flexors (medial shin splints) and long extensors (anterior shin splints).

So when a patient comes into my office with shin splints, I need to see what type they have (medial, lateral, anterior, or posterior) and if I can figure out what they did wrong other than add a new sport. I need to check if their pronation is excessive (and you have to watch them run since running and walking for a patient can be totally the same or different). I need to measure for achilles tightness or over flexibility since the achilles tendon can be the source of both power and problems for athletes. I need them in their normal running shoes. If they are a pronator, I also want to categorize them as mild, moderate, or severe, so I can determine what level of support needed in my treatment to lower the tissue stress threshold so they can heal. This is where podiatry usually excels since proper shoes, custom or OTC insoles, appropriate strengthening exercises, and taping can speed up the rehabilitation and prevent re-occurrences. PART II will discuss stress fractures, anterior and lateral shin splints, and other general rules.

The video below is on posterior tibial strengthening when a weak muscle is found in medial shin splints.