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Wednesday, April 28, 2021

Pain Scale and Its Importance

     For over 15 years, and probably longer, the pain scale of 0 to 10 has been both a valuable and mis-leading part of medicine. For those who read my blog regularly, you know that I relie on patients keeping the pain scale between 0-2 in my rehabilitation programs. It is in the 0-2 range out of 10 that I am insured that the patient is most likely not hurting themselves further, and most of the time allowing the injured tissue to heal. I try to get the pain down to 0-2 as quickly as possible, and hold pain level until they are back to complete function. 

The illustration above shows many of the ways to show this sliding scale with the green area pretty much where I need to advise patients to be functioning within. As the pain gets into the next real level of 3-4, the situation goes from tolerable to distressing. 
     Yet to ask a patient what their pain level is, is really asking them to do the impossible at times. Pain levels vary during to the day due to many factors, so I think we need minimum of 5 points during the average day to adequately assess. These points may be: first thing in the morning, during the morning, as the day goes on, with exercise, and after exercise. So, you can see that 5 points may really be 10, and it can get very complicated for an office visit. 
     In our physical therapy department, the patients are always asked how they feel before, during and afterwards. The goal of course is to have the patient feel better, in other words, have their pain go from 5 to 3 during the session. What has this to do with anything? I just think if you are really trying to rehabilitate a patient you should know more than just the average amount of pain they experienced that day. 

Saturday, April 24, 2021

Stubborn Plantar Fasciitis: Email Response

Hi Dr. Blake,

I've been dealing with bilateral foot pain for more than 2 years and treating it as plantar fasciitis.  My primary care doctor ordered MRIs and had them sent to the foot and ankle clinic at a local university medical center.  (I have a podiatrist, but he was not supportive of MRI.)

Anyway, the foot and ankle clinic reviewed the MRIs and determined that it was just a stubborn case of plantar fasciitis.  They offered to give me a cortisone shot and left it at that.

Anyway, I declined the shot for now.  I'm about to start PT again with someone who does active release technique.  Nobody has told me whether the plantar fascia tissue looks healthy or degenerated.  Is this something you can discern from looking at the MRI images?  

I am curious about the integrity of the tissue for two reasons:
(1) If I get the cortisone shots, is there a risk of rupture?
(2) Am I a good candidate for shockwave?  If the tissues still look healthy, then I wouldn't want to bother with the expense of shockwave.

I did some shockwave in the past and found it very effective.  However, I did not have the other components in place -- flexibility and biomechanics -- to make the results last.

Let me know if I am not sending you useful images.  There were so many to choose from.  And I would love to know if you think this could be something other than plantar fasciitis, such as nerve entrapment, bursitis, etc.


P.S. Thanks for your help.  Your blog has been the greatest resource.  I just made a donation.

Dr. Blake's Response:
Hey, just not enough images. Take photos of all T2 images (probably 10 or more from different directions) that show the plantar fascia and heel. The T2 are the ones where the bone is dark. Rich 

Patient's Response:
Thanks Doctor.  Here is a selection of the ones not marked T1.  There were quite a lot, so I did some guesswork.

Dr. Blake's Response:
You did well, the ones with the bone dark are the T2 images. No inflammation and no fibrosis (thickening) is seen. The plantar fascia looks normal on these images. The cortisone is for the inflammation and the shockwave for the scarring, so neither seem indicated. It does appear nerve. Consider 10% alcohol shots (typically a series of 5 once a week) for the nerve, along with a topical like nerve compounding cream and neuro flossing. Sometimes, TENS units help since you can do 3 times a day. Send me the report so I can read. See the video below. Also, do you have low back or spine problems that can cause nerves to be sensitized. Rich 

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Wednesday, April 14, 2021

Types of Orthotic Devices

The following is from my upcoming book "Practical Biomechanics for the Podiatrist" coming out in 2022. 

Orthotic Type:

1.     Functional 

2.     Sports 

3.     Dress

4.     Accommodative


     How can we truly differentiate these orthotic types? It is difficult on the surface, but let me tell you how I look at these. Every custom orthotic device I put in a shoe is functional by the fact that I am trying to have the orthotic device perform a function. However, being functional by those who manufacture orthotic devices means that function is changed by the orthotic material itself due to changes made to the custom foot cast. This is called intrinsic correction, the positive cast from the patient’s mold or foot scan, is changed to influence a new shape to the foot. Only in this arena, 3-4 degrees of forefoot varus means a lot to the manufacturing of the orthotic device, or a plantar flexed first metatarsal is treated differently than a metatarsus primus elevatus. Functional orthotic devices grew out of the necessity to help patients so crippled that they could not walk, or at least they were having a lot of symptoms. And yes, the Inverted Orthotic Technique, Root Balanced Technique, Dynamic Support Insole System, DC Wedge, Kirby Skive, Mueller Posterior Tibial, and Bi- and Tri-Axial Devices are all functional. Any repetitive motion or standing position can be the subject of change from a functional device. Therefore, motions like cycling, running, walking, rowing, golf, elliptical, etc, are all subject to predictable changes with orthotic devices. Activities like tennis, basketball, squash, etc, would be put into the sports orthotic category for sure. Therefore, if some measured degree is important when you make an orthotic device, you are probably making a functional one. 

     Sports orthotics have some element of the patient’s foot shape, but deviate from those truly functional by adding both a full length aspect and cushion full length or only in one area (like the heel). The motions in sports are so much more varied than straight walking. Both the predictability and the unpredictability has led to designs for various individual sports like ballet, basketball, tennis, soccer, etc, with relative incredible success. The full length aspect is so crucial since many athletes spend the majority (or over half) of their time just on the balls of their feet. Sports orthotics have their origin from a totally different place than functional orthotic devices. The function that the provider is attempting to fix is less a foot problem (like the degrees of forefoot varus or valgus), and more a sports problem (like the amount of heel cushion needed for a runner). A great example would be the orthotics made for ice-skating boots or ski boots that can only have a small forefoot correction and no rearfoot posting if they are to fit into a tight fitting boot. In this individual case, the boot itself gives so much support that less can be needed from the orthotic devices themselves. However, so many sports orthotic devices are so functional, and so sophisticated, that the phrase “sports orthosis” should not imply less support or “less function” by any means.


     Dress orthotic devices typically are just smaller versions of functional orthoses and can be made lower in the heel cup and a narrower cut. Of course, custom foot orthotic devices are always narrowed from the medial side, as it is crucial to be in full contact with the lateral border of the foot. Normally, thinner materials like carbon graphite or fiberglass are used so that the orthotic device takes up the least room possible. It is important to already know that there are no adjustments needed, as these thinner materials can not be adjusted for high spots. They can be adjusted for length and width. I typically tell my patients that I will make the athletic pair first, and based on the response and corrections needed, decide if I can use the same cast for the dress pair. With the advent of removable inserts, bigger versions of dress orthotic devices can now be made, and sometimes even an athletic cut orthosis can be fit into a “dress” shoe. So many sports, or at least foot deformities, need a great deal of correction. These corrections are built into the mold normally that is used for all orthotics. The practitioner must decide if the same mold can be used for a dress version as the correction may need to be reduced due to the bulk created. I prefer separate molds for athletic and dress orthoses when there are major corrections in the athletic cut. Some shallow shoes can not tolerate the use of a rearfoot post in dress shoes. Men’s shoes are more adaptable in general. Some of my women patients require hybrid orthoses like “cobra style” which cup the heel and support the medial arch some. 

     Accommodative orthoses protect the foot by off weighting and cushioning. These are the two big functions of this orthotic class. Probably, the over the counter diabetic insole was the first version, but I find that some customization really makes this type of orthotic device so much more effective. I typically will both take an impression cast and even do the corrections that I want in a functional device. The material that I make the orthotic device with will be soft like EVA, plastazote and poron. The EVA or plastazote becomes the heat moldable base that the orthotic device is made off, whereas poron or Spenco are just added layers like top covers for more cushion. Accommodative orthotic devices can be made in both athletic or dress versions, or standard orthotic length, sulcus length, or full length. The Hannaford device is one such full length accommodative orthosis that is very special to my practice. Multiple layers of plastazote, softest against the skin, are utilized to make this device. This device can be made off a corrected or uncorrected impression cast. Since there is no plastic, it can be adjusted in any way that fits the patient’s needs: thinned, narrowed, made stiffer, sweet spots added, varus or valgus wedging, metatarsal support, various top covers, and the list goes on and on. 


     In this book on Practical Biomechanics, it is hard to get away from foot orthoses. So, how do we all get better at prescribing this modality. I always feel that you should have a range of options when prescribing orthotic devices. It is important first to decide the type you will prescribe: functional, sports, dress, or some type of accommodative devices. When the patient sits in front of you, and you have just taken some form of image of their foot to send to a professional lab, first ask what do you need to accomplish. Here is the list of questions to help you make that decision?

1.     Do I need to change foot function by supporting a measurable degree of deformity, like 4 degrees forefoot varus or 5 mm metatarsus primus elevatus (Functional)?

2.     Do I need to change foot function or position not caused by a measurable degree of deformity, like correcting heel valgus from posterior tibial weakness or equinus forces (Functional)?

3.     Do I need to change the stresses occurring in sports, like dampening the impact force at the heel causing heel pain(Sports)?

4.     Do I need more stability in a narrow dress shoe (Dress)?

5.     Do I need to off weight or cushion a specific spot or the entire foot (Accommodative)?

The answers to these 5 simple questions should help you begin. 



Tuesday, April 13, 2021

Gout: Our Office Handout

Gout: Treat the symptoms Immediately


By Richard L.Blake, DPM



  Gout can affect many patients in a podiatry practice. The number one location for a gout attack is the big toe joint, but the other foot joints, the ankle, and the knee can have the excitement of an acute gout attack. In the photo below, the man's left big toe joint is slightly enlarged with some run of the mill wear and tear, and a prime suspect for developing gout in the future. Gout attacks have a propensity for affecting already damaged joint surfaces.




    I look at the source of a gout attack from 3 angles (or a combination of all 3): the kidneys for some reason are not flushing out the uric acid from the blood stream well enough, there is a systemic reason for increased metabolism which is producing more uric acid into the blood stream (uric acid being a normal breakdown product of nucleic acids called purines), and a recent diet of food rich in purines (which breakdown to uric acid).


    Common food concerns include:

  1. Limit organ meats, herring, mackerel, and anchovies
  2. Limit red meat such as beef, pork, and lamb (only 4-6 oz daily)
  3. Limit fatty fish and other seafoods such as tuna, shrimp, scallops, and lobster
  4. Limit beer
  5. Limit white bread, cakes, and candies
  6. Limit high fructose soft drinks and sodas
  7. Increase use of plant based proteins
  8. Increase use of low fat and fat free dairy
  9. Increase 100% juices
  10. Use of 5-10 ounces wine daily okay
  11. Use complex carbs such as whole grains, fruits and veggies
  12. Use of 4-6 cups of coffee for men seems to be helpful



 When you get an acute gout attack, your involved joint is normally red, hot, and swollen. The health care provider asks about your kidneys, your overall health, medications you are taking that may affect uric acid metabolism, any recent crash dieting, any recent changes in your diet like a vacation of eating rich foods, beer, etc, and possible infections anywhere that could have seeded the sore area, like a sore throat. A Gout Attack Looks Like An Infection. To help in the diagnosis of possible infection, the lab is asked to get Uric Acid, CBC with differential, and Sed Rate. The last 2 help with infection evaluation. Patients with an infection also may have systemic signs of fever, chills, malaise, etc, not seen with gout attacks.


 It is extremely important to know that once you get a gout attack, uric acid levels in your bloodstream drop as the crystals go into the joint, and your blood test is read as normal. But, you are still high normal, and you still did have a gout attack. At my hospital, Saint Francis Memorial Hospital in San Francisco, 8.7 mg/dl is still normal. When a patient comes into the office after a gout attack, the lab may read between 6.5 and 8.0. This patient has gout in my mind. I ask them to get a repeat uric acid test in 1 month and then 2 months to see what the uric acid levels are doing. In a patient whom has suffered a gout attack, even if they are mindful of their diet, their uric acid levels begin to go back up over the next 2 months. It takes these 3 blood tests to get a feel of how unstable the uric acid levels are for this patient.


 When a patient has a gout attack, any anti-inflammatory medication helps, like Advil, but I prefer to use indomethacin, but not advised in the elderly or children or those with a history of GI problems. In a normal size adult, you can use 75 mg 3 times over the first 24 hours as a loading dose, then drop to twice daily for the next 9 days. After these first 10 days, it is obvious how easy or hard it is going to be to get the symptoms under control. Most of my gout attack patients are placed into a removable cast to minimize the bending of the big toe joint, with EvenUp on the other side. The patient is advised to take food with indomethacin since it can be hard on the stomach. Gout attacks can occur from 2 days to 3 + months, so you need to treat quickly. Icing is important to both reduce blood flow to the inflamed joint and for pain relief. I prefer the ice slush, but how cruel can I be!! Patients are told to drink, and drink, and drink water to hydrate, deluting the concentration of uric acid quickly in the blood stream. They must also become familiar with foods rich in purines, and try to minimize the ingestion (not eliminate) on a daily basis. Injections into the involved joint to analyze the crystals seem too academic to torture the patients initially, but if the pain is not subsiding in 4 or 5 days, then aspiration and injection of steriod may be appropriate to reduce the inflammation quickly. Since cortisone takes 3 to 7 days to work, and the acute aspect of the gout attack may naturally be over by then, it takes some sixth sense to know who should have the joint aspirated. Ask anyone with an acute gout attack and they will say that the injection was somewhat draconian!!


 The blood level goal has always been 6mg/dl, but to accomplish that your primary care doctor is normally reluctant to place you on kidney eliminating drugs for the rest of your life like Allopurinol. So, most doctors prefer to counsel their patients on hydration (the more dehydrated you are, the higher the concentration of everything goes in the blood stream including uric acid), exercise for weight reduction, sensible dieting,  and medications to possibly change.


    To summarize: the top 10 initial treatments for gout are:


  1. Begin a series of 3 uric acid levels.
  2. Rule out infection with history, evaluation of area, and blood work up.
  3. Immobilize the joint involved.
  4. Ice the involved area 3-5 times daily with various forms of cooling.
  5. Begin using an oral anti-inflammatory medication like indomethacin or ibuprofen.
  6. In very severe cases, or if symptoms are not calming down quickly, consider an oral Prednisone Burst, or cortisone injection into the joint. To use cortisone you must be sure that you are not dealing with an infection.
  7. Hydrate well (4-8 glasses of 8 oz water daily).
  8. Understand what foods to avoid.
  9. Discuss the possible role of any new medications started before.
  10. Discuss overall health and weight loss/gain situation.




Saturday, April 3, 2021

Tap Dancing and Diabetic Foot Health

I have to thank Dr David Armstrong, leading expert on wound healing, to show this article on the positive health advantages of tap dancing with an emphasis on diabetics.

Thursday, April 1, 2021

Great Video on the Importance of Vitamin D

If you are an athlete, you sort of know that Vitamin D plays a role in whether you break a bone or not while training for your sport. The following is a great reminder to keep our Vitamin D levels in its normal range. Low normal is 31 so I prefer my athletes to be near 50 to stay out of trouble. Here is a pre-quiz for you based on the information in the video?

1. Vitamin D is metabolized by the kidneys. True or False
2. Sunlight typically destroys our Vitamin D stores, so we must take supplements. True or False
3. The active form of Vitamin D is 1,25 Dihydroxy D3. True or False
4. Salmon and other oily Fish along with Mushrooms are great sources of Vitamin D. True or False
5. The thyroid helps control the body’s manufacturing of Vitamin D. True or False


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