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Monday, January 30, 2023

Great Videos on the Nerves of the Foot, Ankle and Calf

     Dealing with patients with nerve pain all the time, this is a great video that I could watch over and over again. I have watched it several times today, and learned something that I had forgotten about the deep peroneal nerve for instance. 

My next blog post will be a 10 question test from points made in these videos. And, the next blog post will be the answers. 

Friday, January 27, 2023

Tuesday, January 24, 2023

RED-S. Relative Energy Deficiency--Sport (Syndrome)

     This is a must read for any health care provider treating athletes! Thank you Dr. Karen Langone for pointing it out to me!

Progressive Collapsing Foot Deformity Classification by Dr Allen Jacobs

Patent Leather Shoe Stretching: This Article gives some Tips


  I had a patient yesterday with bunion irritation from her beautiful patent leather shoes. We talked about getting the bunion stretched some so this article should help. The difference between patent leather and leather shoes is that patent leather shoes have a plastic coating over the leather to give it its incredible glossy shine. That plastic however makes stretching the leather part harder.

Monday, January 16, 2023

Great video on some powerful exercises for External Hip Rotator Strength: Much need in Over Pronators

     As Podiatrists we are always treating over pronation linked to a myriad of problems. Here is a simple but powerful video by Dr Clifton Bradeley on some exercises to help. Rich 

Friday, January 6, 2023

Adding more Support to your Foot Orthotic Device

     So often in clinical practice, we have either designed orthotic devices, or are evaluating previously mad orthotic devices, and we find that the stability could be improved to help the patient. 4 simple improvements are supporting the arch, adding a temporary Kirby skive, changing the shoes to more stable ones, and power lacing those chosen shoes. 

Simple Medial Arch Reinforcement here with 1/4 inch Grinding Rubber

Or, a Temporary Kirby Medial heel skive along to the medial heel cup

     The following is a simple video and discussion on power lacing. 

Wednesday, January 4, 2023

Sesamoid Injury with Vasomotor Skin Changes

     A patient today presented with a sesamoid injury and sympathetic overload signs of vasomotor insufficiency (also called vasomotor dysfunction). This involved his right foot. The sesamoid injury went from mild to totally disabling as the nervous system went wild in an over protective manner. Instead of getting better and better in the last 3 months (the injury is about 5 months old), it is getting worse and worse (only explained by this nervous system issue). He has become less and less active. I opened this post to be a 3-4 month post as I follow his progress. He will be starting Lyrica most likely, and perhaps getting a sympathetic block (which could be done sooner than later). I did not get a photo of his two feet today, but I will ask him to send me one to post. Rich 

Here is the requested photo. This is what the injured right foot and leg look like each afternoon. Most of the time it is better in the morning. Occasionally, if he does too much, he will take 2 days to get back normal. 

Sesamoid, under the first metatarsal, injured 5 months ago is now not the main reason he is having problems. 

Monday, January 2, 2023

Email Advice: 9 months after Sesamoid Injury and AVN diagnosis

Hi Dr. Blake,

Thank you so much for your blog posts over the years on sesamoid pain! They have helped me greatly in my diagnosis with sesamoid AVN.

I'm 19 years old and was diagnosed July 2022, though my pain started February 2022. My affected leg was immobilized in a CAM boot for ~10 weeks before I transitioned to orthotics. I still experience pain occasionally while walking.

I'm wondering if you could provide some insight on some patterns of pain I've noticed:
1) My sesamoid tends to hurt when I walk after sitting or lying down for long periods of time. After I've walked for a while, the pain disappears.

Dr. Blake's comment: This is called post static dyskinesia, meaning pain after rest. The tissue either tightens from swelling that collects during the rest period, or some neural tension that develops while the tissue is immobile (nerves like motion). Both of these causes hurt at the beginning of activity and then disappear as the nerves relax or the swelling dissipates. Either way, it is consider good pain in that 0-2 pain range. You should try to warm it up before you begin to walk like foot massage, big towel range of motion with your muscles doing the motion. Patients will do both by placing a towel next to their bed. When they wait up, they lassoe the toes and pull gently up and down with the towel, or massage the area like you are drying your foot after a shower motion. Remember, total healing (meaning when your body will stop trying to heal everything) typically takes 2 years with these sesamoid injuries. So, recognizing when it is good pain is crucial. 

2) I used to go on 30-minute bike rides. When I finished the rides and started walking, I felt virtually no pain in my sesamoid.

In both cases, I suspect 1) walking for some period of time and 2) biking increases blood flow to my foot and therefore sesamoid, which temporarily alleviates my pain. Is this the likely explanation? If so, I'm wondering why this relief is only temporary (the pain returns after extended periods of inactivity), and if not, I wonder what alternative explanations could be. I am especially curious about the physiology behind temporarily increased blood flow and temporary sesamoid AVN relief, if there is a relationship between the two at all.

Dr. Blake's comment: Increased blood flow with activity, contrast bathing, after icing when the area warms back up, acupuncture, massage, warmth, all play a role at daily increasing your chances to save a bone that underwent AVN (avascular necrosis). As some may not know, the sesamoid normal blood flow is tiny, and alittle swelling in the bone can cause compression to the bone vessels temporarily shutting them off. No one knows why AVN occurs in one person and not another, but daily use of Exogen bone stimulator and contrast bathes are my go to treatments to make sure that bone gets more normalized blood flow. Temporary is fine and short lived, but it is the utilization of temporary methods of increasing blood flow daily for 9 to 12 months that will produce the best chance for the bone to get healthy, really healthy again.

     The other main component to a healthy bone is weight bearing more and more each month. You will be fine if you live in that 0-2 pain level, or the good pain levels since we also need to gradually re-mineralize the bone. Good luck and I hope this answers your concerns. 

Thank you very much for taking the time to read -- I appreciate your help!

Happy New Year and All the best,

Sunday, January 1, 2023

Happy New Year 2023

    All of us will have different dreams for this year. I always love saying goodbye to one year, with its ups and downs, and welcoming a brand new year full of promise. This year will bring the end of my full time practice of Podiatry with the joy, and sadness, that accompanies that decision. It will bring much more time for family with afternoons with my first grader Henry, and trips to Carlsbad to visit my grandson William. We have trips to England, possibly Norway, Hawaii, Palm Springs, and Lake Tahoe already planned, so I won't be bored. I plan on continuing to write (especially my blog), teach at the local Podiatry school, mentor my replacement Dr Ajitha Nair, and enjoy life. Thanks to all the readers who have entrusted their foot problems with me these many years. Hopefully, I have a few more inside of me. Happy New Year!!