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Thursday, December 31, 2020

Stretching Principle #1: Static Stretching Rules

•#1   Hold each stretch for 30(minimum) to 60 seconds, and repeat twice.

Even though we all would like to be able to stretch like this dancer, our stretches should be at a level to get a nice pull in the muscle and tendons we are trying to stretch. 

Remember: Every one should daily stretch their calves/achilles, hamstrings (as demonstrated here), quadriceps, and low back. These 4-5 stretches done routinely will make a huge difference in our legs. 

Treating Injuries: Many Decisions along the Way

     First of all, I want to wish everyone a Happy New Years. We are all so happy to end this sad and disturbing year with the hope for the future. Please stay safe. 

     When treating athletic injuries, there can be many decisions along the way, and many directions that must be followed. There are standard approaches, and new avant-garde approaches to consider like PRP and shockwave treatments. The sports medicine approach which was avant-garde in 1980 is now more mainstream where the patient and doctor work as a TEAM. Google searches have also had mainly a positive influence on my patients whom seem more prepared. 

     The goal of this post is just to remind you to that an active role next year in helping to direct your health care providers, yet with full respect. We all get tunnel vision on problems, and follow that orange line above even when the patient is not improving. Some physicians are black and white and can not easily bend, therefore 2nd opinions become necessary. Usually your Primary Care doctor will know someone for you that may have to think out of the box at times. 

     So, here’s to a great healthy New Year!!!! Rich 

Wednesday, December 30, 2020

On Death Experienced: That Deep Sense of Loss can come from Many Sources

                                By Richard Blake

The fist is hard
As it explodes so deep
The emotions so high
Talk seems so cheap
Death of self plays a sour note
A loss so deep that everything
Is affected and actions in remote
Continue the self while the soul begins
In that very death, flowers do bloom
Priorities shift
As inward
we drift
The self being sifted
When death is experienced
The grief cycle will play
Inner strength must end it
With friends we can say
I'm ready to go on now
At least for another day
To work with you in the garden
And accept my stumbling along the way.

This was an early poem I wrote dealing with the loss felt in our human condition from many sources: a divorce, a death, a terrible injury with permanent disability, a job loss, retirement for some, etc. 
Yet, the resilience of the human condition normally does express itself after the various stages of grief, and our job as parent, spouse, doctor, or friend, can simply just to be there for support. 
The garden of life has sunshine and rain, flowers and weeds, and even beautiful roses have thorns that can cut and cause infections. Yet, gardens are normally ignored in the winter hard times, and bring us much joy in the spring with new growth. 

Good vs Bad Pain: How can any pain be Good?

Foot Pain: Dilemma of Good vs Bad Pain

This is the Post all my athletes need to read.


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 out through, or to feel afterwards. Bad pain is discomfort that must be stopped, 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,” in probably several languages. They can participate at very high levels with pain, hoping that they can work through it. Sometimes they can, but many times they can not 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 can not be tolerated. This group may actually learn to accept some pain as okay, or good pain. 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 an injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt. 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 with this?

4 Golden Foot Rules 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.

 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 3 pain level (scale 0 to 10).

Let us focus on these 4 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 and it is best to stop. Participating with 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, 6 hours before an event is permitted. Many of the anti-inflammatory drugs 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 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 still may exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, 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 hurt then for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 3 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. Good pain, is not perfect, but 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.

But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more deconditioned 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 fix.
 If you still believe "No Pain, No Gain", I can not wait to see you at our sports medicine clinic as a regular customer. Learn about your body through this process. It has prevented 3 surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletics. Good Luck!!


Monday, December 28, 2020

Philosophy: Why Aging in Medicine Strikes at the Heart!

“One must go further, one must go further.”
This impulse to go further is an ancient thing in the world.
—Søren Kierkegaard”

Excerpt From: Kim Lim. “1,001 Pearls of Spiritual Wisdom.” Apple Books. 

Boy, is this true or not!
The world keeps spinning round and round
Yet it is moving slowly in a certain direction. 
Where spinning denotes staying in the same place, 
We know change is occurring, and a newest is on the horizon.

After 40 years a podiatrist, my world really does not exist any more
Is it time for me to move on, like so many of my fellow classmates?
Are there secrets to the human body I can still teach?
Will anyone listen?

Yes, humans must move in a direction that they think is progress.
But does progress denote too much change
Do we have to change what is working?
Progress, or the impulse to progress, demands it.
The old must die, the new born babe is the future
We can not do what our fathers did
We are inbred to not become our fathers!

Reading Inserts: These are from the Top of Some Custom Made Orthotics

I love the art of reading inserts from shoes or from the top of an orthotic device. Here if you look at the medial rear foot, you can tell that there is more pronation force on the right side. As the weight moves forward on the insert, it is too far on the lateral side especially on the left. The weight distribution on the metatarsals is quite even on the right and slightly more lateral on the left. However, the Hallux pressure shows good push off both sides. 
I am happy that there was not blockage of first ray plantar flexion with pressure showing up at the distal medial aspect of the orthotic device. The pronation at heel contact has been blocked, the foot re-supinates and gets weight forward and slightly lateral, so that the first metatarsal phalangeal Joint can have an active push off. 

Healthy Hiker: A Great Blog to Follow

Alicia Filley writes a great blog. If you are a hiker, her tips are very valuable. If you are just trying to get some exercise and be healthier in the New Year, you will also find great inspiration. January 1st she is sponsoring a webinar that looks great to get motivated this coming year!! Here’s to Great Health.

My 2021 Health Goals:  (in no particular order)

     Be More Consistent with Doctor Appointments

     Use my Peloton Cycle 3 Days a Week

     Get My 10,000 Steps Daily on Average

     Be More Consistent with My Balanced Home Program: Legs, Core, Arms

     Eat Healthy 

     Meditate More

     Schedule Several Hiking Vacations (when it is safe)

     One Long Hike Per Weekend (Over the normal 10,000 steps)

     Reduce Hours at Work to Take Care of Health

     Spend more time with Friends (when it is safe)

     Get My Covid 19 Vaccination 

Sunday, December 27, 2020

A Typical Orthotic Manufacturing Day

As many of you know, I make my own orthotic devices. Occasionally, like today, I have fallen behind and I need to finish around 5-6 pairs all at once. Typically, my goal is one per day, and I can do that during a day I see patients. But, today is Sunday, after my glorious week off for Christmas, so here I go. 
My brother Robert Blake, or just Uncle Bob to my children and grandchild, works Friday and Saturday for me completing 70% of the orthotic process. I have to prepare the work load on Thursday and Friday nights, I also personally review the positive cast he has prepared, and make modification as are necessary, so I am always happy with the correction for the patient before pressing the plastic. 

Orthotic Device #1

This is your typical dress orthotic device. There are no rear posting and it is made narrower than an athletic pair. When you narrow an orthotic device, since the lateral or outside border of the foot should be a perfect match for cuboid stability, you always narrow from the medial side. 

Here I have added 1/8th inch Poron to the top of this orthotic device. Poron is one of the best shock absorbing materials (which will be helpful for this patient with hip arthritis). Poron however is fragile and has to be covered by something so I am using a thin soft piece of leather. 

Orthotic #2 through #6 The Hannafords
The initial grind is making a heel cup 

Today I will be making 5 pairs of Hannafords. Two of them for a patient with chronic metatarsalgia and the full length nature of the device is wonderful and soft. The memory foam gradually creates a perfect impression of the foot. 

Typically I make my Hannafords 2 inches longer than the foot and then trim to the shoe insert at the time of orthotic dispense. 

After the heel height is made, the width is taken in removing all but 2 mm thickness in the heel area only

2 Pairs of Hannafords shown here with the heel cups made and the thickness of the heel cup about 2 mm all the way around from medial to lateral

After grinding the heel cup, the medial and lateral borders must be straightened so it will fit in a shoe. All the excess from the heel to the toes must be removed medial and lateral. 
Bottom view of all the side excess gone

Top view of all the side excess removed

And now for the bottom grind. The bottom is ground flat and parallel with the front surface. Any varus or valgus tilts needed for a patient’s biomechanics is applied later. The Hannaford, which can be made off any representative mold that you trust, does not balance forefoot to rearfoot deformities (like plastic based orthotic devices can). 
The bottom grind starts at the junction between the firmer and more durable white plastazote layer and the softer (against the skin) orange plastazote layer. It is important that this transition is smooth and the white layer all the way back to the heel is parallel to the orange. 

The flat base grind shows a contact point exposed of orange material at the heel. When the initial press is made, 1/2 inch of full length orange plastazote is glued to 1/2 inch sulcus length firmer white plastazote, heated only for about one minute in 450 degree oven before vacuum pressed. The longer you heat, the more the plastazote will compress in the vacuum press thus becoming thinner. 
Here I am attempting to show a flat base from heel to toe after my grind. 
Here is just a reminder that I am doing each step to 5 pairs of Hannafords at the same time. 

The outline is the material on the bottom of the orthotic device that did not get ground flat. The part around the heel is removed by blending into the heel cup. The part in the arch is ground smooth to make a distinct arch. 
Here the heel area now has 2 distinct parts: flat bottom surface and heel cup walls.
Now the front (tip of the toe area) is tapered down, compared to a non-tapered Hannaford which would crowd the toes too much
The front is smoothed flat and the transition from front to arch area smoothed
Here you can compare the smoothed top (probably needs alittle more work) versus one that has not been touched at all on the top surface. 
Smoothed Transition into the arch

Non smoothed transition
Smoothed medial arch

Medial arch before smoothing
Example lateral arch before smoothing

Lateral arch with some smoothing
It is important to note that memory foam orthotic devices like Hannafords get their stability from the walls of the shoes that they are placed in to a big degree. I never touch the top surface of a finished Hannaford, other than forced to use a metatarsal pad occasionally, since I want the top layer to become a perfect fit to the patient after about 30 hours. The bottom layer however can be modified as much as seems fit. 
And yes, I did finish 5 today!! This is a nice 1/16 inch neolon top cover.  When the orthotic compresses, I replace this at the month follow up visit with 1/8 inch Spenco. 

Some of my patients gave me the shoe insert so I could fine tune the sizing before they come in. Smarter than me!!

Saturday, December 26, 2020

Knock Knees or Genu Valgum: Biomechanical Challenge

This patient obviously has a huge challenge. The knee mal position or mal alignment causes incredible compression forces on the lateral knee compartment. Standing stability is gained by the opposing pressure created at the medial thigh area and widening the base of gait. More to be added tomorrow. 


Wednesday, December 23, 2020

Heel Pain When You Stop Walking: Email Advice

Hi... Dr. Blake , I work in hospital. When i walk on floor or standing I have less pain on my heels but after I sit down ,I start feeling burning on my heels. When I wear shoes on my walking ,my feet feel ok but when I sit down feels like my shoes choke or feel tight on my feet. So I wonder why I feel burning on my feet after walk when I siting down.thank you

Dr. Blake's comment: there are 3 possibilities. First of all, it is typical plantar fasciitis with its symptoms after prolonged inactivity. The second possibility is low back compression of typically L4/L5 nerve root. You should feel better if you lay down and get up then sit and get up, or at least different. Thirdly, you it can be venous, where the veins are not working as well as possible. Again, sitting can be the worse, laying second, and walking around getting the circulation to move best. Check these scenarios out. Rich

Saturday, December 19, 2020

2nd Toe Problems: Email Advice

Hi Dr. Blake,

I'm not sure if you remember me, but I am a former patient of Dr. Hannaford's and after he retired, you helped me adjust a semi-custom orthotic he made for me for running. I was reviewing your blog because I'm having a 2nd toe issue but the page I want to access keeps directing me somewhere else. I am hoping you may be able to help over email?

My right 2nd toe is swollen and a bit warm to the touch at the tip part (to the first bend). There are no cuts, I didn't jam it. Walking is ok, I can feel it is a little swollen but it doesn't really hurt. Oddly a little itchy yesterday but ok today. There have been a couple times while running that I've felt something strain a bit but it's more towards the bottom of the ball and it quickly goes away. Should I make an appointment to see you? Or just take ibuprofen for now? I do think I should have my orthotics looked at again and adjusted. I'm starting to get a small callus on the ball of my foot in between where the big and second toe align.

Thanks in advance for any advice you can provide.

Dr. Blake’s response: Thanks for the email. The primary culprit would be a slight ingrown toenail that can fester for months. The second culprit would be some soft tissue irritation if the second toe is your longer toe (Morton’s Syndrome). Yes, it would be good to see you and perhaps make some room for that toe by adjusting the padding on the orthotic devices. You can make sure that you have the correct size of shoe by standing and see if you have a full thumb width length to the end of the shoe. You can remove the shoe’s insole (if possible) and check where the impression is for the 2nd toe (say closer to the end of the insole than the uninvolved left one). If you have been walking a lot lately, and there are a lot of downhills to walk, the 2nd toe if longer can just be sliding forward in the shoe even if the correct size shoe. Some of my patients buy a medium foam toe cap to put over the 3rd toe to make sure the 3rd toe is taking a little more pressure always from the second. Other patients have bought a small toe crest (there are individual for the right or left side) and placed the loop for the 3rd toe to lift the 2nd off the ground. Make sure you cut your nails a little shorter than normal to see how that works. Try a week of a 30 minute warm water soak each evening to pull out some inflammation. I love that over drugs. Hope some of these ideas help. Rich