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Tuesday, March 30, 2021

Okay, I will Admit it, I always wanted to be a Legend!!

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Wednesday, March 3, 2021

Timing of Hallux Rigidus Surgery: Now or Can We Wait and Get more Information

Dear Dr. Blake,

You can imagine my surprise when a podiatrist here in Davis, California just told me that the bunion bothering me is Hallux Rigidus
Apparently my daughter whom you have seen inherited this condition from me. Since you took such super good care of her I really hope you can see me too. The first available appointment with your reception is April 16. I plan to be in NM visiting my grandkids March 18-April 15, and since those visits include tons of hiking I would greatly appreciate it if you can somehow see me before I go.The x-rays today showed NO cartilage left, and the doctor suggested fusion surgery and orthotics. Apparently I should have been using orthotics for years now, but the podiatrist I saw for the bunion in 2015 told me simply to wear shoes with a slight heel lift and I’d be fine. Hmm...I went to today’s appointment because the toe area often hurts and clicks as I walk. I still play tennis 5 days a week and am generally very active, so I dearly hope you can help me!


Dr. Blake's comment: 

Thanks for your email and compliments. For sure I should be able to see you. Call and make sure you are on the wait list. Surgery can always be done, so if you can put it off indefinitely, that would be nice. Right now surgery and your symptoms make no sense. Rich
If you can make it, tell them I can see you 11:30 on 3/5 Friday

Addendum: The patient was able to schedule at that time. Rich 

Dr. Blake's further comments: I am not a surgeon although trained as one. Just not my interest, so I gave it up to be home more when my kids were small, but also to focus on sports medicine and biomechanics my true loves in podiatry. In situations like this, meaning problems that may need surgery at some point, I love to be able to work with a surgeon so the patient understands the whole process. The assessments I routinely use in this scenario are:
  • Assess when the health of the patient needs immediate surgery (like in alot of fractures we see in sports medicine)
  • Assess if the risks of surgery are less than the patient's problem (said another way----the patients disability now has to be worth the disability short and long term from the surgery)
If we use this rationale, yes, the patient may need surgery, but their activity level now is too high to warrant that surgery. They should know about the surgery, but what if there is a complication and the patient can not play tennis again? 
Some of this reminds me of how doctors get in trouble giving too many pain pills. Some of it is because they do not want the patient to have pain. Some of it is that they do not want to be looked at as a bad doctor. This is why I search for ways daily at getting my patients in the 0-2 pain level out of 10 consistently. If they can not accomplish this, we can talk about surgery and definitely get some opinions. Just because the xrays or MRI indicate a problem, does not mean we have to address that problem with surgery. Rich 

Tuesday, March 2, 2021

Review of Oral Medications Used in Peripheral Nerve Pain;year=2019;volume=67;issue=7;spage=32;epage=37;aulast=Lovaglio

  • Lyrica (pregabalin) and Neurotin (gabapentin) are Calcium Channel Ligands and the fixtures of first line treatment
  • Tricyclic anti-depressants, especially amitriptyline and nortripyline, are normally mixed right after maximum dose is achieved with the first line.
  • Other anti-convulsants (carbamazepine and clonazepam or lamotrigine) may also be added, along with other neuroleptic drugs
  • The goal is to drive this pain down (8-10 VAS to 0-2 VAS) and then maintain the dosage for several months before beginning the wean process
  • Based on the Pharmacological principle of Potentiation Synergy 2 or 3 drugs are so much better than one 
  • Therefore, Tricyclic + Lyrica or Neurontin = First Line then add Anti-convulsants 
  • 2nd line anti-depressants are venlafaxin and duloxetine
  • Gaba usually 300 mg daily for 3-4 days then gradually built to 1200 mg 3 times a day
  • Or, Lyrica (which works both peripheral and central) start with 50-75 mg day and gradually increase to 600 mg which is spread over 2 or 3 doses
  • Anti-depressants (also called serotonin-noradrenaline reuptake inhibitors) are started at 10-25 mg at bedtimes and slowly increased to an effective dose of 50-150 mg/day
  • Topicals (lotion or patches) tend to have lidocaine
  • However Capsaicin topical also works on some (from peppers)
  • Other non-pharm options are: alcohol or marijuana, psychotherapy, hypnosis, occupational therapy, PT, acupuncture, and TENS 

Monday, March 1, 2021

Use of Bike Shoes for Immobilization of Various Foot Injuries: And a big help for bad backs

One of my patients just tore her plantar fascia and needs to be immobilized. We have to stop impact stress (so no running for now), and we have to stop the bend of the ball of the foot (which puts stress through the plantar fascia back to the heel). These patients have been traditionally treated with removable boots (aka cam walkers). Even with the use of EvenUp type shoe accessories for the other foot, these removable boots tend to put a lot of stress on the back. Like me, so many of my patients have back problems, and so these bike shoes that do not bend (and look fairly normal) can be a God-send.