Teamwork

http://www.dreamstime.com/free-stock-photography-air-show-rimagefree2983223-resi2565486

I hope you will grant me a short bit of reflection for today is my 30 Year Anniversary of being a podiatrist at Saint Francis Memorial Hospital, San Francisco, California, at the renowned Center For Sports Medicine. This photo represents who I am--A Team Player. I team up with my wife for a great marriage, I team up with my kids and one spouse and friends, and I team up at work to be the Best I Can. When I play sports, winning is secondary to how I held up my end of the bargain and played hard for my team. When I am at work, I am always thinking about others (my staff, my fellow docs, my patients). I strive to be a great Team Player and never ever let them down. Do I? of course. Do I want to let them down? never. 

I must admit I am tiring after 30 years. My energy level is waining. I continue to fight my battles, but I feel a deep call to simplify and keep centered. I know I have to re-invent myself every few years, so last year I started this blog, started teaching more, and I am currently trying to learn Electronic Medical Records and ICD 10 codes. Everything I do is for a team of one form or another. My office, my hospital, my patients, my family. So, I was sad no one knew that this was my big day. And I am  very very proud of this day.The significance of today was all I could think of. 

I am 57, and after spending a lot of money getting 2 kids through private colleges, need to continue to work for retirement. But, the next 15 years can be at a more relaxed pace. So, with the help of good health, I look forward to the last 1/3 (15 years) of my practice life as a sports medicine podiatrist increasing my blog as a form of teaching, increasing my formal teaching and lecturing, maybe a little research, maybe a few trips for R and R. 

Thank you for allowing me to have this special time with you. Please let me know topics you want to hear about. Consider us a Blog Team. I don't want to let you down. You are part of my team as we try to help people with various foot and ankle problems.

Laser for Toenail Fungus

http://www.lagunabeachindependent.com/2011/09/07/podiatrist-offers-high-tech-toenail/

I like Dr Sabet's approach to this new treatment. His is a 3 part treatment which sounds smart. First you thin the nails as much as possible. Then you laser the nails to kill the fungus. Then you apply daily for 6 months some topical anti-fungal to keep new fungus from getting into the treated nails.

     If there are any patients out there that have had this treatment that want to comment, please feel free. I have personally seen a 50% change in patients, but they had just had it (no where near the 6 months Dr Sabet recommends).

Samuel Merritt University Lecture on Gait Evaluation 9/18/11

        First of all, why do we perform gait evaluation on patients???

What are we looking at when we watch someone walk or run?

Where do we start? How about the Head and work our way down?

A Basic Checklist to use while watching someone walk or run follows.

[ ] Head Tilt

[ ] Shoulder Drop

[ ] Asymmetrical Arm Swing

[ ] Limb Dominance

[ ] One Hip Higher and Low Back Structure

[ ] Asymmetrical Hip Motion

[ ] Asymmetrical Knee Motion

[ ] Smoothness of Weight Transfer

[ ] Signs of Poor Shock Absorption

[ ] Heel Lift Issues

[ ] Apropulsive Push Off

[ ] Digital Clawing

[ ] Angle of Gait Asymmetry

[ ] Angle of Gait Position

[ ] Summary Right Side

[ ] Summary Left Side

http://www.drblakeshealingsole.com/2011/09/checklist-basic-gait-evaluation.html

And Here is Tiffany again who introduced me, our star podiatry student, walking barefoot. Again let us start at the Head.

What were our gait findings?

• Slight Head Tilt to the Right
• Little Dominance or Drift to the Left
• Slight Left Shoulder Drop
• Left Arm Swing Greater
• Outwing to Left Hip
• Leads with Left Hip
• Increased Internal Patellar Rotation
• Excessive Supination following Heel Contact left greater than right
• Digital Clawing

Here Tiffany is demonstrating excessive supination on the left side following Heel Strike and dangerous Varus Thrust at the Knee.

Now Tiffany herself will discuss the components of the Orthotic Device designed to prevent this contact phase supination following heel strike.

Here Tiffany demonstrates the elimination of the excessive supination with the above mentioned orthotic corrections.

This short video demonstrates Limb Dominance seen primarily in Short Leg Syndrome with body lean to the long side (80%) and to the short side (20%);

So, let's review the findings in gait evaluation which will give you an excellent idea if their movement can be correlated to their symptoms. But, this time, I will start at the feet and work our way upwards. The Green Areas symbolize normal motion or position.

Checklist Basic Gait Evaluation

Basic Gait Findings

(  ) Head Tilt

(  ) Shoulder Drop

(  ) Asymmetrical Arm Swing

(  ) Limb Dominance

(  ) One Hip Higher

(  ) Low Back Structure

(  ) Asymmetrical Hip Motion

(  ) Asymmetrical Knee Motion

(  ) Smoothness of Weight Transfer

(  ) Signs of Poor Shock Absorption

(  ) Heel Lift Issues

(  ) Apropulsive Push Off

(  ) Digital Clawing

(  ) Angle of Gait Asymmetry

(  ) Angle of Gait Position

(  ) Summary Right Side

(  ) Summary Left Side

Sesamoid Fracture: Email Advice

Dr. Blake, I have been diagnosed with a fractured medial sesamoid bone. I wish I had a good excuse, such as training for a marathon or heavy duty salsa dancing, but I think I have to chalk it up to simply being a lover of high heels for most of my 35 years of life.

I went to 1 podiatrist, who after 1 month of electrotherapy and taping, recommended surgical removal. I sought a 2nd opinion from another podiatrist, and he thought it was simply sesamoiditis. He started by putting me on anti-inflamatories and gave me the short orthodic boot. 1 month later, and not much better, he recommended heavy duty steroids for a week. I went back in and still felt pain. He then recommended the weight-bearing air cast, which I wore for 1 week. I woke up one evening in the most pain I have felt since I started with this problem.

I called the next day and demanded an order for a bone scan to determine once and for all if it was inflammed or fractured. Results confirmed it was indeed, fractured.

Questions:
1) In your experience, could the use of the air cast have actually made it worse? I swear I feel more pressure on my sesamoid using the walking air cast, than simply wearing my Birkenstocks.

Dr Blake's Comment: Yes Victoria, the boot could place more pressure and aggravate the problem. I need to modify these boots all the time like in the photos below. Some boots are too rounded in the front forcing the big toe into too much bend. Other boots are constructed okay, but the patient wearing it tries to bend the toe naturally as they walk, driving the broken sesamoid into the stiff (somewhat hard) base. Unfortunately, it probably felt comfortable wearing it. And it was not until after that the symptoms occurred. If one does get a medical device for some purpose, and it causes pain, it must be discarded as good idea, or modified to create a painfree healing environment.

Accommodation of a Sesamoid (Big Toe Joint) placed on a removable insert that can be placed into a cast.

Adhesive Felt to accommodate (off weight) a sore sesamoid bone under the big toe joint.

Example of an accommodation with 1/4 inch adhesive felt for a fifth metatarsal fracture placed into a removable boot to create a painfree environment.

1/4 inch felt sheet prior to cutting into shape (customizing).

This type of accommodative pads for pain under the foot can be crucial in creating a healing environment for the injury.



2) All in all, nothing seems to have helped my foot more than wearing Birkenstocks. Besides being a great marketing story for Birkenstock, is there science behind this?

Dr Blake's Comment: I find that pain in the front of the foot (where the sesamoids are) is influenced by many factors. Each of these factors can produce a positive or negative body reaction. The rule is too see what seems to effect the injury at hand the most. These factors are: Heel Height, Cushioning, Flexibility, and the Combination of these 3. Some injuries need no heel height to transfer weight forward, others it is okay. Some injuries need alot of cushion, others it makes little difference. Some injuries need maximal flexibility, other max stiffness (rigidity) immobilizing the injury. Some injuries seem to have a delicate balance with these 3 variables: the right heel height, the right cushion, and the right flexibility. And now we should add the 4th variable of forward roll that some shoes like Sketchers seem to produce and all removable casts have that should roll you easily through your foot.

For you, birkenstocks probably provide just the right amount of minimal heel height and forefoot stiffness, that cushion is not an option.

3) No one has ever suggested taking extra calcium or simply going all out with a plaster, non-weight bearing cast with crutches. Would this be overkill? I am a very patient person, and would rather try every alternative possible before resulting to surgery.

Dr Blake's Comment: Thanks for your intelligence on this simple fact. You need to produce a painfree environment for the next 6 months, while you work on the bone strength (Vit D and calcium and possible bone stimulator), muscle strength (daily foot strengthening exercises), anti-inflammatory (daily icing and contrast baths whether you hurt or not--total of 3 sessions daily of something that reduces inflammation), perfecting spica taping for the next year plus, and getting orthotic devices that off weight the sesamoid (which should be worn for strenuous activity for 2 years to protect it, and will enable you to wean out of the cast sooner).

I would greatly appreciate any insight and recommendations you have. I have read about all the risks of removing the sesamoid bone, and besides being vain and wanting to avoid bunions, I am ready to get back into an active lifestyle to lose some baby weight and get back in to a healthy lifestyle. Thanks much in advance-

Victoria

Here is a chronically broken medial sesamoid that developed nonpainful non-union. We may have to surgically remove someday. Patient is completely active at a high level without pain.



Was it the heels that caused the injury? Probably not, but they are sure painful when you are dealing with a sesamoid issue under your big toe. At least I have been told!!



Dr Blake's comment: Hope all of this helps. For now, stay in the Birkenstocks which seem to give you good protection. 









Posterior Tibial Tendon Dysfunction: Pronation and the Shoe Store Recommendations

Hi Dr. Blake!

First, let me say that I love the fact that you've put so many informational videos online. It's been incredibly helpful in my attempts to understand my own Posterior Tibial Tendinitis/tendinosis.

I was prescribed orthotics by my podiatrist back in January, yet my condition has not fully healed. I recently bought a new pair of shoes, hoping this would help. My previous pair of shoes was designed for those who, like me, overpronate. However, the shoe salesman suggested that I get a pair of neutral shoes so that the structure of the shoes wouldn't interfere with my orthotics.

Do you think that would be the smart thing to do?

Again, thanks a hundred times over.

Basil

Basil, Thank you for the email and the kind words. There are 3 common misconceptions that shoe salespeople have that greatly effect my patients. These are:

1. If you have orthotics, you do not need motion control or stability shoes (70% of the time wrong!)
2. If you have a high arch foot, you need cushion not stability. (50% of the time wrong!)
3. Pronation is the big problem to reduce, so if you produce supination with a stability or motion control shoe, no big deal. (100%  of the time wrong!)

Your question Basil has to do with number #1. If you have severe pronation and posterior tibial tendon dysfunction, you have a 5% chance that a neutral shoe is acceptable, 25% chance that a stability shoe is acceptable, and 70% that motion control is what is needed along with your orthotic devices, and power lacing, and perhaps varus midsole wedging. I hope this helps. Rich

Short Leg Syndrome: Check Lifts for Stability

This short video documents how lifts patients are wearing to correct for a short leg may become unstable, shift out of position, be placed on top of an orthotic instead of under, and must be checked routinely (at least monthly). Here is a simple test a patient can do to check if the lift is stable. The lift on the right failed that test.

Short Leg Syndrome: Difficulty with Lifts (Email Advice)

Dr Blake,

      I'm interested in what you have to say about this problem.  I have had standing x-rays of my pelvis on several different occasions by chiropractors and have been told I have a 9mm difference, as in my left hip is that much higher than my right.  The problem is, this feels like a lot in a shoe and won't even fit in some.  I am using the clearlyadjustable heel lift. I have taken them in and out of my shoes over and again, hoping and praying that custom orthotics would correct the pronation and I don't really need the lift.  They never have helped.
   
      I have a large knot in my right forefoot area/calf pain and tightness and a stretched out, weak feeling in the front of my left hip with muscle pain and tightness in that glute/hamstring.  I'm experimenting with a 5mm heel lift under a custom orthotic on the right but it feels low.

I just want to get back to running and weightlifting(deadlifts and squats).
I look forward to your suggestions if you have time.


Thanks,
Jody from Canada

Jody,

    Thank you for your email. To summarize, you seem to have 3 biomechanical problems, each with different causes and potential treatments. These are:

1. A short right leg of 9 mm or 3/8th inch.
2. Excessive Pronation requiring some amount of pronation control from orthotic devices.
3. Weak Areas needing strengthening, bracing, or biomechanical changes.

Please use full length lifts for your athletics since heel lifts create their own instability and do not help when you are on the front of your foot (in running or weightlifting). If you go up 1/2 to 1 full shoe size, and choose your running shoes with good depth (like most Brooks, and some Asics), 3/8th inch correction is normally do-able.

 

I have to choose with my patients at times whether we start with lifts or orthotic devices. The question to ask is whether the symptoms are more related to the pronation or the short leg. A compromise is made at times if the severest pronation is on the short side to just use the orthotic devices on the short side for awhile. 

So, in the decision making with you, the following must be addressed:

1. Can you go to bigger shoes?
2. Can you use full length lifts instead of heel lifts?
3. What symptoms are more important to treat first?
4. Are those symptoms most related to over pronation or a short leg syndrome?
5. Can I use lifts in my weight lifting shoes and orthotics in my running shoes or vice versa?
6. Is the pronation worse on the right side so I possibly can try to correct the shortness with a right orthotic device and 1/8th extra full length lift?

Jody, I hope this at least is asking questions that can be answered in the next few months. Please read my posts on short leg syndrome for more info and email me back if you have more info to share. Good luck. Rich

Hip Replacement Surgery and Short Leg Syndrome

     Once you have had hip replacement surgery, there are incredible muscle and soft tissue weaknesses and tightnesses to overcome. Physical Therapists are key in correcting the soft tissue/muscular problems which develop due to surgery. Remember, all joints are weaker after surgery and need to be restrengthened.

     Yet, hip replacement surgery, in my estimation, leaves most patients with a short leg. Unfortunately, the xray shown above is not commonly done preop, so the surgery itself may be lessening the difference. But, in treating patients post hip replacement surgery, treatment of their short leg with lifts can be an extremely helpful part of their progress. I do try to save radiation as much as possible, but these Standing AP Pelvic Xrays can be vital at establishing the exact amount of leg length difference to start Lift Therapy.

Supinators: Various Gait Videos

    The video demonstrates excessive supination left side worse than the right clearly demonstrated by Tiffany. This is the first of a series of videos on supination and what orthotic modifications are utilized to treat it. Here also the varus thrust at the knee is shown  in the left knee, a potentially disabling force. As the tibia moves on the femur after heel contact in a varus direction, at a time when the knee should be flexing and tibia becoming more valgus, the medial knee joint compartment gets beat up.





This second video shows Tiffany with orthotic devices to prevent supination. A separate video showed the components of this orthotic device. The supination seen in the first video is eliminated after heel strike, and the varus thrust greatly reduced at the knee. There are patients who have foot pronation whom also exhibit varus thrust at the knee.




Tiffany here is seen without the Denton Modification (one of the simple orthotic modifications used to prevent excessive supination). Without the Denton Modification (and there is a separate video on its manufacture), Tiffany definitely supinates more following heel contact.


The components of gait evaluation are demonstrated by Tiffany Hoh, 3rd Year Podiatric Medical Student at Samuel Merritt University in Oakland, California. The findings include:

• Little Head Tilt to Right
• Little Dominance or Drift to the Left
• Slight Left Shoulder Drop
• Left Arm Swing Greater
• Outwing to Left Hip
• Leads with Left Hip
• Increased Internal Patellar Rotation
• Excessive Supination following heel contact left greater than right
• Digital Clawing (toe gripping)

Here Liz is seen excessive supinating with a running gait pattern. Excessive Supination is also called under pronation or lateral instability.

Severe Heel Pain: Email Advice

 Dr Blake's Note: This nice young lady is a good sport letting me publish this. What we do to our bodies sometimes!!! I can only lie and tell you I would never do a dumb thing like this. We are all capable. I hope my comments to her are helpful.

Dear Dr. Blake:

     I am awake at 5:07 am EST due to severe generalized pain in my right heel, with touch sensitivity on the posterior/lateral aspect and a severe ache in the medial/plantar area. This has been going on for about 5-6 days now, but this is the first time I have been unable to sleep due to pain. I am currently unable to walk to the bathroom, and have had to crawl. Ouch.

     I am pretty sure this was brought on by my own blatant stupidity in pursuing a 2-day bricklaying project, in the course of which I (unbelievably enough) repeatedly rammed bricks level into their bed of stone dust, using only my own dumb foot/heel, protected only by one of a pair of flip-flops. I have never had any significant heel pain before, although my then-50ish sister did have a prolonged bout of plantar faciitis some years ago.

Dr Blake's note: Hope you will send a photo of this project someday.

     Because I had to be brave and bring my last kid to college three days ago (sob!), I looked up on the Web how to do taping for relief of the pain. This allowed me to hobble around Providence for a day, and the subsequent couple of nights (after daytime taping) were tolerable. However, yesterday I did not tape and also did not walk too much (although I did do some yard work). Now I am in agony.

     I am 61, in good general health, no meds except the recent q6h ibuprofen (which has been giving me some relief-- but not tonight). I have used, infrequently over the years, a few quick, tapered courses of oral Prednisone for nasty poison ivy rashes that had persisted for days. I had no problems with this. Tonight, as I lay awake in pain, thinking about inflammation, I decided to research the use of oral steroids for plantar faciitis, and found your site. My question is this: as my fasciitis appears to be due to repeated, but acute, self-induced trauma, do you think I might be in increased danger for rupture were I to take a short Prednisone course? I want this to go away fast, of course, and will do a real period of complete rest/ice/stretching if that's the best idea. I am not prepared for cortisone injections and certainly not surgery,

Thanks for your advice.

Sincerely,
Sheila
Boston, Massachusetts


     Sheila, hope you don't mind me using your email on my blog tonight. All identifying info will be removed. With that history, u have a calcaneal fracture until proven otherwise. Get an MRI to rule out. If negative or positive all of the decision making will change. Do not take NSAIDs or oral cortisone due to the potentially negative impact on bone healing. Rich. Good luck. 


Dear Dr. Blake:

    Thanks so much for your excellent advice. I had already scheduled an MRI for this Thursday to r/o Fx, which, given the pain today, I'm thinking more and more possible (although I know the pain from plantar faciitis alone can be intense).

Feel free to post, but thanks for protecting my anonymity: wouldn't want even more people to know about my unbelievable stupidity! Hope this keeps it from happening to someone else, but really: who else would be so dumb???

Best,
Sheila

Dear Sheila, Thanks again for being a good sport about this. I get alot of emails, and I wanted to post this one to focus you and my readers on what you should expect.

1. If you have a positive MRI for calcaneal (heel) fracture, the treatment is 3 months in a removable boot. 
2. If you have a positive MRI for plantar fascial tear, the treatment is 3 months in a removable boot.
3. If you have a positive MRI for intense inflammation only, the tapered cortisone course, with contrasts and ice, with a short course of removable boot, with some PT or accupuncture are all helpful.
4. If you have a positive MRI for any of the above, you may still have nerve trauma/sensitivity concurrently. The pain from nerves is difficult to treat, and has been solutions.
5. If you have a negative MRI, then you have plantar heel bursitis (may not show well on MRI) or nerve trauma, or both. If I think there is bursitis, with a negative MRI, I like ice massage, physical therapy, or cortisone shots (which you correctly are not a fan of, but may be crucial). 

So, where do you go from here? Can the MRI and see what it says. Positive or Negative is helpful to rule things in or out. Try to create a painfree environment. Because there can be an element of nerve trauma with your history, pain begets pain, and the symptoms can spiral out of control. Take the pain seriously, and do all you can to completely eliminate it for the next month. You are bound to heal quicker that way. And if you are in the Back Bay area and see a young lad that looks like the photo below, that is my son Chris.

Supinators: How to Make a Denton Modification

This short video describes how to make a Denton Modification to control the forces of supination. It was created by Dr Jane Denton, Podiatrist, and can be used on custom made and some over the counter orthotics.

Running with Knee Pain: The Cause May be the Hip or Foot

Runners, given enough time, may develop some form of knee pain. This short article below makes the point to look for the cause above or below since treatment may be greatly influenced by what is found.

http://www.bcm.edu/news/item.cfm?newsID=4369

Supinators: Orthotic Modifications to Help Control Supination Motion

Tiffany Hoh, 3rd Year Podiatric Medical Student at Samuel Merritt University, discusses for Dr Rich Blake's Blog the components of orthotic devices that help prevent excessive supination. These include:

• Root Balanced Orthotic Device
• Zero Degree Extrinsic Reafoot Post
• High Lateral Heel Cup
• Lateral Phalange
• Denton Modification
• Valgus Wedge
• Reverse Morton's Extension
• Forefoot Valgus Extension

Basics of Gait Evaluation: Foot and Ankle Motions

The green squares show normal motion of the foot. Mild Pronation of the foot followed by resupination of the subtalar joint. The Heel Lifts in propulsion just before the heel contacts on the opposite side. There is a smooth transition from heel strike to toe off without feelings of foot slap or inability to move easily.


The common abnormal motions noted at heel strike are:

• Excessive Supination after heel contact or in propulsion
• Mild to Moderate Lateral Instability after heel contact
• Severe Lateral Instability
• Excessive Rapid Pronation
• Maximally Pronated Foot throughout gait
• A Loud Heel Strike is noted

The common abnormal motions in the middle of the step are:

• The heel lifts early (tight achilles?)
• The heel lifts much later than normal
• The gait is antalgic (limping noted)

The common abnormal motions noted at pushoff are:

• Wind Swept Feet (one foot pronating, one supinating)
• Sagittal Plane Blockade occurs (the patient finds it difficult to roll through the foot)
• Apropulsive (no push off is noted) 

Posterior Tibial Tendon Dysfunction/Tarsal Tunnel Syndrome: Email Advice

Dear Dr Blake,
                           I was wondering if you could give me some advice.   Three months ago I did some heel raises and foot stretches after a very long bushwalk. Two hours later I could not walk and had very mild swelling on my left foot. I could not weight bare for 6 weeks and  within a day I saw a physio and podiatrist who diagnosed PTTD. I faithfully did stretches to strenthen the post tib tendon, and wore the orthotics.
    I am slowly getting better, though not as quickly as I would like. I can walk short distances but walking up and down steps can give me a mild ache.
  I saw a sports doc who said that I would need surgery as my arches are getting flatter and an ultrasound confirmed accessory navicular, and the tendons were in tact with no tears and no nerve compression or inflammation. I have seen slow improvements but wish to avoid surgery and the sports doc said that I may if i wear aggressive orthotics , my current ones are rigid but dont have a huge arch in them.
    In your experience is it possible to avoid surgery? I have always worn supportive shoes and have not had problems with my feet. I would appreciate any advice that you have.   By the way I love your site!
                                                                                                                                        sincerely   myf

Dear MYF,

      Thank you so very much for your email. If you have seen slow improvements, wait it out. Do everything you can to create a painfree environment. If that requires you to wear orthotics and supportive shoes to the Opera, so be it. Respect your tendon. It has a long way to go to supporting you through life. Be kind to it for a few more months while you work on the swelling and strength of the tendon daily.

     Only a very small percentage of patients with accessory naviculars need surgery, so it only raises the odds slightly of going under the knife

    .It is also an extremely unusual presentation of PTTD (posterior tibial tendon dysfunction), but more consistant with some tarsal tunnel syndrome (sharp totally incapacitating pain without swelling that was not there yesterday). Tarsal Tunnel is a nerve problem with different treatments and a possible low back cause. Hopefully the physio and podiatrist have ruled these out.

     Before you have too much physical therapy, consider an MRI to look at what tissues are irritated. Could be revealing. If negative, consider a nerve conduction test with a neurologist or physiatrist.

     So what should you be doing now? Create that painfree environment. Gradually strengthen your ankle, especially the posterior tibial tendon. Ice or contrasts or both three times daily to the sore area. Wear a removable cast part of the day to reduce the motion across the area. Wear orthotics and supportive shoes if they help with your pain. If not, seek advice regarding better shoes and better orthotic devices (may seem to be crucial if the pain is difficult to manage.

    If you plateau, where progress is at a stand still, perfect all the variables--better information gathering, better orthotics, better anti-inflammatory regimen, better painfree environment (?casting), and better strengthening program.

       September (today is August 30th in at least some parts of our small world) should be a better month than August, and October better than September. If not, please let me know. If you email me again with further info, I will attach it all to this original. I sure hope this helps. Rich Blake

MYF sent this response to my email.


Dear Dr Blake,
                           Thanks so much for your opinion. I raised the possibility of tarsal tunnel to docs as I had burning and tingling pain for the first 8 weeks and now only after standing for long periods of time. I will get onto looking at that , I also have a dreadful lower back with nerve pain/muscular tightness.   Who would have though tthat our wonderful bodies can be so complicated!   thanks again    myf

Basics of Gait Evaluation: Foot and Ankle Positioning

Here are the common gait observations way down at the foot made. The green circles are the ideal, most stable, positions. These include:

1. Slight External Angle of Gait
2. Lateral Heel Strike
3. Normal Arch Height
4. Centered Push Off through 2nd and 3rd Toes

The blue circles are the deviations from normal. These include:

1. Intoeing or Excessive Outtoeing
2. Centered or Medial Heel Strike
3. High Arch, Low Arch, or Wind Swept Feet
4. Too Lateral or Too Medial Push Off

All of those deviations can lead to over pronation problems, over supination problems, or asymmetrical compensatory problems. These problems can effect the weakest link in the chain, anywhere from the foot upwards. See the link below and listen to the great Kapena music from Hawaii.

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-3.html

Supinators: Gait Evaluation Video

This short video shows the damaging motion of over supination (aka under pronation or lateral instability). Focus on Tiffany's left foot in particular following approximately every other heel strike where the heel rolls to the outside. Then focus later on her left knee motion demonstrating the varus thrust which can accompany over supination causing medial knee compartment compression forces and possible injury. This is the first of 5 videos entitled "Supinators". The entire series will show the correction of this problem with orthotic devices with the particular modifications needed and the introduction of the Denton Modification. See the link below to the possible injuries associated with over supination.

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-13.html

Basics of Gait Evaluation: Lower Legs

As you watch someone walk, you proceed from the head, to the shoulders, to the arms, to the hips , then the knees, and on to the lower legs. As the green outline shows, it is ideal to have the legs straight with the knees centered over the ankles. It is so important with this assessment to make independent observations of the right side from the left side. Old injuries can produce calf size asymmetry (even when my chart above truly shows I can not spell). This asymmetry can greatly effects leg function. The tilts in the legs (tibial varum or tibial valgum) can be much different allowing the feet and ankles to behave differently.




The video above shows tibial varum causing a varus tilt to the ankle which greatly effects how the foot and ankle align with the rest of the body. 

Knee Pain With Runner: Possible Ilio-Tibial Band Syndrome

Hi Dr. Blake,

I am a runner (no more than 10k races) and have had a pain on the side of knee for the past month or so.  I was told that it could be my IT band and to do stretches to help recover from the pain.  I run in the City so I thought the pain might also be from running downhill. 

Dr Blake's Note: The Ilio Tibial Band runs down the lateral or outside aspect of the leg from the pelvis to the tibia. It most commonly causes symptoms on the outside of the hip or the outside of the knee. 

Can you recommend the most efficient stretches and any other suggestions for a quick recovery? 

Dr Blake's Note: IT Band Syndrome is almost a pure runners problem. Rarely ever see it in other sports. Here are some common IT Band stretches.

 Should I be icing my knee after every run?

Dr Blake's Note: IT Band Syndrome is a form of tendinitis. All the common treatments of Tendinitis should be employed to help. Please see the link on BRISS for tendinitis treatment. 

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

  Is it possible that it could be something else?

Dr Blake's Note: Definitely, it is uncommon for women to get IT Band tendinitis around the knee, but not rare. If there is any swelling, it is not IT Band Syndrome. If it does not feel better with stretching during a run (I love the lateral wall lean stretch while running), it is not IT Band Syndrome. It could be lateral knee joint pain, lateral collateral ligament, lateral hamstring, etc to name a few. If the pain is on both knees in roughly the same spot, it is most definitely IT Band. 

  Would a knee brace be unnecessary if it really is my IT band?

Dr Blake's Note: If it is IT Band, knee braces should not help, and may hurt. If you experiment with a simple knee brace while running, and you feel somewhat better, continue to wear. 

It take me a few days to recover from the pain after a run.  I have my longest race coming up in September and don't know if it's safe to run because the pain is still bothersome.

Thank you,

Lesley

Lesley, Thanks for the email. Definitely do not run through pain that starts in the middle of a run.You will definitely make it worse.  Stop, try to stretch out the IT Band, and then continue to run only if the pain subsides. If you can get PT for it with the upcoming race, go for it. They can normally calm it down quite well. For a race in September, it is too late to change you biomechanics too much, but is would be okay to make a shoe change if your shoes are too worn down (usually over 500 miles). Hope this helps. 

Basics of Gait Evaluation: Knees

When I first started working at Saint Francis Memorial Hospital in San Francisco in 1981, I joined their already prestigious Center For Sports Medicine. I was the first podiatrist in an MD clinic. Patients were coming from near and far for treatment of their knee injuries. The renowned orthopedist Dr James Garrick called on my biomechanics expertise (I was just off a Biomechanics Fellowship) time and time again to help with his knee patients. I always found it funny, yet exciting, that I would spend some days never looking at a foot problem.

When you watch gait and observe knee function, use the following checklist:

Is the knee moving a normal amount?

      Or is it too Stiff?
      Or is the motion Excessive?  

 Is the rotation of the knee placing it in the center of the leg?

     Or is the rotation too internal?
     Or is the rotation/position too external?


Are there structural issues to be concerned about?

    Is there genu valgum (knock knees)?
    Is there genu varum (bow legs)?

Are there very damaging forces at the knee?

    Is there hyperextension of the knee?
    Is there varus thrust of the knee?
    Is there valgus collapse of the knee?

Posterior Tibial Tendon Dysfunction: Changes with Inverted Orthotic Technique and Shoe Wedging

Ruth is seen in the above video with her third left, and second right orthotic device. Serial orthotic corrections are used with some patients since their feet are so flat, and the complete correction so drastic a change, that intermediate steps are taken. Hopefully you can tell by the video that complete correction is attained on the right with 50 degree inverted orthotic device (giving 10 degree inverted heel change) and 1/4 inch varus midsole wedge (giving 2-4 degrees inverted heel change). Since Ruth started out at 12 everted resting heel position, adequate correction was attained. Her right heel now stands 1-2 degrees inverted to the ground.

Ruth's left heel started 17 degrees everted. Her third orthotic device on the left side was 60 degrees Inverted (giving 12 degrees of heel inversion). The initial 1/4 inch varus midsole wedge gave 2-4 degrees of inversion, leaving her left her 1 to 3 degrees off vertical. At the time of the office visit, I increased the shoe midsole wedging another 1/8 inch (giving 1-2 degrees of correction).This left side is so so close. The pain she gets in the medial arch is reduced by the reduction in pronation, but also in the accommodation of the plastic area below the sore spot under the first metatarsal-cuneiform base.

The 1/4 inch varus left midsole wedge is deemed inadequate support while watching Ruth walk.

Just above the wedge, the midsole is cut from the heel to the toes and a 1/8 inch additional wedge beveled along one edge.

Here the cut and additional wedge is noted.

After both the shoe and wedge are glued, and the glue is left to air dry for 5 minutes, the initial wedge is placed into the midsole of the shoe.

The additional 1/8 inch midsole wedge is glued and then Superglued to the shoe. You can see I let the shoe wedge go further out  towards the toes since Ruth seemed to be pronating more when her weight went in front of the original 1/4 inch wedge.

To help with the pain at the base of the first metatarsal-first cuneiform, the plastic is thinned and 1/8 inch pink plastazote (memory foam) is layered between the plastic and topcover.

Here the side view of the plastazote layering.

Basics of Gait Evaluation: Hips



When watching someone walk and/or run  (also known as gait evaluation), it is important to look at what the hips are doing. The hips are a reflection of shoulder motion (right shoulder and left hip), intrinsic hip and low back conditions, and  foot motion (or lack of). The green circle reflects normal hip motion and symmetrical right to left hip heights. The light purple circles represent some of the more common conditions seen. I am always asking if the hip evaluation represents shoulder abnormality, hip and/or low back abnormalities (including scoliosis and pelvic asymmetries), or foot and knee rotations. It is exciting to try to put the patterns together and make some sense out of them.

I remember one of my first race-walkers that I treated. Maryann had right hip pain with a long left leg, excessive foot pronation, exaggerated hip motion even in normal walking, and very tight ilio-tibial bands. As I co-treated her with a physical therapist, we successfully leveled the hips, stopped the excessive pronation, and stretched out the IT Bands. Yet, her hip pain was just as bad. A low back consultation felt that her pain did not come from the back, and the physical therapist did not feel that it was referred pain from her knee. Finally, I went to the track for one of her race walking training sessions. As I watched her walk, I realized and her coach, she did not move her left shoulder (or her right shoulder for that  matter). The hips should move equal and opposite to the shoulders (right hip and left shoulder) for maximal efficiency and ease of motion. The solution to Maryann's problem and then many years of painfree race walking was to get her to move her shoulders freely.

The checklist of hip gait evaluation observations is:

• Symmetrical Hip Heights and Motion
• Low Back Issues

1. Lordosis
2. Flat Back
3. Scoliosis

• Hip Motion Symmetry
• Hip Height Difference

1. Right Higher
2. Left Higher

• Trendelenberg (Hip Drop)

1. Drop to Right
2. Drop to Left

• Hip Hike

1. To Right
2. To Left

• Excessive Hip Motion

1. Forward to Right
2. Forward to Left
3. Out to Right
4. Out to Left
5. Transverse Plane
6. Sagittal Plane
7. Frontal Plane

• Limited Hip Motion