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Monday, October 31, 2022

Top 10 Treatments for Accessory Navicular Syndrome

Accessory Navicular circled on the inside
of the arch just in front of the ankle

The top 10 treatments for accessory navicular syndrome:
1.  An MRI is very important to discover what the source of pain actually is: stress fracture, joint inflammation, or tendinitis. There is a joint between the navicular and its accessory bone.
2. Use one of the stretch tapes (KT tape, Rocktape, or Kinesiotape) or Quick tape from tape or a classic low dye taping technique intially 24/7 and then for extended activities.
3.  Ice pack the sore area 10-15 minutes 3 times daily.
4.  Go into a removable boot (such as an Anklizer) for 2-3 months if needed to calm the foot down.
5.  Strengthen the posterior tibial tendon starting initially with active range of motion like ankle circles.
6.  Check out the Aircast Airlift PTTD brace to see if it is helpful for you and can get you out of the boot faster.
7.  Custom foot orthotics are a must for a 2 year period. They must produce a good force against the navicular, but it may take time finding the right orthotic guy/gal.
8.  You can use Sole, Powerstep, or Pure Stride OTC orthotic devices with medial longitudinal Hapads initially until a good protective orthotic device is made.
9.  Create a pain free environment as soon as possible (level 0-2) and maintain this through the rehabilitation process.
10.  If the MRI shows bone reaction (edema), order a bone stimulator as soon as possible to start strengthening the bone.

Dr. Kevin Kirby and Subtalar Joint Axis Theory

     One of the great minds in Podiatry has been Dr. Kevin Kirby. Here he explains his concept of the Subtalar Joint Axis. This concept has influenced my practice and thousands like me. I hope you enjoy listening. Rich 

Saturday, October 29, 2022

Patella Problems: Rambling of Thoughts

Patella (kneecap) Problems: General Thoughts

Probably the most common knee complaint that a podiatrist will be called into treatment involves the kneecap.
  • Also called Runner's Knee, Biker's Knee, Dancer's Knee

  • Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc…

  • Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation illustrated by the young women with her right knee below

  • All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO with short arc single leg press and quad sets, and
  • Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing.   

Bauerfiend GenuTrain Knee Brace for Patellar Tracking Issues

Here is some advice I emailed a patient inquiring about knee pain and flat feet:
Dear Dr Blake:
I am in a conundrum.  Spend out of pocket to see a podiatrist or spend out of pocket to see a PT.I am Flat footed.

In 1990, my right knee hyper-bent with 150 lbs of backpack weighing me down with my right foot stuck in snow as the left foot slipped downward.
Current symptoms:
- Clicking knee cap
- Kneeling on carpet, great pain until the knee cap pops into place from pressure upwards
- Grinding knee upon flexing
- Pain on the inside of the rt knee and lower left quandrant of patella
- Pain and tightness from right side of knee up to the hip
- Pain behind my knee at the back (anterior)
- Extreme pain in knee and hip when rising up from a kneeling position
Wonder what he did??

- Pain and tightness on the inside of my thigh at the knee
- Feeling of being swollen in the knee itself
- Walking in running shoes with support is OK at best
- Walking in dress type shoes with no support results in pain after 25 yards or so
- When I use to take spin classes, the instructor noted an outward or inward? movement of my leg/knee and asked me to keep it straight, which I could not.

I have sat at a desk for 8hr/day for the last two years ~ the first desk job in my life and this may be part of the problem.
I am self pay ~ no health insurance.
What would the cost range be for a diagnosis by you, treatment and possibly orthotics?
How long would it take, should we work together, to know if your regiment for me is working?
At what point would it be wise to pony up for an MRI?  Do I need one?
I am 53, and until recently, in good shape if not great shape.  I need help!
Best always and Happy New Year!
Robert, Thank you for the email. This is definitely a question about timing of treatments when both can be very helpful.
  With that much knee pain, you are really in the immobilization/anti-inflammatory phase. Orthotics would be part of a restrengthening/return to activity phase. The immobilization is anything that creates a pain free environment, from braces, to shoes, to activity changes, and yes, to orthotics if that is what it takes.
   I would tend to have a PT cool your knee down first, and then add orthotics when you are ready to increase your activity again. Orthotics can play a role when you are throwing everything into the treatment arena but the kitchen sink (an approach used with unlimited funding).
This is why the kitchen sink is not included
Definitely, cool the knee down with PT and Icing. The icing for the knee must be 30 minutes 3 times a day. Yes, 30 minutes is normally needed to get deep into the knee.   Try to stay away from anti-inflam meds since they can slow bone healing. Get an MRI, around $500 self pay, if your symptoms plateau (look at it one month at a time). Try to create a pain free environment over the next month, which may mean staying in your most stable shoes. You can also try Sole over the counter Arch Supports (get one of the soft athletic versions). These are easy to adjust. You have already established a relationship between your feet and knees, but see if you can get them calmed down, less fragile, over the next several months.

    The top 10 initial treatments of Patella problems are:
  1. Create a pain free environment.
  2. Ice 30 minutes 3 times daily
  3. Start Quadriceps strengthening painlessly on day one
  4. Stretch the quadriceps and hamstrings 3 times daily, although avoid knee flexion over 45 degrees.dreamstime_m_15225478.jpgToo much knee flexion for kneecap pain
  5. Knee Brace for Patellar stabilization like Bauerfiend Genutrain Knee Brace
  6. McConnell knee taping with Leukotape and underwrap or KT taping.dreamstime_m_36278072.jpg
  7. Core Strengthening for external hip rotators, including gluts, iliopsoas and piriformis muscles.dreamstime_m_17645150.jpg
  8. OTC or Custom inserts to stabilize any overpronation tendencies, or just varus cant. Goal is to get the knee to function in the center and not internally rotated.
  9. Use activity modification to get cardio without irritating the knee. Consider raising the seat in cycling to prevent too much flexion (over 45 degrees the patella starts pushing hard on the femur). dreamstime_m_18879601.jpg
  10.  If it is a running injury, shoes are crucial for stability. Have a good running shoe store help you pick out a great stability or motion control shoe for you.
Your shoe selection should help avoid the heel valgus seen here where the heel rotates outward driving the knee inward too far.

Monday, October 24, 2022

Good vs Bad Pain: Very Important Lesson to Learn when You Are Injured

Dilemma of Good vs Bad Pain

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 through, or to feel afterwards. Bad pain is discomfort that must be stopped; it is 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!” and probably in several languages. They can participate at very high levels with pain, hoping they can work through it. Sometimes they can, but many times they cannot, 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 cannot be tolerated. This group may actually learn to accept some pain as okay. 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 the injury is to a nerve, the more it hurts. The more your body swells with any injury, the more you hurt, especially with deep swelling that cannot escape the joints, bones, ligaments, or tendons. 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 of this?

Four Golden Foot Rules that 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., and even icing.
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 2 pain level (scale 0 to 10).

Let us focus on these four 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 (as you have hit the threshold of tissue strength) and it is best to stop. Participating in 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, taking medication six hours before an event is permitted. Many of the anti-inflammatory drugs (NSAIDs) 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 step 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 may still exist, but you can do everything athletically your heart desires. But, it can take months and months of icing, stretching, strengthening, and 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 then hurt for several days? Does the pain come with increased swelling? These are all signs of bad pain. Good pain stays in the 0 to 2 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, although a temporary sharp twinge lasting seconds is typically okay. Dealing with good pain is not the perfect scenario for my patients, but it is 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. It can be your training guide and friend.
But, you may ask, why not just wait until you have no pain before you go back to activity? The more inactivity, the more de-conditioned 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 and sometimes unnecessary fix. If you still believe “No pain, no gain,” I cannot wait to see you at our sports medicine clinic as a regular customer, but I will try to convince you otherwise in the long run. Learn about your body through this process. It has prevented three surgeries for me. And the same rules can apply to anyone recovering from any type of injury, not just athletic injuries. Good Luck!!

This is an excerpt from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

What to do when the Bottom of your Heel Hurts: Excerpt from Book 2 of Practical Biomechanics for the Podiatrist

This following is an excerpt from Book 2 of Practical Biomechanics for the Podiatrist

Plantar Heel Pain Problems
     Plantar Heel Pain is presumed plantar fasciitis, end of question, thank you, on to the next topic! Yet, there are plenty of reasons for plantar heel pain like bursitis, plantar fascial tearing or degeneration, heel spurs, intrinsic muscle soreness, stress fractures, bone bruises, neuritis, arthritis, to name the most common causes. Each of these entities can require some of the same treatments, and some other treatments than plantar fasciitis. Because plantar fasciitis dominates the landscape, we have to have suspicions early on that it may not be fasciitis. Most of my patients with plantar fasciitis have the following: worse pain in the morning, onset very gradual over months, no swelling is noted, normal treatments help somewhat (stretching, icing, arch supports), pain rarely over 4-5 on a scale of 0-10, and primarily in the heel where it attaches.
     For most clinicians, their treatment like mine will be gradually adding pieces to the treatment. You decide quickly if tests like x-rays and MRI are in order, if the fitting for a Cam Walker is appropriate, or if PT is necessary sooner than later. You do what you can to drive the pain to 0-2 as fast as possible with arch supports, taping, limiting barefoot, and then you have the patient ice and stretch both the achilles and the plantar fascia. After your patient’s feedback, for me that is on a monthly basis, you begin to make changes in all of the modalities listed below.

MRI with normal looking plantar fascia right above my sensor
     To tie this into Chapter 3 and 4 on gait and biomechanical examinations, when a patient presents with plantar heel pain problems, the most important examinations to do in 10 minutes (or 20 minutes) are:
  • Signs of Pronation Medial Overload
  • RCSP
  • Equinus with AJDF
  • Functional Hallux Limitus
  • Metatarsal Alignment (Metatarsus Primus Elevatus)
  • Forefoot to Rearfoot (signs of forefoot varus)
  • Antalgic Gait
  • Side to Side Heel Compression Pain
  • Signs of Hard Heel Contact in Gait
Common Mechanical Changes for Plantar Heel Pain (with the common ones in RED)
  1. OTC and Custom Orthotic Devices
  2. Heel Cushions
  3. Avoid Strong heel strike
  4. Avoid Barefoot
  5. Avoid Zero Drop Shoes
  6. Heeled Shoes
  7. Taping
  8. Achilles Stretching
  9. Plantar Fascial Stretching
  10. Metatarsal Doming and Single Leg Balancing
  11. Limitation of Toe Bend
  12. Physical Therapy Prescription
  13. Cam Walker with or without Crutches in the Immobilization Phase
  14. Plantar Fascial Rest Splints
  15. Plantar Fascia Socks
  16. Slippers with Arch Support
     OTC and Custom Orthotic Devices work in many ways to help heel pain. Their mechanical functions vary with all the modifications that can be applied. One of the primary ways is in the mere transference of weight from the painful heel forward into the arch. I like Sole, Pure Stride, or Power Step inserts that can leave my office at the first visit customized with the right arch support, and I typically soften the heel some. I want the inserts protecting the heel and transferring weight to the arch immediately.

Here all the heel hardness has been ground away and replaced with a soft ⅛ inch spenco or poron or neolon pad for extra cushion
     Who for and when will I make custom orthotic devices? This will depend on how the patient is progressing with their heel pain, how long they have been dealing with the problem, what their biomechanics are like, and what is their history of possibly biomechanically related problems. If the person on top of this foot with plantar heel pain, who may have only had the problem for a few weeks, but has terrible biomechanics, or long standing biomechanical issues that I can help, we will begin to have a discussion at their first or second visit with me. If the patient’s problem seems related to heel strike only or predominantly, I will consider soft based memory foam Hannafords as my initial custom orthotic device. If their problem seems more related to pronation issues, that a plastic insert will work fine with, I will move into the myriad of orthotic devices that help pronation.
     So why are OTC or custom made orthotic devices useful in plantar heel pain? For any individual patient it may be impossible to exactly sort out, but you are trying to affect the following: transfer the weight from the sore heel to the arch (you can see that heel controlling orthotic devices like Inverted or Kirby may not be appropriate in acute heel pain situations), decrease the pull of the plantar fascia on the heel bone, take tension off of the Achilles’ tendon fibers that run into the plantar fascia with some heel lift and heel centering towards neutral), and free up the plantar fascial tension at heel lift by eliminating functional hallux limitus when present. Occasionally I have to remove the extrinsic heel post when there is acute heel pain due to the accumulation of stress on the heel itself caused by the heel post (which may later be put back).
     Heel Cushions come in many sizes and shapes, made of foams, gels, low durometer EVAs, etc. Their mechanical function is to soften the heel, and sometimes transfer weight forward off the heel. The goal of all of these is to soften the heel at impact, decreasing the pain. I always experiment with patients with heel pain if they can tolerate heel cushions or not (it is something you should have stocked in your office). I have a range from very spongy to somewhat firm. Heel cushions also act as heel lifts transferring weight forward ideally, and easing the tension off the Achilles’ tendon attachment onto the heel.

Here is a hybrid heel cushion which can both cushion and stabilize by decreasing any heel motion
Practical Biomechanics Question #313: With plantar heel pain, what are the two main functions of an arch support (OTC and custom)?
     Avoidance of Strong Heel Strike Gait Pattern is another common tool to help heel pain. Its mechanical function is to decrease the stress on the plantar heel. Many patients are strong heel strikers, you can hear them coming, and when they get heel pain, it is a pattern to try to change. You probably will not notice this until well into your treatment when they start walking normally again if they had an acute injury. With running, I can typically get a heel striker to be a full foot striker with some coaching. Try to learn the concept of Chi Running. With walking, it can be very hard, and I usually rely on physical therapists trained in gait to help.

Over Striding is a Common Cause of Excessive Heel Strike that can be helped in coaching
     Avoidance of Barefoot is one of the gold standards of plantar heel pain. Its mechanical function is to dampen the stresses through the heel with a layer of material between the heel and the ground. Whatever the cause of the heel pain, going barefoot can keep the heel irritated and not allow healing to occur. Patients with chronic heel pain are very frustrated by the permanence of never going barefoot again. However, as the symptoms calm down, you can initiate flat footed barefoot foot walking, especially on the stairs at home. For awhile, many of my patients wear Oofos sandals as a house slipper for cushion, or even an indoor only athletic shoe with orthotic devices. The podiatrist must ascertain if this is needed based on the amount of barefoot they do, and the aggravation of symptoms produced.
     Avoidance of Zero Drop Shoes can only be a general guideline, but the faster you walk, a slight heel is important. Its mechanical function is to prevent overstretching of the achilles at contact, and over stretching the plantar fascia at push off. Zero Drop shoes are all the rage now, but they make the wearer actually more flat footed, staying more on their heels, and then harder to move forward. There is more tension on the plantar fascia and intrinsic muscles as they lift their heels. Many times I have had to use orthotic devices with heel lifts to neutralize this effect on the heel.
     Heeled Shoes or Boots are the opposite, at times, of going barefoot or wearing zero drop shoes. Their mechanical function is to transfer weight forward from the heel and decrease tension on the achilles tendon. Here you are trying to use a heel to shift body weight forward enough to take the pressure off of the heel area. Unfortunately, with some heeled shoes, the force is placed too much on the heel, and the heel pain increases (especially with spiked heels!) It is not the softness of the heel that matters in this regard, since Dansko clogs with their hard wooden base is the poster child for this process.
Practical Biomechanics Question #314: What are the pros and cons of a heeled shoe with plantar heel pain?
     Taping is another gold standard in the treatment of plantar heel pain. Its mechanical function is in reducing the stress on the tissue that attaches into the heel. It is also the basis of how podiatrists decide if someone should get orthotic devices based on a negative or positive response. This practice is from the early days of biomechanics and should be abolished for there are so many reasons you are utilizing orthotic devices differently than how a specific tape works. I use only two types of taping routinely for heel pain: low dye taping and Quick Tape by In fact, Quick Tape is used first, and if it doesn’t work, and only if it doesn’t work, I begin the process of trying the many versions of low dye until I find the best version.
Quick tape can stay on for 5-7 days so ideal for backpacking trips, or in the transition from a cam walker into normal activities
     Achilles Stretching is another gold standard for plantar heel pain. Its mechanical function is to decrease the stress on the arch structures attaching into the heel. The less achilles tightness, the less strain on the arch, and plantar fascia, in fact the entire foot. I have always considered plantar fasciitis as an inflexibility issue with the achilles and plantar fascia. At times, plantar heel pain is a problem of plantar fascial inflexibility especially with hallux limitus or pes cavus. At times, it is a problem of achilles inflexibility with tightness in the gastrocnemius, soleus, both, or only one. The ability to measure the Achilles’ tendon reliably should be an important tool (described in both Book 1 and chapter 4 of Book 2 here)
Plantar Fascial Wall Stretch with toes bent, heel on the ground, and knee driven towards the wall..
     Plantar Fascia Stretching is another gold standard for plantar heel pain. Its mechanical function may be in stretching the tissue around it more than the fascia itself. You are attempting to loosen up the fascial bands with gentle non painful stretches. I love the Plantar Fascia Wall Lean Stretch, and the rolling ice stretch with a frozen sports bottle, but have mixed feelings about the Graston technique used by physical therapists. Part of the problem is that loose tissue can feel tight with nerve hyper innervation due to pain, or swelling may make loose tissue feel tight, or muscle fatigue may make the tissue feel tight. There are some many false positives in muscle or fascia tightness, that I do not think we know this process very well. I prefer simple plantar fascial wall leans or rolling sports bottle stretches to gently pull on this very inelastic structure.
Practical Biomechanics Question #315: Plantar Fascia is a ligament, and ligaments are almost impossible to stretch, so why does this stretch work so well?
     Metatarsal Doming and Single Leg Balancing have been discussed at length in this chapter and are crucial to take the strain off the plantar fascia. Their mechanical function is in strengthening the injured tissue. As a reminder, the plantar fascia is the third most important structure for arch support. The most important is the ligaments holding the bones together, the second most important is the intrinsic and extrinsic muscles, and the third most important is the plantar fascia. Every 10-20% stronger that I can make the intrinsic muscles, I am taking a tremendous load off the plantar fascia. Metatarsal doming and Single Leg Balancing are the best, and safest, ways to strengthen those intrinsic muscles.
     Limitation of Toe Bend has developed in my practice due to MRI images. Its mechanical function  is in reducing the stress on the plantar fascia. So many patients, with chronic heel pain, had degenerative changes seen only on MRI. I placed them on a three month program of no toe bending (with Hoka One One shoes, spica taping, Cam Walkers, Carbon Graphite foot beds, or Bike shoes with embedded cleats) and they did well.
Bike Shoes with embedded cleats are successfully used to rest the plantar fascia by limiting big toe joint bend
Practical Biomechanics Question #316: What are five common ways to restrict big toe joint motion of dorsiflexion?
The plantar fascia should be dark black all the way back to the heel bone. This MRI shows a 2 inch section of fascia irregularities from the heel bone forward. Treatment is helped with limiting big toe joint motion for a few months.
     Physical Therapy is very common for my patients with plantar fasciitis. I typically write a specific prescription for 8 sessions to start. Its mechanical functions are strengthening, stretching, mobilizing, and activity modification stress reduction and modulations.  But, what mechanical help am I prescribing? Of course, physical therapy will always include anti-inflammatory measures, but the four main aspects I ask a physical therapist to help with are achilles and plantar fascia flexibility, foot and overall leg strength, cross training guidelines for the patient, and gait training for the heel strikers.
     Cam Walker with and without Crutches for the Immobilization Phase is something you should not forget about. Its mechanical treatment is in complete rest of the plantar fascia when it needs to be immobilized from a tear or symptoms consistently over the 0-2 level. Plantar Fasciitis treatment has to undergo the same criteria of treatment as all other injuries. You must create that 0-2 pain level, and keep it there during the entire rehabilitative course. Sometimes, before an MRI is done, there can be stress fractures or even plantar fascia tearing, that only the Cam Walker can bring the pain down. Many patients get 4 hours a day in their Cam Walkers with EvenUps on the other side just as a means to cool down their injuries as we create a healing environment.
Practical Biomechanics Question #317: Any injury that is so common can tend to be subject to protocols. Protocols do not individualize, so patients can continue to hurt themselves. What pain level is crucial to maintain in injury rehabilitation that almost guarantees great healing?
     Plantar Fascia Rest Splints have dominated the landscape over the last 25 years, and now the DeHeer Equinus Brace, which crosses the knee joint, may be a better mousetrap. Their mechanical function is to put a long grade by consistent stretch on the injured tissue. At present, I have limited feedback on the DeHeer, but since it crosses the knee joint, if the knee joint can take the stress, it should work well. All of the plantar fascia braces do produce some relaxation to the tissues, and I think that a patient who has several months of pain (especially in the morning), should begin to wear during the day when they are at rest. It can be an hour at a time throughout the day (while they are working at their desk, eating meals, watching movies, etc.) If the morning soreness is more than a couple of minutes, and if they seem to be tolerating it during the day, they can try sleeping with it. Sleeping is always the best time to heal, so disrupting that sleep at all, should be well thought out if needed.
Classic Plantar Fascia Night Splint with adjustable straps to pull the foot into more dorsiflexion if needed. I rarely feel a need to use these straps at all.
     Plantar Fascia Socks are a helpful support, under the regular socks, and routinely sold at athletic stores.
     Slippers with Arch Supports, like Teva or Vionic, have been a great help to heel pain sufferers. They can be at the side of your bed when you get up in the middle of the night. For many patients who do not wear shoes in the house, a house-only slipper or sandal, that cushions and supports has been a wonderful compromise. 

Sunday, October 23, 2022

We Need Sleep for our Health!! Great Article

     I am personally going to have to stop watching Netflix until the moment I go to sleep. Getting sun exposure during the up coming winter months will also be a challenge unless I get that walk in at lunch. 

Saturday, October 22, 2022

Relaxed Calcaneal Stance Position: One of the Most Important Measurements made by Podiatrist

  Relaxed Calcaneal Stance Position

     Measurement showed over 10 Degrees of Heel Everted Positioning

     The Relaxed Calcaneal Stance Position (aka Resting Position or RCSP) is utilized for understanding of Pronation Syndrome, Supination Syndrome, Poor Shock Absorption, Limb Length Discrepancy compensations, Tight Muscle compensations, Weak Muscle gait patterns, and other issues. Therefore, I always perform this test due to its importance. Here are some images showing how to bisect the heel in a prone position before standing the patient up (my preferred way). 

Here is the Typical Starting Point of Bisecting the Heels for Subtalar ROM and RCSP or NCSP with the Patient Prone Heels Angulated

It is so Crucial to Make Sure the Posterior Surface of the Heel is Aligned (Parallel to) with Your Eyes so the Opposite Leg is Bent and Externally Rotated and the Patient may need to roll over on their hip (side being measured)

By Palpating the Medial and Lateral Borders of the Heel Three Times from Superior to Inferior The Examiner can Bisect the Heel

Here is a Close Up of My 3 Bisection Points and the Solid lines represent the Medial and Lateral borders of the Posterior Surface which are Divergent (They are Never Completely Rectangular)

Here the Bisected Heel on the left is Stood Up and the Heel is Measured either Vertical, Inverted, and Everted (The Right Side will be slightly to significantly different to the Left Side)

     This crucial examination technique is to bisect the center of the heel prone, and then stand the patient up and see if the heel is vertical, everted, or inverted. This test can also be done with the patient standing, but I prefer to start with the patient prone. This is very useful in the initial evaluation for orthotic devices in writing your prescription to make a biomechanical change. It is also used when orthotic devices are dispensed, by having the patient stand with and without their orthotic devices to check if the orthotic corrections are achieving the desired results. However, you also have to correlate standing correction to walking change to make sure that they substantiate each other. One of the highlights of my career is when I use a relaxed standing position measurement to follow the development of a growing child as I progress to less pronated feet through orthotic support (as originally taught to me by the renowned Dr. Ronald Valmassy). It is also used in the preoperative and postoperative evaluations of flat foot surgeries. And, as you can see from the syndromes that it helps with at the start of this discussion, it can really help you understand a lot about the biomechanics of a patient. The change in the relaxed calcaneal stance position can help you understand corrections in pronation, supination, compensations for short leg syndrome, if someone is a poor shock absorber, if I am supporting a posterior tibial tendon dysfunction patient enough, or allowing a genu varum patient to have less stress on their knees, etc. I would put it as my number one test overall. 

     The posterior surface of the calcaneus or heel bone is usually flat and will be angled from posterior lateral to anterior medial on weight bearing (and this does not take into account the angle of gait). You must keep the posterior surface of the heel bone in line with your eyes. You must find the medial and lateral borders of this posterior surface and put your fingers so they align right along those borders from superior to inferior. 

Fingers Flush with the Medial and Lateral Calcaneal Borders and 3 Points Placed 1 inch Apart to Bisect the Heel

Your fingers should be flush with the medial and lateral borders in the middle of the calcaneus from superior to inferior, and clearly just on the medial and lateral edges, not on the posterior surface of the heel bone. Then make 3 points about one inch (2.5 cm) apart from superior to inferior bisecting the two sides.

After Each Dot Applied Continue to Check the Sides to Make Sure of Your Bisection

Medial and Lateral Borders Checked Against Your Bisection Points

2 Bisection Points Made

When Placing Your Points, Leave One Hand on One Side to Not Lose Your Reference

Here All 3 Points are Checked with the Medial and Lateral Heel Sides to Insure a Great Bisection

After the 3 Points, Draw a Straight Line Connecting the Points

     Draw a straight line downward connecting these three points. This can be done weight bearing or non-weight bearing (one method will feel easier to you although I prefer non-weight bearing). When you are learning, do this and other measurements with others to see if you agree. Examiners when learning this technique tend to align/favor one of the two borders, even when those borders are divergent. When the patient is non-weight bearing, please remember the posterior heel is best measured when completely parallel to the plane of your eyes, so angle their body to bring the posterior surface to this reference (helped by bending the opposite knee and placing over the knee on the side you are examining). The typical orientation of the posterior heel’s medial and lateral edges will be like a rectangle with straight parallel edges, or more rhomboid with divergent edges (as in the photos on this page). After a few feet, students get the feel of this quite easily. It is such an important measurement that you should check your line several times.

     Once the heel has been bisected, extend the line as straight as possible another centimeter superiorly and another centimeter inferiorly. When the patient stands, look at the back of the heels and make sure your line looks straight all the way from inferior to superior, and make sure the line looks like it matches what the heel looks like (you will be able to see vertical, inverted, or everted heels without lines someday). By this I mean, when you stand several feet behind the patient, does the heel and line both look straight, both everted, both inverted from right to left, or with asymmetrical feet some combination of these 3 positions. With weight bearing, use an angle measuring device that is parallel with the posterior surface of the heel running posterior lateral to anterior medial (I use both a tractograph and an app called Bubble Level XL). Now you are ready to measure the heel position to the ground. This measurement is typically done without orthotic devices, called the resting calcaneal stance position, or resting heel position. But, it is used to see how your orthotic devices, or surgery of some sort that should affect the heel, has done its job. An orthotic device, even with a deep heel cup, will not distort this line. 

Measurement of RCSP using Bubble Level XL app

Here the same measurement staying on top of custom orthotic devices

     What are common examples of the use and meaning of the relaxed calcaneal stance position, or simply the resting heel position? First of all, your definition of the heel as everted, inverted, or vertical speaks volumes. I think it is fine to just estimate how far from the heel neutral position it is at this early point in your evaluation (heel neutral is where the subtalar joint has been placed in its neutral position). This will be based on your estimating the amount of tibial varum or valgus, and influenced by genu varum or valgus.  This estimate will talk about compensations, and I like them to make sense. They can also mean injury, like when a heel is more inverted then it should be from peroneal tendon or lateral ankle ligament damage, or the heel is more everted than it should be from the advancement of posterior tibial tendon dysfunction stages. The common examples of RCSP that influence my orthotic decision making include:

  • 7 degrees everted in resting with normal /foot and leg structure (why so everted is the question?)

  • 7 degrees everted in resting with genu valgum noted (is the eversion all because of the knee valgus deforming force?)

  • 4 degrees inverted in resting with severe genu valgum noted (is the inverted RCSP compensation for the knee valgus?)

  • Vertical heel in resting with high tibial varum noted (is this vertical heel position also its maximally pronated position?)

  • 4 degrees inverted in resting with normal foot and leg structure (why so inverted is the question?)

Normal Left Biomechanics Structurally doesn’t Explain 4 degrees RCSP inverted positioning

  • 3 degrees inverted in resting with tibial varum noted (does the foot have the ability to get back to vertical or is it in its maximally pronated position?)

Our examination at this point is just the beginning of our understanding. 

     There will be 2 standard variations of your RCSP measurement that are commonly done. The first was popularized by Dr Kevin Kirby’s Maximum Pronation Test. It is very important to know if the patient is standing maximally pronated (for injury evaluation and treatment) no matter if the RCSP is vertical, inverted or everted. You measure the RCSP first as just described, then you ask the patient to attempt to lift up their lateral metatarsals off the ground while keeping the knees straight. If the RCSP does not evert more than 2 degrees further, you can assume the patient is functioning maximally pronated. You then measure the second RCSP no matter what and record the degrees. Then, and only if the RCSP is inverted, you ask the patient to rotate their bodies from the hips internally as far as they can without lifting off their feet, to see if this internal or pronatory force can bring the heel more towards vertical. This is a version of the Coleman Block Test which lifts up under the lateral forefoot with a ¼ inch pad or wedge to see if the inverted heel can be made straight (crucial in supinators when you are designing a possible orthotic device to bring them at vertical). There will be more on these concepts in the orthotic prescription chapter. 

     Max Pronation Test (described by Dr Kevin Kirby) is done by first measuring the RCSP and then having the patient attempt to lift up the outside of the foot (more pronation) by firing the peroneus brevis. Dr Kirby first shows the patient the foot motion desired by moving his hands. You then measure the RCSP again. An alternative is to have the patient internally rotate the entire limb, one side at a time, and again measure the RCSP. A change of 2 degrees or less in the RCSP means that the patient has been functioning maximally pronated.

     Here the RCSP is inverted with all the symptoms of over-supination (discussed further in Chapter 9 of Book 3). In an attempt to help this patient, you want to find out if the patient can be pronated with an orthotic device or valgus wedge closer to the vertical heel. The Coleman Block Test uses a wedge under the lateral forefoot to attempt this change in the RCSP, or the patient can also be asked to internally rotate the entire limb to maximally pronate the subtalar joint. The RCSP should be measured each time you attempt a change and compared to the normal RCSP. 

Inverted RCSP, but can it get to Vertical for orthotic ordering

Exact degrees measured

Examiner’s hand under the 4th and 5th metatarsal heads simulate the Coleman Block Test (heel easily everts to heel vertical and beyond)

Everything measured

This is an excerpt on an examination technique discussed in both of my Books 1 and 2 of "Practical Biomechanics for the Podiatrist"