Shoe Evaluation: Shoe Flexion Test

The Shoe Flexion Test checks flexibility of the front of the shoe. You are testing whether the shoe bends correctly or in the wrong place. As you walk or run, you need to bend your foot in the metatarsal or ball of the foot area as the heel lifts off the ground. This easy motion is called propulsion or push-off. It should occur only at the right place or injuries may occur. Grab the shoe again (like the post of Shoe Torsion Test) firmly at the heel. Then, grab the toe area and simulate toe bend by bending the toes upwards. The second photo demonstrates the shoe easily bending, not at the ball of the foot, but at the arch. This is how injuries to the arch, or plantar fascia, can occur. The shoe actually forces the foot to bend at the wrong place. Ouch!!! Combine the Shoe Flexion Test with the Shoe Torsion Test with Heel Verticality Test from other posts and you are beginning to have a clear understanding on how evaluate the safety of the shoes you buy. Good Luck!

Shoe Torsion Test for Stability

One of the best tests you can do at the shoe store when looking for a stable shoe is the Shoe Torsion Test. The photo above shows a shoe from the side. Grab the heel firmly. Grab the front of the shoe and attempt to twist the shoe as demonstrated in the photo next to this text. If the shoe twists easily, it fails the stability test, and you should not buy it. After you do this test on 5 different shoes, you will have a good understanding of the range of stability offered in the current market. Golden Rule of Foot: Avoid Shoes that fail the Shoe Torsion Test.

Achilles Stretching Technique

Proper Stretches for the Achilles Tendon are a vital part of every pre and post activity, and especially with injuries to the achilles, calf, plantar fascia, and hamstrings. Please refer to the post entitled "Generalizations in Stretching". There are two muscles, gastrocnemius and soleus, that make up the achilles tendon. These two muscles can be stretched separately by first having the knee straight (gastroc stretch on the left photo above), and then having the knee bent (soleus stretch on the right photo above). With both stretches, it is important to keep the heel on the ground. Hold each stretch for 30 to 60 seconds, or 8 deep breathes. Deep breathing gets oxygen into the stretch, a good yoga principle. Do not bounce, ballistic stretching. It is never good to jerk the muscle or stretch through pain. You want that good ache feeling. Try to stretch several times a day to actually gain in flexibility, even on days you do not do your normal activities. When non-athletes complain of cramping in their calves, often low potassium or dehydration is blamed. Have them try stretching 2 or 3 times a day and many will experience complete elimination of the cramps.

Hill Running Tips

San Francisco: A Runner’s Paradise (with a hilly twist)


Those of you who live in the San Francisco Bay Area know the true beauty and allure of San Francisco. Once you move here, why would you ever leave willingly? I work in the only downtown hospital in San Francisco, Saint Francis Memorial Hospital. Millions of people work in the downtown daily. People from all over the world travel to this area on vacation and business trips. It is truly an exciting place to live, or even experience briefly. Runners can train year round so they love the great climate.

When runners move to San Francisco, they are immediately faced with potential danger---the San Francisco Hills. There are 7 of them. Finding a flat running routine can be challenging. The 7 miles 5 days a week they were running in flat Dallas can not be transferred into hilly runs in San Francisco without danger lurking. Hill runs can be great in moderation, but must be gradually incorporated in your running program.

     This photo does not do justice to one of the steepest hills in San Francisco called Lansdale Avenue. The hiking area to the left is Mount Davidson Park and the incline is intense. As a high school runner at Archbishop Riordan High School here in San Francisco we would do twice weekly interval training up this hill to the base of the huge Cross at the top of the hill. Probably why we won the league championship on a yearly basis.

     When you are training for some event and increasing the intensity of your workouts, think about these key points. Never increase the 3 main variables at the same time---distance, speed, and hills. First, build up your distance to where you would like/want it. Then stabilize the distance at that same amount, and add two speed workouts or two hill workouts per week, not both. These two workouts per week are normally in the middle of the week, like Tues/Thurs, with an easy run on Wednesday. Speed and Hill Workouts provide different stresses to the body and will make you faster and stronger. Just do not increase both at the same time. Give yourself 3 weeks at hills or speed, level off that variable, then add the 3rd variable. Try 3 weeks with one speed and one hill workout per week, then try 3 weeks just adding the 3rd variable. Do you see how safe, albeit slow, this procedure is? Since this is a medical blog, I am going to emphasize safety.

     One way to safely add hills is in the middle 1/2 of a run. So, during a 6 miler, run 1 and 1/2 miles flat, 3 miles in a hilly area, and the last 1 and 1/2 miles flat. Do the math! Charge up as many hills as you feel up to, pumping extra hard with your arms to help pull you up, but go easy down hills. Down Hill Running is one of the biggest dangers for injuries, especially during the last 1/4 of the workout when the muscles are fatigued. There is only damage to your joints as a benefit of down hill running, other than mortgage payments for orthopedists. But if you run up, you must run down, so go easy. The stresses to your body running down hill can be up to 10 times body weight as you land on each foot. Go easy with down hill running and last much longer as a runner. The occasional race where you need to fly down a hill to win a prize or something is just fine, but avoid the pounding of down hill running during your normal training runs.

    

A Cane for Sitting

Harvy Quad Seat Cane - Black

The secret of movement that keeps people healthy in body and mind is greatly helped by wonderful devices such as the Harvy Quad seat cane that you can order at Target or Amazon. There are several versions, but the basic type allows prolonged rest when you begin to get symptoms. Many of my patients are able to function so much more with the use of these canes. Their whole personality can change to extreme happiness from depression, if their physical ailments have beat them down for too long. The one shown is lightweight to carry and holds up to 300 lbs. Think of the museums that could be conquered with the use of this device. Keep moving that body even if it is less than you want. Golden Rule of Foot: 1 Foot of Movement is better than none. Golden Rule of Foot: Move the Body, Strengthen the Brain.

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.

 

Hamstring Stretch: Various Positions can be Key to Flexibility

Hamstrings tightness is very common to athletes. Stretching of the hamstrings is one of the 3 most important lower extremity stretches that should be done both before (to prevent injury) and after (to gain flexibility and relax muscles) exercise. The other 2 muscle/tendon groups crucial to stretch are achilles and quadriceps. Various posts will be dedicated to each variation of stretch. I feel most stretching articles are too overwhelming with 5 plus exercises. I would rather you understand one well, before proceeding further.

The photo above shows the basic lower hamstring stretch getting the muscle/tendon loose around the back of the knee. The patients are told to place their heel on an elevated surface, like a chair or bench, where they feel no tension placing it there. The knee should be held straight and the toes straight upwards. The patient should not attempt to touch their toes which places too much stress on the back. It is emphasized to the patient to lean forward over the leg being stretched feeling the bend at the hip joint, not the back. Imagine the back as completely straight. Lean forward over the leg until you feel tension behind the knee. It is very important since you are standing on one leg to feel very stable. Be near a wall or table that you can hold on with your arms if needed to gain stability.

           Once you feel a great stretch, hold the stretch for 30 to 60 seconds (I love 8 deep breathes to get oxygen into the stretch. With every exhale, go slightly deeper  into the stretch). There should never be pain with stretching either during or after. Pain during stretching will always mean 2 hours later you are tighter than when you started. Pain after stretching means you stretched too hard and next time stretch easier. Please read the separate post on Generalizations of Stretching.

When stretching both legs, I like to alternate sides. The three stretch variations for the lower hamstring is all based on the big toe position. Let us discuss the right side, and I will leave it up to you to do the opposite for the left side. With the big toe at 12 o'clock, lean forward over the leg until you feel the pull of the hamstring behind the knee. Hold this painfree stretch for 30 to 60 seconds, or 8 deep breathes. Then do the left side. The second stretch for the right side is with the big toe at/near 9 o'clock. This gets a greater stretch on the medial hamstrings (semi-tendinosis and semi-membranosis). Then do the left side. The third stretch for the left side is with the big toe near 3 o'clock. This gets a greater stretch on the lateral hamstrings (biceps femoris).

You may be very surprised that one of the three stretches gets the sore muscle/tendon better than the other two. If so, do one more stretch to this variation for 8 more deep breathes, or go back it that stretch alone several times a day. Soon I will have a post on Upper Hamstring Stretching (the apparent mystery stretch to 99% of my patients whom have never heard of it).

Plantar Fasciitis or Plantar Heel Bursitis: Rolling Ice Stretch

The Most Time-Effective Treatment for Plantar Fasciits is a 5 minute Rolling Ice Stretch. It combines anti-inflammatory, mechanical massage, and plantar fascial stretch all beneficial in helping plantar fasciitis. If there is a plantar bursitis, an additional 5 minutes of massage just to the bottom of the heel is performed. A plastic bottle of any shape (patients do have their favorites) is filled 1/2 to 2/3 full of water and then frozen. The water will expand with freezing. Then, a towel is placed on the ground, and from a sitting or standing position (I personally like standing but not with full body weight), the arch from heel to toes is gradually massaged from 5 minutes. Patients are told to gently massage the skin for the 1st minute, the 2nd minute they can massage a little deeper into the soft tissues, and the 3rd to 5th minutes the massage should get deep into the deeper tissues (fascia, muscle, and tendon). This treatment should be done three times daily. The bottom of the heel gets its own 5 minutes if a bursitis is present. Remember with icing the 4 to 1 rule. If you ice for 5 minutes, the tissue is tight for the next 20 minutes, prone to pull if used, so be careful to go easy on it during the thawing-out phase. This treatment can be used for many months until the final healing of the plantar fasciitis.

Morton's Neuromas: Nerve Pain in the Front of Foot

This is going to be a reader (are you guys out there?) based post on various topics. But I want the focus to be POSITIVE NEWS. Emphasize what has worked for you. Do not emphasize what has not worked for you on this site. If you can relate in 1 to 6 sentences at most what was HELPFUL in your treatment, you will help hopefully 100’s who read the post (eventually!!). I will comment occasionally and will initially try to have my own patients generate a lively conversation. I am very sure that we all will learn a lot from those who post comments. With most injuries, it takes 2 to 5 treatment avenues (for example, icing, stretching, inserts, physical therapy, etc.) to completely get better and prevent reoccurrences. STAY POSITIVE for the reader. With all the negativity in the news and on the web, and when a patient is dealing with pain, they need a POSITIVE HEALING message. Pain is negative, let your comments be positive. POSITIVE NEWS brings HOPE and hope allows for HEALING. Please be a part of the HEALING PROCESS. I will place this paragraph at the top of each of these Reader Speak Outs.

Question for the Reader(s): If you have had pain in the front of your foot that has been diagnosed a Neuroma, what 1 treatment do you think was helpful/most helpful? If you have more than 1 you would like to discuss, please do a separate post.

What is Sports Medicine?

What is Sports Medicine?



The sports medicine approach to injuries, athletic or not, can be very different from general podiatric or orthopedic approaches. Sports Medicine evolved from the professional and college teams needing to get their players safely, but as quickly as possible, back onto the playing fields. It evolved away from the surgical treatment of injuries as the mainstay of treatment. Was there another way to treat an injury, besides surgery that led to the same results without the surgical scar and without the time off required for surgery? Was there another way to treat an injury without prolonged casting/immobilization of the body part?


The sports medicine approach is a switch from “Doctor please heal me!” to “What can I do to help myself get better?” The sports medicine approach is a switch from pills and shots and casts to ice, soaking, alternative exercise, home exercise programs, braces, etc.


Sports medicine doctors will use surgery when needed, shots when needed, casts when needed, and medicine when needed. The doctor’s orientation to an injury is less doctor focused, and more physical therapy focused, and more patient involvement. Treating a patient with a sports medicine approach is truly an attitude difference. Hopefully, the various posts on this blog will infuse the reader with this attitude.


A sports medicine approach is in its purest sense a team approach---patient, therapist, doctor, other specialists (acupuncture, trainers, dieticians, coaches, etc.) Everyone’s input is vital, looking at the same injury from different perspectives. The patient’s subjective view, but experiencing the problem first-hand, is balanced by others sometimes more objective views. Having treated many athletes and non-athletes, I realize patients can be very objective about their injuries, or not at all. Most importantly, no one should advise anything that potently harms the patient (patients have a way of doing that to themselves too much already).


From 1975 to 2000, sports medicine explosion happened. Prior to 1975, there were sporadic sports medicine centers across the country, now they dominate the health care world. Everyone wants to use the word sports medicine in their practices, but do they practice sports medicine?


The consumer needs to find the sports medicine doctors and therapists in their areas by talking to fellow athletes, the running shoe shops, the cycling stores, the athletic clubs, and online services like Yelp.com. They need to shop around if there initial treatment plan is lacking in patient home programs, physical therapy programs, alternative exercise programs, and other signs that this doctor practices sports medicine.


I personally do not think the doctor or therapist needs to play sports to be good at sports medicine, but it helps immensely. Does the doctor/therapist understand your need to get back to exercise quickly? A typical proactive program contains a minimum to 4 and sometimes 7-8 activities for the patient to do between office visits to get better. Some sports medicine physicians do leave this to the therapist, but I prefer some individualization from the doctor.

1. What stretching can be done?

2. What strengthening can be done?

3. How often do I ice the area, or should I soak it?

4. What does physical therapy have to offer?

5. Would alternative exercises (for example, biking if it is an injured runner) help and what kinds?

6. Should I take medicine? And when?

7. Should I wear a brace, splint, or do some form to taping?

8. Should I change something about my shoe gear, equipment (for example, have my bike pedals adjusted), lacing, shoe inserts?

9. Should my training be different?

10. Will I need any tests, and how it that decided?


These are such basic questions that must be answered within the first 2 visits of a typical sports medicine visit.


Since 99% of all sports medicine injuries are non-surgical, the sports medicine specialist or his/her team should be the expert in rehabilitation. It is so important for our bodies to get the best and safest treatments. We need these bodies to be fully functional for hopefully a long time.


Every health care profession has a sports medicine division. That can be a good place to look for a specialist in your area. For podiatry, the American Academy of Podiatric Sports Medicine www.aapsm.org is the appropriate starting place. But, I have found that no matter how you label yourself, the patient must evaluate whether or not you really have the sports medicine attitude.

Movement--One of the Secrets of Life

For over 30 years I have watched a wonderful group of patients dedicate themselves to motion of some sort or another. They are not the athletes you read in the papers, some would not consider themselves athletes at all, but they deeply understand that movement is crucial to their lives. I have helped them occasionally through life’s ups and downs, but mainly observed them and been inspired by them. This motion may start physically with some activity, but it is part of a larger pattern of involvement in life. They are engaged in life, inspired by some passion, or just very very grateful for their time here. Daily they open the package called the Present and celebrate in their own unique ways.



I have come to appreciate the movement or rhythms of their lives. I can only weakly imitate some, as I try myself to find my rhythm of success. It is a type of success in life that is taught through movement. Respect of the body and of others. Respect of the soul, that inner force, that calls each of us. That movement is away from the couch, away from self-pity, from inertia. It is one of the deepest secrets in life that I know. Most 80 year olds know that if you stop moving, you might as well cash it in. They understand. I hope I understand at 56. Can most 20 year olds understand, it probably depends how reflective they are?



The struggles to keep going is sometimes the food of the soul. In injuries, or disabilities, great lessons are learned. But in appreciating movement, deep truths are experienced and learned. An athlete that is self-centered has not learned the truth. A true athlete will learn many truths (humility, patience, kindness, etc.) when the secret of movement is realized.



One example of a person in motion is from my early days at Saint Francis Hospital in San Francisco. There was a funny old doctor when I first started—Dr Waldo Newberg. Funny because he ran everywhere, between the office to the hospital, his car to the office, the elevator to the lunch room. When I first met him, I didn’t know what to think. I hadn’t learned the secret lessons of motion, even though I was an athlete. Dr Newberg had 7 children, donated time and money to the missionaries in Africa, ran the San Francisco Marathon when he was 80, and he never was rushed to say hello, or to answer any question.



Yet, my mother-in-law Marilyn is another wonderful example even though she would say she is allergic to exercise. Her day is one of beautiful movement. A mother of 5 with all her children and grandchildren daily in her conversations and concerns, she is always helping out. Always driving where she is needed, always bringing the family closer, always a beacon of love for those fortunate to know her. You never know what city Marilyn will spend her day in, but everyone always feels her loving force, moving the conversation along, moving the grandkids to another event, moving the inertia personally from this world in a fully-centered way.




So, this movement is with the body, but it must come from the heart. It must come from deep within us. When it comes from this depth, a force is noted by all those around. It becomes an inspiration of how to live our lives. I feel that with my basketball. I feel a deep connection to my being in my struggles and in my successes to move my body as I did as a 20 year old. My job would tie me to a desk, dragging me into stillness, dragging me into 40 more pounds. I need the movement of basketball 3 to 4 times a week to pull me out of my inertia and awaken my soul. I am a better person because of it. When I can’t play basketball anymore, I pray I can find another way to keep moving, keep being engaged, keep caring, keep loving today for the Present it is.

Cortisone Shots: The Thought Process Behind

• Cortisone shots can be divided into short-acting or long-acting.

• Short-acting shots normally are beneficial for 3 days and are used to quickly reduce inflammation. They are commonly betamethasone (6mg/ml) or dexamethasone (4mg/ml) formulas. Since even short-acting cortisone can cause damage/weakness to tendons, if given into tendon sheaths the body part should be immobilized for the 3 days. It is the long-acting shots that are the true healers when the inflammation is out of control, and normally what people are talking about when it comes to a cortisone shot.

• This post shows that cortisone normally is not a quick fix as some athletes hope, but it can speed the return to a high level of athletic activities when given appropriately.


• Long-acting shots have a crystalline base which slowly dissolves over a 9 month period. They are commonly Kenalog (10mg/ml) or Celestone (6mg/ml) brands. Any shot after the first long-acting cortisone shot within the 9 month period is considered a booster shot.


• Long-acting cortisone shots are normally mixed with a 5 hour local anesthetic. This way the shot also becomes very diagnostic. The long-acting cortisone itself takes 3 to 7 days before it begins to work. This is why you wait 2 weeks to see its effectiveness. I ask the patient to tell me how much pain relief they received in the first 5 hours, and then over the next 3 to 14 days. The initial 5 hours tell me if the cortisone was deposited in the right place.


• Following a long-acting cortisone shot, and after the local anesthetic has worn-off, there can be a period of 2 to 7 days where there is more pain due to the added swelling produced by the shot. This is why patients are encouraged to ice the area of the shot 3 times daily during the first week, and twice daily during the second week.


• Patients are told to come back in 2 weeks if they have less than an 80% pain relief (normally no pain walking, greatly diminished pain from before the shot).


• Long-acting cortisone shots are given routinely to diminish inflammation for bursitis and neuritis situations.


• Long-acting cortisone shots should never be given into tendon or tendon sheaths (the covering of the tendon) since they are associated with tendon ruptures. It is important to keep the cortisone as far away from the neighboring tendons as possible. 


• Long-acting cortisone should only be given into joints when MRI s (not x rays) have documented no bone/cartilage damage to be of concern, or when the only alternative is surgical treatment. An arthritic joint, for example, can have up to 5 injections per year to calm down the inflammation, but if the injections stop working, surgery in some form will be the only alternative. The patient must know this going forward with the shots.


• Long-acting cortisone is never injected into the plantar fascia itself, but into the bursitis under it. Tears of the plantar fascia can occur with injections into the plantar fascia directly.


• No running/high-demand/weight-bearing sports are allowed for 2 weeks after a long-acting cortisone shot is given. This is why athletes run from the thought of cortisone shots, even when they are limping, and vow they will ice hourly as long as they can still run. More realistic is to try 3 to 4 weeks of physical therapy to cool off the inflammation, then to maintain their relief with a daily icing regimen.


• Most foot injections are 10mg of cortisone each. Most knee injections are 40mg of cortisone each. Most epidurals (spinal) are 80+mg of cortisone each.


• Injections are given until 80-90% improvement is noted. Golden Rule of Foot: Never Give A Shot You Are Not Sure Is Needed. This may require 1, 2, or 3 shots, minimally spaced 2 weeks apart.

• What is an 80-90% improvement? It is crucial to understand this concept!! Golden Rule of Foot: 80-90% improvement is when full activity can resume with only mild symptoms easily maintained with non-invasive conservative treatments like icing, contrasts, activity modifications, stretching, anti-inflammatory medication, etc.


• Most of the time 2 injections are needed to bring about this 80-90% improvement (a month of no weight-bearing athletics). However, 20%+ need 1 injection, and equal number need all 3.


• There should be no pre-determining how many shots are needed. The first shot is given and the athlete returns in 2 weeks. The area is evaluated, and the doctor and the patient independently give an estimate on what improvement (if any) has been achieved. It is crucial that the patient ice the area 3 times daily (see post on icing) during these 2 weeks. This can accentuate the anti-inflammatory aspect of the shot, hopefully eliminating any need for further shots.


• When patients call me wanting an appointment for another shot, I normally have them icing 3 times a day, if they have not, for 3 days to see if they really need the shot. Over 50% of the time, they do not need the next shot.


• If after the 2 weeks, it is hard for whatever reason to determine how much improvement was attained, before giving another shot, the patient gradually returns to full-activity with anti-inflammatory oral medicine (after, not before, activity), icing, stretching, etc. If full activity is not allowed, thus not a the 80% improvement level, a booster shot is given and the process continues for 2 more weeks. You can see how once Cortisone Injection Therapy is initiated, it can take a while to finish.


• In the worse case scenario, 3 injections may not bring the inflammation down to achieve this 80-90% improvement expected. The decision must be made on further diagnostic tests or removable casts for immobilization.


• But normally, 1, 2, or 3 shots do bring down the inflammation, coupled with the 3 times a day icing, and with the 80-90% improvement, weight-bearing physical activity can begin.


• Hopefully, during the time of inactivity, some level of cross-training has happened, so return to activity at a higher level will not be too stressful on the body.


• Once the initial 80-90% improvement is attained, I will see patients at 3 months, then 6 months. If a re-flare of symptoms occurs, and icing does not diminish greatly, booster shots can be given one shot at a time.

Achilles StretchIng: One Stretch to Avoid (when you have achilles tendinitits or plantar fasciitis)

     A vital part of the treatment of achilles tendinitis and plantar fasciitis is stretching these structures. Please check out the post on the Generalizations of Stretching. The photo above shows a very powerful achilles and plantar fascial stretch. It normally feels great as you lower one or both heels off the edge of a stair or curb. But this stretch called Negative Heel Stretching can be damaging to your tendon and/or plantar fascia. I do not recommend it at all, but I emphasize it with my achilles and plantar fasciitis patients to avoid with a passion. With the heel in a vulnerable, non-protected, position, the heel is lowered into a position it is just not used to being. If you think about heel position in life activities (functional activities), our heels are either at the same height as the front of the foot, or elevated above the front of the foot as in a normal heeled shoe. Negative Heel Stretching places our heels in a position that life has not accustomed them to being. Almost our full body weight goes into the achilles attachment in the back of the heel and into the attachment of the plantar fascia into the bottom of the heel. Golden Rule of Foot: Avoid Negative Heel Stretching. Do not take a chance that this stretch is overloading the weakened areas leading to greater damage of the tissues. There are too many other ways to stretch these areas which will be handled in other posts.

Heel Pain: Reader's Speak Out

This is going to be a reader (are you guys out there?) based post on various topics. But I want the focus to be POSITIVE NEWS. Emphasize what has worked for you. Do not emphasize what has not worked for you on this site. If you can relate in 1 to 6 sentences at most what was HELPFUL in your treatment, you will help hopefully 100’s who read the post (eventually!!). I will comment occasionally and will initially try to have my own patients generate a lively conversation. I am very sure that we all will learn a lot from those who post comments. With most injuries, it takes 2 to 5 treatment avenues (for example, icing, stretching, inserts, physical therapy, etc.) to completely get better and prevent reoccurrences. STAY POSITIVE for the reader. With all the negativity in the news and on the web, and when a patient is dealing with pain, they need a POSITIVE HEALING message. Pain is negative, let your comments be positive. POSITIVE NEWS brings HOPE and hope allows for HEALING. Please be a part of the HEALING PROCESS. I will place this paragraph at the top of each of these Reader Speak Outs.


Question for the Reader(s): If you have had pain in the bottom of your heel, what 1 treatment do you think was helpful/most helpful? If you have more than 1 you would like to discuss, please do a separate post.

Blisters: General Principles on Care

• Always drain blisters as soon as possible and use a sterile pin or needle.

• Sterilize the needle or pin with rubbing alcohol or passing it through a flame, when letting it cool for 30 seconds.

• Before performing the procedure, and try to make Marcus Welby MD proud, make sure you have topical antibiotic, band aids big enough to cover completely, gauze to collect the fluid, and moleskin or athletic tape to cover the band aid.

• Push the fluid towards one side of the blister and puncture the dead top layer of skin keeping the needle/pin parallel with the skin, sort of above the fluid.

• Do not push the needle/pin into the live, deep layers of skin below the fluid.

• You must puncture the skin 3 to 5 times in different places to ensure that the top will not just reseal over and allow a new blister to form.

• Even with the best intentions, 30% of all blisters have to be popped again.

• After popping the blister, soak in warm water in a basin with two tablespoons of any type of salt for 30 to 60 minutes (the longer the better) to pull out the fluid. I do like the sound of the SALTS from the DEAD SEA.

• After soaking, dry off the blister well, apply topical antibiotic over the holes made by the needle/pin, or any other exposed, open skin, and cover with a band aid(s) bigger than the size of the blister.

• Place with firm pressure tape or moleskin over the band aid(s) to give an added push on the roof of the blister to re-seal with the underlying skin.

• Take off the dressing twice daily to soak for 30 minutes until all the soreness is gone. It is so important to continue soaking until the soreness is gone to pull out extra fluid and inflammation. This can take 1 to 7 days based on the size and depth of the blister.

• Once the soreness is gone, the dressing can be removed except when you are in a situation that a re-blister may occur (perhaps that next hike!).

• Keep moleskin or tape over the old blister area for 2 weeks more to protect against re-blister. It is extremely important to massage softening creams or moisturizers into the area for these 2 weeks to re-soften the skin. Massage twice daily for 2 minutes. All the soaking you do in the first week dries the skin and deep tissues.

• The goal is to get the skin soft again and the deep tissue not inflammed.

• When the blistering process is severe with skin breakdown and exposed deep tissue (loss of the roof), use one of the over the counter medicines in the water while you soak. See if your pharmacy has any one of these powders or liquids: Domboros, Pediboros, Bluboros, and Burrows Solution. Follow the directions for concentrations.

• The medicated powders or solutions listed above are so powerful drying agents that you immediately have to twice daily use the softening/moisturizing creams on the skin.

• With the severe blistering, more skin protection is also needed like big squares of moleskin attached only to good skin, Silvadene-like silver tainted ointments, and perhaps some padding. The silver ointments are anti-bacterial as well as great for the skin. Ask the pharmacy.

• What if the blister is possibly infected? So you pop the blister and pus comes out, immediately see a doctor.

• What if the blister has blood? Blood is the food of infection. Blood blisters must be taken a lot more seriously, and drained as quickly as possible. If you think it is getting or is infected, see above and see a doctor.

• Every year I have to have an infected blister hospitalized or, at least, see an infectious disease specialist. I hate infections!!

Hammertoes and Metatarsalgia: Possible Help with Budin Splint

Dr. Jill's (Budin) Hammertoe SplintPedifix Toe Straightener #P55

If you develop pain in the front of your foot (toes or metatarsals), one of the most successful treatment modalities is a Budin Splint. It should be initially worn very loosely around the toe. It is worn walking, not sleeping, and can immobilize the toes enough to rest the injured area. Normally, combining a Budin Splint, sometimes called a Single Loop Hammertoe Regulator, with two to five times daily icing can make the symptoms diminish significantly. See the post on icing. The loop that goes over the toe can be used on the toe that seems to be the most painful, or connected with the metatarsal that seems to be the most painful, or on the toe next to it (although not the big toe), or over both toes by opening up the loop wider. These splints can be bought at many locations including Footsmart.com and mooremedical.com. After tightening the elastic band to comfort, cut off any extra material on the under surface of the splint that is not under the pad, and then use tape (any kind) to secure the band to the under surface. The splint should never be worn if it increases pain in any area.

They are commonly used in enclosed shoes, or in socks around the house, to prevent or slow down the development of hammertoes. The photo above also shows an additional metatarsal pad (purchased from www.Hapad.com) for extra metatarsal support. They are an excellent post hammertoe surgery splint worn for up to 2 years. If the splint slips around alittle since it initially may need to be on loose, place a small piece of tape on the elastic band attaching the band to the skin on top of the toe. Golden Rule of Foot: Place the Budin Splint as far back onto the toe, away from the toenail, as possible. The splint itself should never feel like it pulls the front of the toe downward which could cause a hammertoe. The underlying pad is one size fits all so feel free to trim the size down if it cuts into you or interferes with your orthotic device. You should be able to make it work. If you start out real loose for comfort, once a week slightly tighten the band an extra 1 mm (slightly). If you are wearing it for pain, wear it 2 months longer after pain subsides.

Another type of splint has 2 loops, a double loop hammertoe regulator.Budin Toe Splint - Double Toe - Model 65065 I do not like how it pushes the two and third toes apart, so I tell patients to place on the 2nd and 4th toes. The double loop can be tried if only partial success is achieved with the varietions above of the single loop. I sure hope you like these products.

Toe Injuries: Coban Wrap for Compression and Stabilization

Coban Wrap was supposedly invented by a very smart engineer at 3M Company two years before he invented the glue for post-its. Both products have helped me and I am very grateful. Coban does not stick to your skin. The tape also has a latex-free version and can be found at www.3M.com/ The tape is corrigated to bind to itself. It is a stretch tape, so it gives with swelling. With any wrap, it should not be used if someone as poor circulation, but especially if they lack feeling. When you wrap a foot, or toe like in the photo above, you must be able to feel when it is too tight and should be loosened. It is fairly water-proof, so you can shower with it, and the skin dries under it. I have had patients leave on to protect a corn, or other sore, for a month at a time. The photo above shows the tape being used for compression following a broken toe. This will be on totally for 12 weeks to control the swelling and minimize the pain associated with this swelling. There will always be some stabilization of an injured area with Coban which can help speed healing of fractures. "Buddy taping" is when you tape a broken toe to the toe next to it for greater stability. First you wrap the injured toe completely, then continue the tape over the next toe. The big toe can not be buddy taped. The second toe if broken is taped to the third toe. The third toe if broken is taped to the second or fourth, whichever feels the best. The fourth toe if broken is taped to the third toe. The fifth toe if broken is taped to the fourth toe. The normal amount of time of taping is 3 months.

Tips to Avoid Cast/Immobilization Problems

Injuries can bring with them some form of casting to protect the area for a long enough time that the injured part has a great chance to heal. But as healing occurs to one area, other areas can be negatively impacted. The forms of casting available include permanent (plaster or fiberglass-type) and removable. All forms of casting cause a syndrome affectionately called “Cast Rot” or “Cast Disease”. This syndrome includes:

• Muscle/Tendon Atrophy or Weakness
• Muscle/Tendon Stiffness or Loss of Flexibility
• Proprioceptive Nerve Problems with Loss of Position Sense
• Cardiovascular Loss
• Weight Gain due to lessened activity
• Hip/Back Problems when the foot/ankle is immobilized due to height difference from cast side to good side

The permanent cast by far produces the most problems, but even the removable casts can be very destructive.

In the rush of reviewing the x rays or MRIs, making the decision to cast, and orchestrating that the proper cast is applied, many simple suggestions are forgotten that can minimize some of the effects of cast disease. If you have a foot/ankle cast, make sure the opposite foot is raised up evenly. A product called EvenUp® can be applied to the shoe on the opposite side to keep the knees, hips, pelvis, and spine level (as demonstrated in the photo above). Find out what cardio you can do to keep the heart/lungs strong (and remember the HDLs) and contain weight. Some walking is normally allowed with weight bearing casts as the soreness resolves, but stationary bikes on a daily basis can keep leg strength and adequate cardio. Normally you can do pain free isometric strengthening exercises within the cast, but a physical therapist will have to show you how to do these. Normally, push painfree into the cast in all 4 directions, hold for 6 seconds, and repeat 10 times. Do these isometrics 3 times daily. Sometimes, it is appropriate to order a muscle stimulator. This can even be placed on inside a permanent cast to begin strengthening as soon as possible. This is normally ordered and applied at the 2 week cast change.

As soon as the cast comes off, you may not be able to increase cardio, but you should be able to increase strength, flexibility, range or motion, and proprioception. Find out what exercise you can do as quickly as possible without risking harm. Keep pushing the doctor and/or therapist to move your rehabilitation along. A prescription for 3 physical therapy sessions (normally once every 2 weeks) can progressively build a home exercise program that you do daily.

Golden Rule of Foot: For every day you are in a cast,it takes 2 days to get back to normal. Your job, if you choose to accept it, is to move the rehabilitation along as quick as possible, without causing increased pain. Pain causes swelling, which causes more pain, which causes more pain, and the cycle spins out of control. Be your own advocate, ask questions, make sure speedy rehabilitation is part of all those involved mindset for you. Tell them you want to soak to reduce swelling, you want to do exercises for strength, flexibility, range of motion, and proprioception. Tell them you need to get safe but effective cardio as soon as possible. Keep it moving! Another Golden Rule of Foot!!

Marathon Training: Beginner's Guide

April 19, 2010 and the 114th Boston Marathon is now completed. Marathon season to me is now officially begun, although I know there has been a few so far this year. Something about the Boston Marathon is so magical---memories flood my brain of Bill Rogers, Alberto Salazar, Greg Meyer, Miki Gorman, Joan Benoit, and Jacqueline Hansen. What athletes they are!! What excitement they brought for all marathoners when 10 years before most Americans had barely ever heard of a marathon. Yes, 26.2 miles long, but arguably the greatest single athletic feat the average athlete/person can actually do!! Why? I also believe it is beyond doubt proof that the human body is meant to run. It is natural for us to run. My good 2:56:34 as a 21 year old would only be the world record for 70 year olds. Maybe I will journal my marathon training soon!! The photo is of my son Steve after 14 miles on his way to conquering the 2007 San Francisco Marathon. He didn't win, but everyone is a winner!!

For those of you ready to start training for your first marathon, I will be happy to help. Post your questions to this blog post. If you have a question others have the same question. I love this part of sports medicine. In 1984, I was the medical director of the San Francisco Marathon in which over 10,000 runners finished. It sadly has never been that big, but it is coming back in popularity!! In the 70s, it was marathon training that got me first interested in podiatry. I ran 4 marathons in the 1970s before I ever heard about podiatry. Podiatrists were keeping runners running. Most in medicine were saying how bad it is for your joints. But it is not bad for your joints!! Bad training is bad for your joints!! Bad shoes can be bad for your joints!! But marathon training is a natural activity for the human body, and we can excel in it. Go for it!! But Listen to your body!

I will title my Marathon Training Schedule as Dr. Blake’s Gentle Marathon Training Schedule. Give yourself 6 months to properly train. Use my friends at Team-In-Training to help. www.teamintraining.org/ What an incredible service they provide! My schedule is based on 4 days running per week. For 30 years it has been helping athletes achieve this incredible goal. You must have a long day each week, in which I will use Saturday, but the days can be slightly rearranged based on individual schedules. What is non-negotiable is the off day before the long run and the light jog the day after the long run. I love Grete Waitz’ (9 time NY Marathon Winner) rule of 3 up 1 down as the mileage builds and I have adapted a modified version. This is based on total weekly mileage. Time your first week with the weeks left before the marathon you want to run. Then, step out of your comfort zone and go for it!


Week 1 Total 6 Sun 1 Mon 0 Tues 2 Wed 0 Thurs 1 Fri 0 Sat 2

Week 2 Total 7 Sun 1 Mon 0 Tues 2 Wed 0 Thurs 1 Fri 0 Sat 3

Week 3 Total 8 Sun 1 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 3

Week 4 Total 9 Sun 1 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 4

Week5 Total8 Sun1 Mon 0 Tues 2 Wed 0 Thurs 1 Fri 0 Sat 4

Week6 Total11 Sun1 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 6

Week7 Total 12 Sun1 Mon 0 Tues 3 Wed 0 Thurs 2 Fri 0 Sat 6

Week8 Total 13 Sun1 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 8

Week9 Total 14 Sun1 Mon 0 Tues 4 Wed 0 Thurs 2 Fri 0 Sat 7

Week10 Total16 Sun1 Mon 0 Tues 4 Wed 0 Thurs 1 Fri 0 Sat 10

Week11 Total 14 Sun1 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 9

Week12 Total 18 Sun2 Mon 0 Tues 2 Wed 0 Thurs 2 Fri 0 Sat 12

Week13 Total20 Sun2 Mon 0 Tues 4 Wed 0 Thurs 3 Fri 0 Sat 11

Week14 Total22 Sun2 Mon 0 Tues 3 Wed 0 Thurs 3 Fri 0 Sat 14

Week15 Total22 Sun2 Mon 0 Tues 4 Wed 0 Thurs 4 Fri 0 Sat 12

Week16 Total24 Sun2 Mon 0 Tues 4 Wed 0 Thurs 2 Fri 0 Sat 16

Week17 Total26 Sun3 Mon 0 Tues 5 Wed 0 Thurs 5 Fri 0 Sat 13

Week18 Total28 Sun3 Mon 0 Tues 4 Wed 0 Thurs 3 Fri 0 Sat 18

Week19 Total26 Sun3 Mon 0 Tues 5 Wed 0 Thurs 3 Fri 0 Sat 15

Week20 Total30 Sun3 Mon 0 Tues 5 Wed 0 Thurs 4 Fri 0 Sat 18

Week21 Total 33 Sun4 Mon 0 Tues 7 Wed 0 Thurs 6 Fri 0 Sat 16

Week22 Total 35 Sun4 Mon 0 Tues 6 Wed 0 Thurs 5 Fri 0 Sat 20

Week23 Total 30 Sun4 Mon 0 Tues 6 Wed 0 Thurs 5 Fri 0 Sat 15

Week24 Total 20 Sun5 Mon 0 Tues 8 Wed 0 Thurs 5 Fri 0 Sat 2

Week25 SunMarathon


This gentle training schedule is based on multiple factors which include:

• Slow long run on Saturdays building up to one 20-miler concerned with distance only to build endurance
• Easy cool down run on Sunday to relax muscles
• Faster tempo runs on Tuesdays and Thursdays to build up leg speed (never on track as intervals or focusing on hills for the beginner). These runs should be a comfortable pace.

One very common change based on how the athlete feels is to remain for 4 weeks at levels 7, then level 13, and finally level 17. This is done to add 9 weeks more to the over-all program when the running is going slow with too many aches and pains, job interruptions, building better leg strength, or simply timing the date of the marathon.

Are you an Athletic Personality??

There are many ways to analyze personalities. Are you extroverted or introverted, etc? But one way to group people that I find very fascinating categorizes people into 4 personality types. They are:




• Social People
• Emotional People
• Intellectual People
• Athletic People

Based on this classification you have one primary focus/life force that comes easy to you, you are a natural at it, and you need to work hard at the other 3 areas to develop them. If you think of your friends or family members, you should be able with a little thought to know what type they are. I am an Athletic Personality, my wife a Social Personality, my boss at work an Intellectual Personality, and my sister-in-law Kathy an Athletic Personality. We all therefore have to work real hard at being well-rounded, developing the sides of us that do not come easy. It is easy for me to go to the gym due to my personality, but I have to work harder at studying/learning, being social, and expressing my emotions. See how this works. What is your basic personality type?

Why am I discussing this in a blog on podiatry? Each of my patients is coming into the office with a different perspective on their injuries. I have to get a feel for their attitude on their injury, based on their personality, and work with them from their center, not mine. If I approach all patients with my Athletic focus, I may not totally meet their needs.

I try to approach an injury from all 4 aspects at least until I know the patient well. When you approach an injury from these 4 personality types, you can achieve more success, since the patients will work with you. What is the social environment of their injury and rehabilitation? What emotions do they have caused by their injury? What is their intellectual approach to this injury? What is their athletic approach to this injury? Here are more questions to help you assess the patient.

Social
• Does their injury affect them socially due to the pain?
• Do they work out alone or with groups they like?
• Does the workout affect them socially because of their physical benefits?

Emotional
• What emotional stresses does the injury produce?
• What is their emotional reserve to handle the injury?
• How do emotions play in the view of the injury?
• How do emotions play in their attempt to get better?

Intellectual
• How much research are they doing to help themselves get better?
• How much are they analyzing what is working and what is not helping?
• How well are they logically progressing in their rehabilitation, or are they letting their emotions get in the way and ignoring pain?

Athletic
• How well do they understand good versus bad pain?
• Are they cross-training well when one activity is prohibited due to their injury?
• Are they allowing their knowledge base of their body to help in their rehabilitation?


I hope that this post touches a few chords with each reader. Health care practitioners and patients need to look at injuries from different angles to speed rehabilitation. With many injuries, patients develop a team, each working from these different angles. A commonly seen team approach is when the physician takes the intellectual side, the physical therapist/personal trainer takes the athletic side, the patient takes the emotional side, and the patients friends, spouses,and teammates all take the social side. Success is on its way!!!

Your Sole Inserts

I love Sole over the counter orthotics. I always have my patients get a soft athletic version and I can modify if needed. The company now has socks and sandals. The sandal, if the arch contour is tolerated by your foot, is one of the best on the market. I, of course, have no financial ties to any product (yet). I tell my patients to always try the orthotic first before heating to mold to your foot. The molding process will always slightly flatten the arch, and if you can tolerate the original arch, go for it!!

http://www.yoursole.com/

Shoe Evaluation: Monthly Shoe Check for Stability

Golden Rule of Foot:Once a month place your running shoes on a flat surface and look at the heels from behind. You will be able to notice if one side or both sides are beginning to lean inward or outward (as illustrated in the photo above). When this occurs, it is important to get a new pair of shoes immediately. I think that this is good practice when buying athletic shoes in general. A shoe should always feel stable, but it must look stable or centered from this back of the heel view.

You can see from the photo above that the right side is leaned to the outside more than the left. This is called excessive supination or lateral instability.

Short Leg: Dominance Seen in Gait Evaluation

The lean to the left in this runner whom just happens to be my wife Pat can be caused by a short leg.

When you watch someone walk, there may be a slight lean to one side which is very consistant. This is caused by many problems, including scoliosis and short leg syndrome. When evaluating for a possible short leg, look for this lean known as "limb dominance". Pat is demonstrating left side dominance. If you have received lifts for a short leg, the lifts should eliminate all or most of this lean. Never use lifts if the prescriber does not watch you walk and/or run with and without them documenting their success. Never use lifts if the lean is made worse by the lifts. If your symptoms seem to be getting worse with lift therapy, stop using lifts for a week to verify that the symptoms are being caused by the lifts.

When you are walking along, do you ever notice you always drift to one side or the other? Do people who walk with you comment that you always bump them if they walk on your right or left side? Do they sometimes joke that you won't pass a sobriety test even when sober? If you walk with hard soled shoes on a hard surface, do you hear one side landing harder (greater sound)? These can all be clues of a short leg. With a short leg, you may lean to the long or the short side, but most adults lean to their long side. I will have another post on the best way of measuring for a short leg.

In my practice I treat short leg for many reasons, but the most referrals I get are for hip and low back pain patients. Ilio-tibial band syndrome is also commonly caused by a short leg. When a patient is always injuring the same side, even though different areas, think short leg syndrome. Lifts to correct for the uneven hips and pelvis can allow the muscles to function equally on both sides of the body easing stress points and allowing muscle imbalances to correct. If you have any clues you may have a short leg, and you are having pain, perhaps lift therapy to correct for the short leg may be helpful for you.

Short Leg Treatment: Shoe Lifts

Most patients have a short leg, either structurally or functionally. A structural short leg is true length difference of the bones, where a functional short leg may be caused by many factors including one arch lower than the other side. As long as one arch collapses more than the other side, the short leg syndrome exists.

Most people have one foot longer than the other, but the long foot may or may not be on the long leg. Remember you are taught to buy shoes always for the longer side (longer foot). If you wear out one shoe more than the other, either by observing the heel of the outersole or the footbed within the shoe, you can tell that one leg may be shorter. Orthopedists normally do not recommend treatment unless over 1/2". Podiatrists have observed that as little as 1/8" difference in leg lengths can cause symptoms. By treating these small differences, and having patients report positive outcomes, leg length discrepancies are a vital part of care.

Treatment of leg length discrepancies is with various types of lifts under the short leg. The photo above shows a shoe with a full length external or outersole lift of 3/8". Due to the swelling in his foot, this patient could not tolerate any lifts within the shoe. Full length lifts, whether within the shoe or on the outer sole, are normally so much more stable than just heel lifts. Heel lifts alone can create a high heel effect with more instability. Also, a heel lift alone can be compensated for with mere bending of the knee negating the desired lift height. So, I love full length lifts and try to always start with these in my treatment. A future post will explore this treatment in detail.

Most athletic shoes can accommodate up to 3/8" lifts. All patients should have a trial of lift therapy with shoe inserts with positive results before external shoe lifts are utilized. Most shoe repair shops can put on external lifts, but there may be one in your area that specializes. Ask around for referrals from local orthopedic or podiatry offices. The external lift must be tapered at the toes, and somewhat flexible at the ball of the foot, to allow the patient to walk smoothly from heel to toe.

The Golden Rule of Foot with lift therapy: Start Low, Go Slow. Normally, if the difference is 3/8" total, 1/8" lift is given for 2weeks, then another 1/8" lift for 2 more weeks, then finally the full 3/8". As you go up in lift therapy, blame any new symptoms on the added lift, take out the additional lift until the new symptoms subside, then try again. Some patients are stuck for one reason or another at one level of lift. Their bodies will reject the higher amounts.

There seems to be more stress on the body when the exact same lift is placed on the outersole as was originally used as an insert. It probably weighs slightly more, or effects the motion around heel strike more. To lessen this change, which may cause symptoms itself, place 1/2 of the overall lift in the opposite shoe as an insert initially. Two weeks later, take 1/2 of that away, then finally 2 weeks later take it all away so you are left with just the desired outersole lift. This eases the process dramatically, allowing the body to relax more in making this big change. Good luck!!

Bunions: Bunion Care 101

Bunions, also known fondly by podiatrists as Hallux Abducto Valgus Deformities, should be treated from the day you start getting serious about them with 6 different modalities. These 6 modalities or treatment choices are called Bunion Care 101 (remember English 101). These 6 modalities are:

1) Medium toe separators or spreaders (www.FootSmart.com) highlighted in the photo above. These are to be worn with any enclosed shoes.

2) Yogatoes or knockoff 20 minutes at least 3 times weekly.

3) Ice massage (when bunion sore) or moisturizing cream massage 5 minutes 2 times per day until the skin looks normal.

4) Adhesive padding(www.mooremedical.com) not over the bunion or on the toe, but just behind the bunion toward the arch in any tight shoe. You place on your foot as close to the bunion as possible before you put your sock on. Never put under the foot. Should be about 1" square, buy 1/4" thick, but cut down to not show.

5) Wear shoes that do not press (perhaps squared toe or no reinforcements across this area).

6) If your foot pronates inward, arch collapse, you need to support the arch with a stable shoe and some sort of arch support. The stable shoe is most important, but an arch support that takes weight and centers the pressures in your foot is vital with pronators.

.

Stress Fracture Foot: Followup Visit with Xrays

Patient seen on 3/30/10 with a 10 day history of pain in his metatarsals was highlighted in post entitled: Patient Footlight#1: Possible Foot Stress Fracture. The x-ray taken above was during the follow up visit on 4/7/10. The patient was already feeling a lot better with the removable cast. Contrast bathing was initiated at the 1 hot 1 cold cycle (see the post on the secrets of contrast bathing).

The x ray shows the subtle new bone formation (just above the magnifying glass marker) seen in stress fractures. You actually never see the fracture line unless the stress fracture has turned into a full fracture. The patient was again reminded about Calcium and Vitamin D. The patient will spend 6 weeks in the cast, then begin to gradually wean out of the cast over another 2 week period.

Golden Rule of Foot:The patient must be two weeks totally pain free in the cast before the weaning process begins. No increase in pain is tolerated during the weaning process. The patient is followed every two weeks. With metatarsal stress fractures, plastic orthotic devices for a balancing function (see post on Orthotic Devices: General Principles) are normally ordered 2 weeks prior to the weaning process. This insures that the patient is walking with orthotic devices and with the foot taped with every step when out of the cast.

These orthotic devices are worn for up to 2 years in athletic/strenuous activities to prevent re-injury. This particular patient walks everywhere in San Francisco in our very hard cement jungle. Taping (to be taught in a later post) is also used with strenuous activities.

Since bones first heal, then double heal, symptoms related to increased circulation can last for many monthes after the stress fracture heals. It is important to do the contrast bathing daily, and ice after strenuous activity, until all symptoms have been gone for 2 weeks straight. The contrast bathes continue to flush out unwanted swelling and the icing minimizes the aggravation of symptoms.

Diabetes: Take Off The Other Shoe Principle

A wonderful patient whom I saw 22 years ago came into our very busy office with complaints of pain in her right Achilles tendon from walking her very big dog. She thought since she always held the leash with her right hand she must of pulled the right Achilles somehow. Very smart observation! She had only taken off her right shoe when I came into the room. I was very busy that day running late with all of my patients. After examining her Achilles, her diagnosis and treatment plan seemed straight forward. I turned to leave the room to get our physical therapist to put her on the proper icing and stretching regimen, but something told me to have her take off the other shoe. Golden Rule of Foot (for practitioners): Always look at both feet.

When she took off the other shoe, it was evident that she would never see the physical therapist that day. This patient turned out to be a brittle diabetic with an infected ulcer on the left big toe. We became good friends as I visited her twice daily in our hospital over the next 3 weeks. I still see her monthly. As an adult-onset diabetic, she never really owned/accepted her disease. Her blood sugars were terrible with the bacteria feeling very happy like kids in a candy store. On that day, the statistics for a diabetic to survive more than 5 years when presenting with an infected ulcer were very small. Statistically, she should have definitely lost her leg. 22 years later she is still going strong, both legs and all. See the link below for Diabetes Self Care and Footsmart catalog for ordering a floor mirror.

Having her take off the other shoe may have saved her life that day. But I hope this message of checking both feet saves thousands from amputations and death. Let's be very greedy. Diabetes is a killer, but owning your diabetes, can allow you to have a great life.

Golden Rule of Foot: Diabetics should daily exam the bottoms of their feet. I think back on that day almost every time I see this patient. Relatively new to the practice of medicine, I learned a valuable lesson. The rush of medicine nowadays will allow this scenario to play out over and over again in various forms. Patients must become more responsible for their own health.

I do not know why I took off the other shoe that day. I was in a rush, way behind. But I did and I am proud that I try to continue to take the extra time. Patients all have a story when they come through our doors. The stories add wonderful color to the practice of medicine. Let’s get better at listening to these stories.

Diabetic Foot Care Guidelines
Dec 18, 2009 ... Diabetes can be dangerous for feet; to avoid serious foot problems follow these guidelines.

www.foothealthfacts.org/footankleinfo/diabetic-guidel... - Similar

Sponsored LinksFootSmart® Official Site
Shop FootSmart for Comfort Shoes Foot & Lower Body Health Products.
www.FootSmart.com

Footsmart: A Great Place for Foot Supplies

FootSmart is a cost effective online shopping website for various foot and leg devices. Many of the products that I mention in various posts will be found at www. FootSmart.com. You may ask to get their catalog delivered to your home or office. My patients have benefited immensely when self-exploring possible inexpensive solutions or aids to their foot ailments. Since patients know their bodies best, they come up with the remedy or partial remedy to their problem within the covers of this catalog/website.

http://www.footsmart.com/

Running: Develop A Base when starting running

Running is one of the safest activities out there. Running seems natural for the human body and can be done relatively safely. Many athletes need great shoes and orthotics, especially if their mechanics are somewhat off, but the average runner can actually run a marathon. This implies good training, but the human body seems to withstand the stresses of marathon training (a truly incredible task) with relative ease. There is really no other feat this impressive that thousands upon thousands of athletes accomplish each year.

But the first year of running is what separates the men from the boys, the women from the girls. In my 30 years of practice, I have found that the first year of running is the crucial survival year. Getting through this first year with its ups and downs, injuries, and discomforts, is very challenging. It is in itself a huge accomplishment. Learning about training, proper shoe selection, pace, what pains to ignore or take seriously, is all part of developing a BASE. Developing a stable base is one of the most important keys to a long running career.

Stress Fracture Foot

Patient Seen 3-30-10

Patient presents with 10 day history of pain in his left foot. There was no acute injury that the patient remembers. Pain was first felt waking up in the morning. Few days later, bruising and swelling were noticeable at the top of his foot in the metatarsal area. Patient normally walks everywhere. Now pain develops after 6 blocks, but has no pain walking flatfooted around his apartment (pain only with bending his toes in push off). He noted that his walking shoes were fairly broken down on self examination. Pain level, on a scale of 0 to 10, was around a 7. Patient states he takes no special supplements, except vitamin C, but does feel he has a healthy diet.

Examination showed swelling and redness on the top of his 2nd and 3rd metatarsals. Significant pain and swelling like this in this area of the foot is a stress fracture until proven otherwise (golden rule of foot). With a sprain of the tissue, you probably would have had to have tripped. With any swelling or redness in the foot, gout or infection must be in the examiner’s differential diagnosis. There were no open wounds suggesting possible infection. Gout however could not be ruled out at present.

I advised the patient that stress fractures may not show for 2 to 3 weeks on x-ray. Many patients get xrays during this time frame only to be told they have no broken bones, when they really do. He was given an x-ray Rx for the next week if he was not getting a lot better. We discussed the role of a good healthy diet, 1200mg to 1500mg of calcium daily, and 400-1000 units of Vitamin D daily(see links below). He was told to ice pack the area to calm it down 2 or 3 times daily for 10 to 20 minutes each time. Please see the post on Ice. After discussing his options on footwear, since he walks daily a significant amount, he purchased a removable cast for the injured side and an Even up® www.EvenUpCorp.com for the good side as shown in the photo above.

He was also given a compression sock for 24/7, and advised on some elevation AMAP (as much as possible) to shrink swelling, at least getting his feet off the ground. For around the house, he purchased a post operative shoe with a stiff sole to avoid bending his toes. The removable cast works well since it has a built in rocker so you do not bend your toes. Can you recognize all the basic components of R.I.C.E. at work here?

• When a suspected fracture is present, patients are told to minimize their use of anti-inflammatory medications since they have been known to delay bone healing. NSAIDs inhibit bone healing - The Boston Globe
Jun 22, 2009 ... NSAIDs inhibit bone healing by blocking a natural substance in the body, prostaglandin, which supports the activity of bone-building cells, ...
www.boston.com/news/health/articles/2009/06/22/nsaids_inhi... - Similar

Follow up of Patient #1 will be given when appropriate for teaching. This patient, as with all I will use in my posts, has given his permission to use the basic information of their care for teaching purposes.

• Preventing vitamin D deficiency — the new breakthrough in ...
Feb 16, 2010 ... Vitamin D deficiency most certainly affects your immune system because .... Nowadays vitamin D3 supplements are widely recognized as the ...
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• Dietary Guidelines, calcium requirements, vitamin D requirements
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