Can a Patient Walk Well and without Problems with Big Toe Joint Fusions for Hallux Rigidus

https://www.facebook.com/download/531737191640275/02_07_2017%20Gait%20Analysis%20of%20Foot%20Compensation%20After%20Arthrodesis%20of%20the%20First%20Metatarsophalangeal%20Joint.pdf?av=1568287145&eav=AfY8moMdRWZwme9PP23bk81Af93vGN1LoENbVVyR_LM05adSRvNRB_f8Ex6t6ZxQsjs&paipv=0&hash=AcoGJAvMX3oPGRywSfE&__cft__[0]=AZWVks2l-WYTD_dHpYlGF8p0otjFiDYKrVcnZMdtauES1JJfZDs8JEL8gwvjaZtsqMnrnuWaWP7Y9SVKu9m6sBfIsILpm-VnQbEq6gGutHwtTKv9tMA4BPFHWiTT2Ey2a32O4kqxJH38zRglc7QlmnXgzS31GyPE2lcrDMeaz9GkMQ&__tn__=H-R

Lecture at this year's Richard O Schuster DPM Memorial Lecture

The Photo is from my lecture at this year's Richard O Schuster DPM Memorial Biomechanics Seminar on Subtalar Joint Neutral Position and its clinical significance.

The Speakers from Left to Right: Jinsup Song DPM, PhD, Howard Dananberg DPM, James Losito DPM (program coordinator at Barry University in Florida), R. Daryl Phillips DPM, Richard Blake DPM, Jeff Cusack DPM, Joseph D'Amico DPM (seminar director), Russel Volpe DPM, R. Paul Jordan DPM, Paul Coffin DPM, Barbara Reseque DPM, and Samantha Landau DPM

Rehabilitation of Injuries: Magical 80% Rule

Injury Rehabilitation: The Magical 80% Rule

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

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

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

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

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

7 Signs That You Should Bring Your Kids In To A Podiatrist: Blog Post

https://www.performpodiatry.co.nz/signs-kids-foot-problems/

Morton's Neuroma Physical Examination Testing

https://youtu.be/_7qNgYNUrmw

Basic Gait Findings to Assess Walking Patterns

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

 

(  ) A Propulsive Push Off

 

(  ) Digital Clawing

 

(  ) Angle of Gait Asymmetry

 

(  ) Angle of Gait Position

 

(  ) Summary Right Side

 

(  ) Summary Left Side

Lifts for Short Leg Syndrome

Short Leg: Heel Lifts vs Full Length Lifts

 

The 8 common biomechanical categories used in the treatment of injuries are:

1.             Short Leg Syndrome (discussed here)

2.             Poor Shock Absorption

3.             Excessive Pronation

4.             Excessive Supination

5.             Tight Muscles

6.             Weak Muscles

7.             Miscellaneous Gait Abnormalities (ie Drop Foot, Polio, etc)

8.             Combinations of the Above

 

Since we are going to talk about lifts I thought I would give your spirit a lift first. I wish to express my gratitude to photographer/artist Robert Stallard for this breathe-taking view of San Francisco Golden Gate Bridge near sunset on one of our cold, foggy San Franciscan summer days.

 

 

 

The heel lift is the main method used in treatment of short legs and their problems. But, heel lifts are inherently unstable, and easy for patients to compensate for by simply bending the knee on that side. Once you bend the knee on the side you are trying to lift, you have lost the correction. Heel lifts, therefore, can make the foot/ankle more unstable by lifting up in the shoe more, and they can make the knee more unstable by producing greater knee bend/flexion.

Doctors are always placing the lift onto an orthotic device. This is not advisable. First of all, it makes it hard to decide what symptoms are related to the lift, and what symptoms are related to the orthotic device, when pain increases with orthotic devices. Secondly, because of the instability mentioned above, the heel lift may negate the added stability produced by the orthotic device. Golden Rule of Foot: Keep orthotic devices and lifts for short legs totally separate.

 

 

 

 

Full length lifts in the treatment of short leg syndrome are much more stable and produce better symptom relief. Full length lifts need to lift the heel and forefoot (metatarsal area), normally equally when 1/4 inch or less, then taper at the toes. This full length lift above, designed around a shoe insert template for W9 (women's size 9), is actually cut off at the toes to give room in the toe box area. Imagine all of the athletes who run up on the ball of their feet, but need a lift for their short leg. How could a heel lift do anything positive for their biomechanics and symptoms? At least 50% of the time most athletes are on the ball of the foot while exercising, so a full length lift seems ideal for the athletic population. Now athletes on the other hand would love the lift to be only under the heel for convenience and shoe fit, but it is so much better to have it full length for their biomechanics.

 

 

 

If you use full length lifts, make sure you make cuts into the material by the ball of the foot to help with smooth push off. This is especially true as you get up over 1/4 inch in lift. Material under the ball of the foot can make it hard to move through, so cutting to increase bend, along with beveling and thinning slightly can all help. You can also see that the front edge of the full length lift is bevelled or skived to make a smoother transition forward. When I am using full length lifts, I always try to get feedback from the athletes on how easy it is to move through their foot. In podiatry talk, I am trying to avoid Sagittal Plane Blockade.

 

 

You can see the cuts do not go through the sides to help with its durability, but they do go completely through from top to bottom.

 

 

Not really demonstrated well, but these cuts do improve the bend of the foot making it easier to move gently through to the toes. When you use lifts over 1/4 inch, it is common to use a greater transition from heel to toe. Typically for 3/8 inch lifts I will use 3/8 inch in the heel, 1/4 inch in the forefoot/metatarsals, again tapered to the toes as one example of this progression. 

Single Leg Balancing: Important for All Lower Extremity Injuries

     Single leg balancing is mandated to everyone with bad ankles in my practice. It is a 2 minute single foot pose done in the evening to fatigue the ankle. The mechanical function is to both strengthen muscle/tendons, but wake up the neuromuscular connections for a reactive ankle responsive to slants, tilts, and cracks in the sidewalk. You need to always make it somewhat difficult or challenging by standing in shoes or barefoot, standing in the middle of a soft pillow or exercise disc, closing your eyes at times, or moving your hands with or without objects. The goal is to keep challenging yourself. The goal standard remains 2 minutes of single leg balancing with the eyes closed, yet only a few of my hearty patients get there. 

Every patient should have a single leg pose or exercise in their daily exercise regimen

Practical Biomechanics Question #346: Single Leg Balancing is a common exercise taught for ankle, knee, hip and low back rehabilitation. How long are these positions typically held?

Excerpt from the Upcoming: Practical Biomechanics for the Podiatrist Book 3

Swollen Heel Bone: General Thoughts around a Calcaneal Stress Fracture

 Calcaneal (Heel Bone) Stress Fractures: A Cause of Significant Persistent        Heel Pain

                                    By Richard L Blake, DPM

 

   Heel stress fractures present the same way as plantar fascial tears. They present with swelling, typically an acute onset, and pain level in the 4-6 range or more. However, unlike plantar fascial tears, they may develop slowly probably progressing from a bone bruise, to stress reaction, and finally stress fracture. They do not show up on x ray normally, making an MRI or bone scan typically needed to confirm. Like plantar fascial tears, if this is suspected, and getting test confirmation is difficult to impossible, it is important to treat it as if it was a stress fracture. You do not want a calcaneal stress fracture to develop into a full fracture (typically needing surgery with some permanent disability possible). If you squeeze the heel from both sides, and you (the patient) is very sore compared to the other side, you may have a stress fracture. If you walk on your heels only for 3-4 steps, and you have excruciating pain, you either have a plantar heel bursitis or calcaneal stress fracture.

The top 10 treatments for calcaneal stress fractures:

 

1. 3 months removable boot and EvenUp on the other side (and many times the heel bone has to be floated for off weighting with 1/2 adhesive felt under the midfoot and forefoot only))

2. 1500 mg calcium and 1000 units Vit-D3 daily 

3. Bone density test if any question on why heel broke (did not make sense?)

4. Vit-D3 level if any question on why heel broke (or if your dietary intake is low, and you do not get much sun exposure without sunscreen). This is especially true when the stress fracture occurs in the winter months)

5. Custom or OTC orthotic device to produce the effect of a soft heel and weight transfer into arch

6. Ice pack 2x/day

7. Contrast bath each evening

8. Activity modification to maintain cardio

9. No NSAIDs like advil or aleve (slows bone healing)

10. Exogen bone stimulator for 9 months (if the diagnosis is confirmed by MRI as x-rays are not great for stress fractures)

 

    Patient presents with swelling under the heel bone. There is pain produced on side to side compression of the heel bone during physical examination. X-rays normally are inconclusive. The patient does not have to have a story of landing hard on the heel. Onset of pain normally occurs over a short time (acutely), whereas plantar fasciitis (more commonly a cause of heel pain) has a typically gradual onset of the pain, worsening slowly over a month or so. The typical differential diagnosis with significant heel pain with swelling is calcaneal stress fracture or plantar fascial tear, with some arthritic conditions much more rare.

    An MRI is the conclusive test. It is important to note how close the stress lines are to the subtalar joint. The closer to the subtalar joint, the more consideration of non weight bearing 8 weeks of permanent casting (yes, a real cast). This is totally devastating to a patient, so avoid when possible. The following are 4 MRI’s for patients with heel pain, each with different findings.

This MRI showed the bone swelling above the bottom of the heel bone due to a tear in the plantar fascia. You can see the intense swelling above and below the plantar fascia. This is not the pattern of swelling of a calcaneal stress fracture. A small blood vessel is seen running through the heel bone which can look like a stress fracture. If it was there would have been reactive bone changes around it eliminating that nice tortuous pattern.

 

This is a tremendous bone reaction from a calcaneal (heel bone) stress fracture that runs from the bottom to the top of the heel to the subtalar joint. A permanent non weight bearing cast for 4-8 weeks could be easily recommended to protect the joint. This particular patient would have mentally lost it, so I did treat this with a removable walking boot. She has done well, but did take longer than normal.

 

Same patient from just above is 3 months into her treatment, still very sore, with still bone swelling within the heel bone. As long as there is bone swelling, there will be pain (like the pain you get from a sinus headache, although you never have to walk with full body weight on your sinuses). I never created a good pain free environment for multiple reasons, so the typical 3 months of immobilization actually lasted 6. She was however able to do intense spin classes and swim without problems during this time.  We consciously as a physician and patient team, traded early function for a potentially longer rehabilitation period.

 

Normal heel bone with organized blood vessels.

 

    Once the diagnosis is made, here is a checklist of events that should happen:

1. Questions should be asked about bone density issues, dietary habits, activity levels leading to overuse, selection of shoe gear, and past history of fractures.

     2.The patient should be fitted for a removable walking boot, unless concern that the  fracture goes too close to the subtalar joint. If the fracture is deemed needing non-weight bearing, a permanent cast is normally used for 4 to 8 weeks. I use a 1/2 inch accommodative pad to float the heel of the walking boot, and tend to use a below the knee cast over a shorter one. An EvenUp is used on the other shoe.    

     3.Over the first 2 weeks post diagnosis, you strive to create a pain free environment. The ease or difficulty in creating this pain free environment is an important clue on how serious the problem is. The average patient needs to be in the removable cast for 3 or more months once the pain free status is attained.

     4. Activity modification is crucial at this time. Bike and swimming are commonly used to maintain cardio, especially if a removable boot is used. Floor exercises for strength and flexibility are recommended. Pilates is a great source of these exercises.

     5.Sole, PowerStep, or PureStride OTC orthotics are used within the cast (and later in the shoe gear) to produce heel padding and weight transfer into the arch.

     6.Contrast baths once or twice daily are vital at reducing heel bone edema (swelling). Swelling within the bone should be minimized since it actually can reduce the normal blood flow important for healing. This can slow healing.

     7. A Bone Stimulator for 6 to 9 months is used. I actually stop 2 months after full activity is resumed. I use Exogen ultrasound for this, but there are other good stimulators. For insurance, since there are no fracture gaps in a calcaneal stress fractures, many will not cover.

     8. The Primary Care Doc should discuss all the factors that affect bone healing including the right amounts of calcium, Vit D3, and other minerals. With bone injuries, I have the patients minimize their use of NSAIDs (like advil, etc).

     9. Monthly return visits can be scheduled for a while to monitor the progress and make changes.

Sole OTC inserts with extra cushion in heel and extra Hapad arch support to transfer weight into the heel.

     10. One month after the diagnosis, the patient is normally casted for custom fitting soft orthotics. I use the Hannaford technique, but most professional orthotic labs have their versions that can/are similar. These are dispensed in 1-4 weeks depending on the need to see that patient (if the pain free environment is established already, waiting 4 weeks to dispense the new orthotic devices is probably fine).

This shows the memory foam of a Hannaford soft based custom orthotic device.

       11. One month later, normally now 2 months post diagnosis, physical therapy can be started to decrease inflammation and work on the damaging aspects of casting: stiffness, weakness, loss of proprioception (balance), and sometimes nerve hypersensitivity. Physical therapy can be helpful until you are back to full activity, probably 3-6 months. Most of the time physical therapy can be effective at 1-2 times per week.

Patient in physical therapy doing contrast bathing to reduce bone swelling and its resultant pain.

         12. Three months post diagnosis should mean that the patient has been pain-free for almost exactly 3 months with all of the above treatments. If it was tough to get the pain level under control, then this landmark may take much longer. It seems that the patient can successfully wean off the removable boot after being relatively pain free for 3 months, no matter how long that takes. To successfully wean off of the boot means that you can not have more pain out of the boot than in the boot. The removable boot or cast (I use those phrases to mean the same thing) is initially weaned off by keeping it on at work, and gradually adding more time out of the boot at home or doing errands. When you are completely weaned out of the boot for home, gradually spend less time at work. During this time there can be no increase in pain, you should ice 2 or 3 times a day extra (ice pack 15 minutes to the bottom of the heel), and the whole process can take 4 to 6 weeks. During this time always have the boot with you!! You never know when you will need it. Once you are out of the boot full time, you can gradually increase your activity.

 

 

When Pronation is a Problem: What are the Tools we Have to Help?? Video

https://youtu.be/8WAnph-kP30

     Next week the Richard Schuster Memorial Seminar will be held at Barry University in Florida (minus an occasional Hurricane!!) Here is a video of my power pointe on tools we have to help with problems created by excessive pronation from 2019's seminar. Rich 

Nerve Pain Supplements Commonly Used

1.      Lipoic Acid 300mg 2x/day

2.      Acety-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

     This is a list I give to my patients with any type of nerve symptoms from numbness to pain. They all have had positive responses with lessening of nerve symptoms when taking for 3 months. Typically my patients try one at a time for 2-4 weeks. If there is any improvement, they stay with that one and start another. I tell the patients that they have to feel an improvement, so do not just take them blindly. Rich 

General Rules Swollen Achilles Tendons

Achilles Tendinosis and Partial Tears by Richard Blake, DPM

     Achilles Tendinosis implies that the tendon is damaged more than inflamed (like in Achilles Tendonitis conditions). Partial Tears are part of this condition that drives everyone, doctor and patient, bananas. There are so many degrees of tendon disease. MRIs, if possible, should always be done to document what is going on. The important physical finding to suspect an achilles injury, more than tendonitis, is the presence of visible swelling. Straight Forward Achilles strains or tendonitis conditions should not have visible swelling. 

     The top 10 treatments for achilles tendinosis and partial tears are:

1.     When the tendon is thicker than normal, or swelling that will not go away, consider an MRI to check if a partial tear is present.

2.     With tendinosis, some form of immobilization is important to create a pain free  environment.

3.     With a partial tear of the achilles tendon, 3 months of cam walker/removable boot is crucial (when a pain free situation cannot be obtained with activity modification).

4.      With tendinosis, physical therapy can occur at the same time as the immobilization, and with a partial tear, physical therapy normally starts after the 3 months of immobilization.

5.       Both of these conditions may require surgery, so a surgical consult should be done to evaluate options.   

6.      As the tendon gets less sore with icing for 10 minutes 3 times per day, gradually begin to strengthen. I love 2 positional Heel raises up to 100 each evening as long as there is no pain, gradually leaning to the injured side, and gradually progressing to 25 one sided heel raises.

 

Here a Heel Raise is demonstrated (also called a Calf Raise)

7.     Achilles tendon stretching, both straight and bent knee, should be done painlessly 3-5 times a day.

8.      PRP injections and Shockwave Therapies are rising stars to hopefully avoid surgery may be considered. At the time of this writing, Stem Cell injections are still not proven to the author.

9.       Like all cases of achilles pain, heel lifts and custom orthotic devices are standard to both stabilize the heel and decrease the stress on the achilles at push off. The solid platform of a standard custom made functional foot orthotic device gives incredible power to the achilles by centering the heel under the leg, anchoring the heel, and easing the stress at heel lift on the achilles.

10.    Avoid barefoot and negative heel positions for a year following the Return to Activity Phase.

When the heel drops below the plane of the ball of the foot, it is considered in a negative heel position, and the achilles can get over stretched and re-torn. In the initial phases of achilles rehabilitation, I prefer to keep my patients in their seats while biking.

General Rules of Posterior Tibial Tendon Injuries

Posterior Tibial Tendonitis/Dysfunction/Tear (by Richard Blake, DPM)

 

    The posterior tibial tendon is the major tendon to support the main arch of your foot. Damage to the tendon causes arch collapse to a major degree. Any sign that this tendon is having (beginning to have) problems must therefore be over treated to avoid long term issues. It is one of the most common surgeries on my patients because of the disability. I work long and hard on each one of these patients both trying to avoid surgery (usually), or in their post surgical rehabilitation. I encourage you to see my videos on You Tube for posterior tibial tendon problems. On YouTube, type drblakeshealingsole posterior tibial tendon and see what comes up. Rich 

    

The top 10 treatments for tibial tendinitis/dysfunction/tear are:

1.  Understand the biomechanics of the posterior tibial tendon to support the medial longitudinal arch and begin to support the arch as part of all phases of the rehabilitation: Immobilization, Re-Strengthening, and Return to Activity.

2.  Start with OTC and advance to custom orthotic devices with maximal support (this is not an injury to settle with less than optimal support).

3.  Learn several different taping techniques: posterior tibial and circumferential arch.

4.  Ice the area 3 times daily for 15 minutes each.

5.  If possible, get a baseline MRI (may be an important comparison 6 months later).

6.  Most ankle braces hold the ankle pronated which is bad for this injury, consider an Aircast Airlift PTTD brace for times you are not using orthotic devices.

7.  Create an initial pain free environment with below knee removable boot/cam walker, and perhaps a Roll aBout.

8.  If the injury is substantial (Grade 3-4 typically), have a hinged AFO custom made at a brace shop right at the start of the injury (it can take awhile to get fitted)

9.  Begin strengthening the posterior tibial tendon as quickly as possible with at least active range of motion exercises. The Posterior Tibial tendon is strengthened by pointing the ankle first and then moving the foot towards the other foot.

 https://youtu.be/w3FXx4OFqec

10. Definitely have a surgeon as part of the treatment.