Video from Dr Richard Blake on Injury Rehabilitation General Rules

https://prezi.com/v/view/wyPiHlcIQ9LKeHoi88I2/

Walk Run Program for Injury Rehabilitation or Beginning Running

The Walk/Run Program

     Most sporting activities require some running. Running can be an excellent return-to-activity conditioning tool. After recovering from an injury, the athlete finds great physical and emotional strength from a gradual buildup of running. Injury rehabilitation can involve crutches, cast, surgery, and rest. Golden Rule of Foot: At some point, when the athlete is back to walking 30 minutes, without pain, and without a limp, a walk/run program can be started.

     The walk/run program that I have used for many years uses a 30-minute time period, based on the more classic 30-minute hard walk test that qualifies the athlete to begin jogging. However, you can start the program based on a 20, 30, 40, or even 50-minute period. It all depends on what you want to get to. I have used the 30-minute program personally twice in my life; once after a back injury, and the other after a knee injury. I found the program difficult since I was out of shape for running, yet safe with its low start and gradual progression. It is not as easy as it looks when you have not run for a while.

There are 10 levels:

• Level 1     Walk 9 min Run 1 min Repeat 3 times for 30 mins

• Level 2     Walk 8 min Run 2 min Repeat 3 times for 30 mins

• Level 3     Walk 7 min Run 3 min Repeat 3 times for 30 mins

• Level 4     Walk 6 min Run 4 min Repeat 3 times for 30 mins

• Level 5     Walk 5 min Run 5 min Repeat 3 times for 30 mins

• Level 6     Walk 4 min Run 6 min Repeat 3 times for 30 mins

• Level 7     Walk 3 min Run 7 min Repeat 3 times for 30 mins

• Level 8     Walk 2 min Run 8 min Repeat 3 times for 30 mins

• Level 9     Walk 1 min Run 9 min Repeat 3 times for 30 mins

• Level 10                    30 min Straight Running

Each level should be done three times minimum, depending on how you feel. Each session should be followed by a rest day to see how you feel. Therefore, completing Level 1 should take a minimum of six days. For example, start walk/run on Monday, rest Tuesday, second session Wednesday, rest Thursday, third session Friday, rest Saturday, and ready to start Level 2 on Sunday as long as Level 1 was fine within the Good Pain         (Level 0 - 2 pain)

Gradually work your way through all 10 levels. Remember to stay pain-free if you pass to the next level, but if your pain starts to come back, rest three days, and go back to the level you were comfortable at for three more sessions. Again try to get to the next level. If you again have trouble, stay for six sessions at the comfortable level, continuing to run every other day. Most patients gradually go through the 10 levels in two months (60 days), but some have taken a lot longer to progress. Remember, if you listen to your body, and don’t push through pain, you should make it very safely.

 The walk/run program works well with even minor injuries where there are questions of when to start running. If you have only been off running for a short time, but you feel anxious about starting running, try this program. In its quickest form, Level 1 the first day, then a rest day, then Level 2, then another rest day, and so on. As long as your symptoms are fine, and you do not push through pain, you can get through the 10 levels in 20 days. This is normally better than running three miles the first day, having a flare-up of symptoms, then stopping running for two more weeks. It allows you to test the waters of running more safely.

 Remember another Golden Rule of Foot: It is better to run 1 second than not at all. Patients ask me all the time if they can start running. If they can walk 30 minutes at a good pace, without pain, and without limping, then they can start running. Any running for most athletes is better than not running. If you cannot do the 1 minute for Level 1 walk/run, try 10 to 30 seconds, running telephone pole to telephone pole in your neighborhood. Getting back into running shape can be safe with a walk/run program. It may require some individualization, but you will go either at the speed you were meant to, or slightly slower. You will get there!!

This was an excerpt from my book "Secrets To Keep Moving: A Guide from a Podiatrist"

Injury Rehabilitation: The Magical 80% Rule

80% is not 100% or 99% or 95%, but is the most talked about number in sports rehabilitation. Why? When you look at the pain scale, the numbers are graded from 0 to 10, with 10 being agonizing pain and 0 no pain. With most injuries, it takes 20% of the overall rehabilitation to reduce the symptoms 80% (normally between 0 and 2), and another 80% of the overall rehabilitation to knock out that remaining 20% (to daily 0 with no reflares). Therefore, sports medicine providers attempt with most injuries to reduce the symptoms to between 0-2 (80% better) and hold the symptoms there for a long time. The patient still has some symptoms as they get back into activity. It can be quite unnerving to some patients to still be experiencing pain while re-attempting to participate in an activity. However, since it takes 20% of the overall rehabilitation to get there, and for simplicity let us say it took 2 months to reduce the pain from 8-10 down to 0-2, then it will take 80% of the time (8 more months) to completely eliminate all the pain. If we wait for no pain to begin activity, the wait is much longer than necessary, and the body gets stiffer, weaker, more deconditioned, and overall, more vulnerable to re-injury when starting up again. So, 80% reduction in symptoms down to levels 0 to 2 pain is considered the gold standard in treating injuries. Golden Rule of Foot: When 80% of symptoms are reduced, and normal walking occurs without limping, a return to activity program can be initiated. This is the 80% related to the pain scale.

But, what about the 80% related to activity. 80% better for function is when you can start running again. Running is the basis of almost all athletic endeavors. The way I look at and discuss with patients the function scale is:

0 to 20% bed ridden,or non weight bearing on crutches or Roll-A-Bout
20 to 40% from beginning to bear weight to off crutches (normally needs removable boot/cast)
40 to 60% Gradually feeling less pain with walking with or without boot
60 to 80% Walking with increased speed with mild symptoms, beginning to do sports specific activities like volleying in tennis, or shooting around in basketball
80% Passed the 30 minute hard walk test without set back, can begin a walk/run program, can begin to play sport with some idea of gradation back into full activity.

It is the magical merging of these two 80% scales that will allow the patient to begin their sport at a high level and begin to feel normal again psychologically. Many patients the scales don't match for a while and the health care provider must have them wait. For example, many patients have 80% pain relief by icing, medications, activity modification, braces, orthotic devices, etc, but when they attempt to walk hard for 30 minutes (standard test), or attempt sport specific activities like solo volleying in a squash court, they have definite increase in symptoms. They are still in the 60-80% range of function. This is the time that physical therapy, injections, changes in orthotic devices, chiropractic, accupuncture, etc, is utilized to get their function off this plateau and onto the 80-100% plateau where they can dramatically increase their activities. A good sports medicine provider is very skilled at this task of raising the plateau. Since the 80-100% plateau can be filled with reflares, minor setbacks, and many good pain/bad pain decisions, it can be the most difficult and challenging time in treating active patients. It is in this time period that most treatment of all the possible causes of the problem occur---short legs, flat feet, lordosis, weak muscles, tight muscles, dietary, etc, etc, etc. It is the fun part of rehabilitation.

I hope this post explaining the magical 80% rule used by most in the rehabilitation world has been helpful. Do not wait until you have no pain to begin to exercise you love, but there is so much thought on how to return to activity during this 80-100% prolonged plateau safely. Good luck!!

Injury Recovery Principles: Crossing from Sickness into Health

http://www.dreamstime.com/stock-photography-crossing-rimagefree1020847-resi2565486

This scene reminds me of the journey we all take during an illness or injury to regain our health. The Crossing from Sickness to Health needs a boat load of people at times to help us. For the normal sports medicine injury that I see, there may only be a few on that boat--patient, doctor, physical therapist, family and friends, shoe store personnel, internet resources, and referring source (like Yelp, Tribe, primary care physician, etc). For more complicated cases, that boat can be pretty full. Yet, sometimes with a full boat in these severe conditions, the patient can still feel very alone since they lose sight of the primary care provider steering the ship. In the crowd of people on that boat, no one is actually calling their name when the time comes to disembark, or change course. Perhaps that person in charge of steering has never been established in the first place, and the boat may not be able to be docked on the other side at the best end point.

http://www.dreamstime.com/free-stock-photo-splash-rimagefree1019674-resi2565486

I imagine sometimes that my patients feel alone in turbulent waters when they do not have good direction, or attempt to do it alone. In a world of super specialities, whom is looking out for that patient as the primary care giver. Every specialist, whether podiatrist, orthopedist, neurologist, etc, tends to look at the patient through some tunnel vision. The medical world needs to see the dilemma facing these patients when no one is truly guiding them. Patients are routinely told when they see a specialist to come back if they want surgery, come back if they want orthotics, come back if they want more physical therapy, etc, but how does the patient make these decisions. And when symptoms get worse, no wonder some patients choose some course of action, only because they do not know what else to do.

http://www.dreamstime.com/stock-images-canoeist-rimagefree1025651-resi2565486

As health care providers, we need to prevent our patients from going it alone, and feeling that way. As patients, if your injury seems difficult or challenging, and the symptoms are lingering or worsening, we need to identify one person who will oversee the problem. One person who may steer that boat to the right landing dock. Podiatrists as a group tend to be generalists, as I am, or super specialists in surgery. When you see a health care provider, find out if they are the one to manage your injury, or only deal with one part. I love to manage my patient's foot problems from start to finish, get second opinions when I am stuck, get one of our MDs to treat their other problems, get the primary care doctor involved when necessary, and work with the physical therapists helping them. I believe email is working well for complicated patients keeping the communication flowing. I am looking into a computer program that patients can keep track of their symptoms, and then email when appropriate. Through this blog I am trying to engage my patients more to understand the complexities of medicine and where it may apply to them. There are no rigid answers, but patients need to find the right person for their injury, be it MD, Podiatrist, PT, Chiropractor, or other allied health professional, to help steer the course from illness to health. Good luck! 

Athletic Injury Rehabilitation: The Law of Parsimony

Deception Point

The Law of Parsimony: When multiple explanations exist, the simplest one is usually correct.

This is my first post being inspired by the Mediterranean Sea along the coast of the Italian Riviera (this time from Diano Marina, Italy).

As I watched the Mediterranean Sea and read Dan Brown's Deception Point thriller, on page 238 he mentions the Law of Parsimony. This is a common law utilized in medicine; a good starting point in the treatment of injuries. I will use the Law of Parsimony in this post to describe the common starting point of treatment based on the commonest cause for several injuries listed below. If you have one of the injuries mentioned below, make sure that your treatment is addressing this issue.

• 
  
  Achilles tendinitis--tight achilles tendons
• 
  
  Plantar Fasciitis--inadequate arch support
• 
  
  Recurrent Ankle Sprains--weak peroneal tendons
• 
  
  Chondromalacia Patellae or Patello-Femoral Dysfunction--weak vastus medialis
• 
  
  Ilio-Tibial Band Tendinitis--tight Ilio-Tibial Bands
• 
  
  Morton's Neuromas--tight front area of your shoe or boot
• 
  
  Posterior Tibial Tendinitis--excessive pronation
• 
  
  Bunion Pain--tight front area of shoes
• 
  
  Metatarsal Area Pain--development/increasing of hammertoes (see post on Budin Splint)
• 
  
  Peroneal Tendinitis--lateral instability in shoes
• 
  
  Generalized Arch Pain--weak intrinsic foot muscles

These are great starting points to treat these injuries. In many cases, it will take awhile to get weak areas strong, tight areas flexible, and correct biomechanical and shoe issues. Other treatments will be used to address anti-inflammatory concerns, and less common causes of the same injuries at the same time to hopefully sped healing along. See the post on Tips for Bunion Care as a good example. Thank you Dan Brown and the Mediterranean Sea for this inspiration. Now off to a great pasta or seafood dinner.

Injury Rehabilitation: When Pain is Superficial, think Deep

   

 In medical school and residency training you are taught that superficial pain in a muscle/tendon/ligament may to secondary to deeper, more serious problems. The superficial structures may be sore for many reasons including deep swelling that has surfaced (like after an ankle sprain), or muscle soreness from strain as they compensate to protect the deeper tissues. Hundreds of examples abound including the diagnosis of  achilles tendinitis only to later find out that there was a chip fracture in the back of the ankle requiring surgery. The diagnosis of achilles tendinitis may have been followed with months of physical therapy, casts, orthotics, braces, and medications. A sports medicine practitioner works hard when superficial structures are identified as the cause of pain to at least consider deeper evaluation if the symptoms do not respond. This is where the patient can greatly help their own cause by asking questions about possible deeper structures involved.

     Golden Rule of Foot: Treat the Patient not the Test (xray, MRI, bone scan, etc) Another common scenario happens all the time, and I will use Judy's story to describe it. In this case, Judy actually developed a superficial tendinitis on the outside of her knee called: Iliotibial Band Syndrome. The smart clinician looked deeper with an MRI and found arthritis in the knee. The decision was made, without proof, and not following our KISS principle (see post covering), that the arthritis must be causing the tendinitis, and the knee required a knee replacement. The patient wisely choose the KISS principle and treated the tendinitis first (on advice from other physicians) to see if the pain would go away and it did. I have had 3 major injuries in my life and all 3 had a surgical option. Good people recommended good surgeries for me. But I choose to try rehabilitation first, and so far, I am fully functional and have avoided surgery. We owe it to ourselves to try rehabilitation first. In Judy's case, her pain was superficial, and surgery on her deeper arthritis was unnecessary.

     The photo above shows the complexity of the knee joint and how soreness in one area may be caused by deeper problems, but may be not. So, deep injuries can be mistreated when the care is only directed at the secondary more superficial soreness. And, superficial injuries with concurrent deeper non-painful  abnormalities can be mistreated when the doctor, therapist, and/or patient mistakenly blames the pain on the wrong structure. Please review one of my earlier posts on Second Opinions. Golden Rule of Foot: Allow time for Rehabilitation to succeed or fail, so that you can possibly avoid unnecessary surgery.