Sesamoid Fracture: Need Help in Los Angeles, California

This is an email sent by a young lady several days ago. I have already sent her to a good friend of mine Dr Daniel Altchuler in Santa Monica. I know Dan personally to have similiar philosophies as I do. When you need help, a good place to start looking is go to the website of the American Academy of Podiatric Sports Medicine at www.aapsm.org  and look in their membership. Most of the podiatrists in this academy are serious about treating athletes and that normally means they are pretty conservative in their treatments (normally!!).  

Hi Dr. Blake,

First of all thank you so much for having an email address where people can reach out to you.  I was diagnosed with a sesamoid fracture in my right foot yesterday.  I went to the Podiatrist two weeks ago with severe foot pain and swelling.  She was treating me for sesamoditis.  Two weeks later, I went back still in pain.  She xrayed me again and this time the fracture showed up.

Dr Blake's comment: Fractures in many areas of the body can take 2 weeks to never to show up in an x ray. Sesamoids, little bones under the first metatarsal at the ball of the foot, are particularly difficult to diagnosis by x ray. The patient and treating doctor when the injury seems to be sesamoid related should initially attempt to create a pain free environment. It will almost make the diagnosis because it will be harder to create this pain free environment with a true fracture vs an inflamed sesamoid (called sesamoiditis). You have to treat the worse possible cause of pain, unless you go right to a bone scan or MRI. If you create this pain free environment, sesamoiditis will need less time overall to resolve where a stress fracture of the sesamoid normally 3 months to 2 years. And some do have to be removed, so we want to calm that sucker down quickly.

  She put me in a cam walker and within an hour or so I was feeling pain at the fracture sight.  She recommended that I go back into UNO boot & surgical boot which is what she had me in when she thought she was treating sesamoiditis.  You mentioned in your blog that all podiatrists know to how to make a walking boot pain free, yet she didn't mention this as a solution.  She also didn't offer me an MRI.  Should I be seeing a "better" doctor? She takes conservative measures so I felt she was capable of treating my fracture.  Can you give me a referral to a Podiatrist in Los Angeles?  

Dr Blake's Comments: Wow, there is a lot to comment there. It sounds like she is trying to rest the area, but is missing some subtle aspect, like accommodative padding to take pressure off. Normally docs do not recommend MRIs initially if they can get the area calmed down in the first followup visit or two. In general, the first month is reserved for making the proper diagnosis, and creating a pain free environment so you and her are half way there. Does not sound like she is lacking in effort, and this is what you want out of the health care provider who has agreed to help you. Those cam walker, also called removable boots, need to be modified alot, but can be very helpful and can even become your friend the next 3 months. For right now, go with what makes you comfortable in all activities, instead of one item that makes you hurt. Common sense and listening to your body is key. Do you need a second opinion? The jury is still out.

While I am emailing you I have another question.  Two weeks ago I upped my speed/time on the treadmill and I also began running for a few minutes at a time.  The day after this I started feeling foot pain and within 1 or 2 days I couldn't walk.  With this increase in my activity it's pretty obvious what caused my fracture.

Dr Blake's comment: Fracture pain comes on suddenly like this, sort of one day you do not have it, the next day you do, whereas sesamoiditis tends to come on gradually. 

  SO about one week into the doctor wrapping my foot in an UNO boot/Surgical boot I started feeling dull aches in the sesamoid in my other foot.  By the way I had surgery 15 years ago to remove a fractured sesamoid from my left foot so I only have one in there.  Fast forward a week or so and the dull ache is still about the same.  I feel it here and there usually when I put more pressure on that foot.  I can still flex/scrunch/point/push that foot without any pain.  I am REALLY praying that I didn't fracture this one as well.  Is it possible that it is just irritated from extra pressure?

Dr Blake's comment: What makes sense here? A fracture or just soreness in an old injured area from compensating. Everyone raise your hand who thinks it is a fracture. 

From what I have learned, sesamoids are very difficult to heal.  I have a 2 year old and 6 month old so this has been a huge burden and I am having a pretty rough time emotionally.  Also I am experiencing shooting pains in my lower back in only one day from being in the cam walker.

Dr Blake's comment: You definitely need to get an EvenUp for the other shoe and may need some time with crutches (but of course that would depend on how successful you and your health care provider were at achieving this pain free environment). Sure hope this helps you. 

Any advice, insight, info along with a referral would SO appreciated.

Best

To All Runners: Barefoot Running Survey---Please Respond!! Research is Needed

From Dr Blake: Barefoot or Minimalistic Running Shoes are a hot topic. Please take time to help these 2 great podiatrists do research which may help to prevent many injuries.  February 21, 2012 RE: Barefoot & Minimalist Running Survey To Members of the American Academy of Podiatric Sports Medicine: I would like to request your assistance in a research project on barefoot and minimalist running. The linked document below is the preamble to a survey we have constructed that attempts to ascertain the scope of barefoot and minimalist running both in practice and runners' attitudes. David Cauthon and I wrote one of the most comprehensive reviews of barefoot running to date that was published last year in the Journal of the American Podiatric Medical Association. The survey we created is a follow-up to that publication. We ask your help in distributing our survey link as widely as possible to reach as many runners as we can. The survey population need not be barefoot or minimalist runners as one of the parameters we are investigating is the scope of these practices so ALL runners are encouraged to take the survey. If you work with any running shoe stores, clubs or teams please pass on to them. If your practice has a web site, please post there. Practice newsletters or practice email updates could be other venues. The preamble to the survey is at: http://www.aapsm.org/survey-preamble.pdf The link to the survey is: https://www.surveymonkey.com/s/RMYTMJJ We greatly appreciate your assistance in furthering research that has the ultimate goal of answering so many questions we have about barefoot and minimalist running. Please distribute this link as you see fit and if you have any additional questions, please do not hesitate to contact me at the e-mail below. Thank you in advance for your assistance. Most sincerely, David W. Jenkins, D.P.M., F.A.C.F.A.S., F.A.A.P.S.M. Professor, Arizona School of Podiatric Medicine /Midwestern University Board Member of the American Academy of Podiatric Sports Medicine Clinical Director of Special Olympics Arizona Fit Feet Program djenki@midwestern.edu

Posterior Tibial Tendon Tear: MRI images

One of my patients recently tore his posterior tibial tendon, the most important ankle tendon for arch support. He is being worked up for surgery and I thought his MRI images may be helpful to some of you suffering from Posterior Tibial Tendon problems.

The 3 medial ankle tendons that go into the foot are: flexor hallucis longus  (FHL), flexor digitorum longus (FDL), and the posterior tibial tendon (PT). See the solid dark circles that make up the FHL and FDL. See the white area where the posterior tibial tendon should be.

The FHL and FDL are well visualized. The medial or inside ankle bone shows old bone chips from a fracture 20 years ago by the sensor.

As we get further into the foot with our imaging, the area of the posterior tibial tendon is more blown-out than the FHL or FDL. Good, solid, tendons should look dark, condense, and have sharp borders. The PT has none of this.

Further imaging into the foot shows the PT tendon non-compact and almost stretched.

This side view of the ankle shows a solid FDL tendon as it comes down into the foot, and an almost nonexistent Posterior Tibial Tendon. 

This is such an important tendon in the body that I am forced to send to the surgeons for repair. Hopefully, once the surgical part is done, I can begin the often 2 years of gradual rehabilitation for full strength.

Video from Dr Glass on Ankle and Subtalar Joint Motions

I want to applaud Dr Glass for his outstanding video on ankle and subtalar joint motions. Even though there are a few typos in the text, the great visual is wonderful. Thank you. 

Plantar Fasciitis and The Role of Flip Flops

PM News

CA Podiatrist Discusses Plantar Fasciitis Plantar fasciitis is an inflammation of the fibrous tissue that connects the heel bone to the metatarsal bones on the bottom of the foot. Symptoms can include a burning sensation and aching on the soles, and dull or sharp heel pain. "If, first thing in the morning, your heel is really painful, and then as you walk around it feels better, that is the classic sign," says Sheryl Strich, DPM, president of the American Association for Women Podiatrists. Dr. Sheryl Strich Surprise: "High heels are not the evil-doer," says Dr. Strich. The most likely culprits are pancake-soled shoes with zero arch support, such as flip-flops, ballet flats, and some casual sneakers. And standing for long periods of time in any shoe -- say, if you work on your feet -- can also cause this common injury. Source: Ladies' Home Journal Below are several youtube videos on plantar fasciitis stretches and treatments.

Leg Pain in a Runner: Tibial Stress Fracture (Part 2)

Recently a long distance runner presented with leg pain of 4-5 months. The pain came on suddenly during a long training run. The patient attempted to run through the pain, because it was not too bad, for 2 months. Then, common sense dictated stopping running for the last 2 months. The pain is not only not better (can I throw a few more nots around) but now hurts walking around which it never did before. He tried changing shoes and icing occasionally. These measures did not help. 

In a runner with leg pain developed with long distance training, the diagnosis is a stress fracture until proven otherwise. The following 3 X-rays just taken show a healing tibial stress fracture with marked amount of new bone formation. Try to look along the normal border of the bone. As the normal border gets obscure, this is the new bone forming. Unlike this X-ray, you normally do not see a fracture line with a stress fracture only the subtle new bone formation. 

On this oblique view, one can really see the fracture line. Fractures look bad for a long time for 2 reasons. The fracture line looks worse then it really is since there is more water content near the fracture itself in the bone. More water makes the fracture look worse. Fractures heal inside out, so total healing may have occurred internally, but the X-ray still shows signs of the fracture still present.

Due to the compression forces and the muscle contractions of the leg muscles, most running stress fractures on the tibia occur on the back surface of the bone. This makes it hard to locate and hard to see any swelling.

Leg Pain in a Runner: Tibial Stress Fracture

Over the next week, I am going to talk a lot about stress fractures. This is a common one in the lower inside of the shin (tibia) seen in a runner increasing his mileage. 

This AP Tib/Fib Xray documented the new bone formation seen next to the marker in a long distance runner. This bone reaction is called periosteal reaction and signifies that the bone is trying to heal. The new bone formation should be the thickest nearest to the fracture.

Lifts for Short Leg

Dr. Blake-

I saw your posting regarding athletes and how if they have a leg length discrepency they should consider a full length foot lift as opposed to a heel lift.  I would like to know where I can buy a full length foot lift that is as flexible as the one you show in your pictures.  I have recently purchased one of the Clearly Adjustable full length lifts, but find it to be extremely ridgid.  I think a more fleixble lift would be more practical for being on my feet a lot.  I used to enjoy working several times a week until a recent possible hip injury.  I was diagnosed with a leg length difference of at least 6mm and have used a heel lift for several years.  I am hoping that trying a full length lift will possibly even out an imbalances in my hips and weight bearing on my feet.  Any help from you on sources to purchase these items would be great!  Thanks!

Jeanne (name changed to protect)

Dear Jeanne, Thanks for your email and sorry for my delay. The material I use is call grinding rubber and you can purchase several 1/8th inch sheets from www.jmsplastics.com. The trickiest part is to skive the leading edge, but try angling the scissors. You can also use 1/8th inch spenco flat insoles and cut out the toes to give more room. Use one pair and you can make a 1/4th inch lift for one side (almost 6 mm). These can be purchased all over. Sure hope this helps you. 

Here the black side of a Spenco insole with the toe part cut out is being compared to a typical heel lift.

Here Grinding Rubber from JMS Plastics is being formed into a full length lift and a heel lift.

Here a Spenco insole is being used as a lift of the short left side and an accommodation for a painful big toe joint. 

Plantar Fasciitis and Sesamoid Injury

Hi, Dr. Blake,

I hope 2012 is treating you well!  You were so helpful to me last year when I was struggling with my sesamoiditis diagnosis.  I am still spreading the gospel of the Even-Up.

I have another question now.  I have had a pain in my right inner arch over the past few days, worse upon waking.  From my reading I suspect it is the beginning of plantar fasciitis.  I read your post about arch height-- for the record I have very high arches and VERY tight calves (one surgeon I saw for the sesamoiditis said I'd never be able to stretch them enough and recommended I get both gastrocnemiuses cut).  I stretch them on a foam wedge every morning but maybe it's not enough.

With sesamoiditis on both feet (I have bipartitite sesamoids) I want to be very careful about how to do stretches for the plantar fasciitis!  I've already refused to "walk the dog" from the downward facing dog in my yoga class, because I feared for my sesamoids...  Do you have any specific instructions?

Also, I guess it's time to face up to the fact that it might be good to wear plantar fasciitis splints at night.  But again, some of them look like they pull against the sesamoids in a bad way!  And I guess I should wear them on both legs, and so the big bulky ones would be hard to manage.  Do you have any splint suggestions?

Thank you for your ideas-- it is such a blessing to feel I can ask you and get a trustworthy answer.

Toni (name changed to protect the identity)

Hey Toni, Thanks for the email. That is not a typical place for plantar fasciitis, but it may be. I have attached a video  on plantar fascial stretches that do not pick on the sesamoid, another video on kinesiotaping for arch support, and ways to accommodate the sesamoid if you do go to the removable boot. Rich Also consider the rolling ice stretch twice daily described in the basic plantar fasciitis treatment posts. Thanks for you confidence in me. 








http://www.drblakeshealingsole.com/search/label/Plantar%20Fascial%20Night%20Splint

Peripheral Arterial Disease: Feet Give Good Clues

Feet Can Hold Clues to Heart Health: MI Podiatrist If you’re wondering about the health of your heart, try looking at your feet. The lowly, stepped-on, shoe-squished foot could very well hold clues about the state of your coronary arteries. If your feet show signs of poor circulation – or peripheral arterial disease – your heart could be suffering as well. Dr. Marisha Stawiski, a Grand Rapids podiatrist, says she regularly checks patients for the subtle signs that could indicate PAD. A loss of hair on the feet is one possible sign of poor circulation.  Dr. Marisha Stawiski checks a patient for PVD (Photo T.J. Hamilton) That doesn’t mean that people who have always had smooth, rather hairless feet have PAD, she said. “But if you have somebody with a lot of body hair and none on their feet and ankles, it could indicate an arterial issue,” she said. Different pulses, very cold feet, or a change in color also could indicate a problem. If she sees any signs of PAD, Stawiski recommends a simple, non-invasive test called an ankle-brachial index. It compares the blood pressure in the ankles to the blood pressure in the arms. Source: Sue Thoms,  The Grand Rapids Press - MLive.com [2/6/12]

Ankle Braces

This is an email I just received from a great tennis player and dad!!

Dr. Blake,

What ankle braces do you recommend?  I have been wearing the lace up type on my left ankle only, but I rolled my right ankle yesterday which proceeded to swell quickly. I have been using ice and compression and the swelling is down.  I realize now that if I want to continue playing tennis, I will need to wear one of the right ankle as well.
Thank you for your recommendations.

Regards,

Steve

Hey Steve (not his real name since he is in witness protection), 

     I love the ASO Ankle Brace and this is the one I use occasionally when my old injured ankles are at risk (like on the basketball courts). 

http://www.tennis-warehouse.com/ASO_Ankle_Braces/descpageASO-ASOAB.html

Metatarsal Pain Email Followup

This nice patient presented one month ago with a 2 month history of very severe pain in her metatarsals (pain levels on 8-9 out of 10). There has to be something broken or nerve involvement to have that high pain level. New orthotic devices were given to her 2 weeks ago since she stands all day at work. We are trying to avoid a removable cast, which will make her job difficult. There is her 2 week email followup and my response.

Hi Dr. Blake. This is the 2 week report. I'm wearing my new orthotics all of the time now and am attempting to be optimistic. When the inflammation occurs after a short shift at work(4 hours), I recover nicely the next day. Yesterday, I had a 7 hour shift and today I'm pretty swollen and need to stay off of my feet. By tomorrow, I'll probably be much better. It seems like I have to be very strategic about how I spend time on my feet. There's a threshold for how much I can handle.
So, do you have any suggestions? Yes, I am alternating hot/cold . I'd love to hear your words of wisdom. Thanks.
 
Bobbie (not her real name), Thanks for the email.
 
     Sounds like you are doing every thing right. Definitely do the contrast bathing once a day and add an ice pack for 10 minutes twice per day.
 
     I could have the physical department experiment with various forms of taping for you to do, and they could do some treatments of anti-inflammatory stuff to cool things down.
 
     A Budin splint can be purchased at our sports shop to limit motion around the metatarsal joints, and I can try a different type of orthotic to control the foot motion possibly better. So, a lot to do. Come back in 2   weeks and we will advance your treatment, hopefully in the right direction. Rich
 
I had 3 types of orthotic devices to choose from initially and I chose the Root Balanced Technique to maximize the metatarsal support. I definitely may have to change it to get more stability.

Ankle Sprain Advice

Hi, Dr. Blake -

It's been almost a year since I last was in contact with you.  I sprained my ankle today, and wanted to check in with you.  Last year it was the right ankle, today it was the left.  I looked at your blog, but I wanted to clarify a few things with you directly.

I am elevating and icing and took some ibuprofen.  I still have a few compression socks and horseshoe padding from last time.  Should I start that right away?  Should I not use the padding while icing?

I remember how to do the contrast baths, but I seem to recall that I'm supposed to wait a day or two before starting those.

I have attached a couple pictures of my ankle.  It swelled up right away.  It also feels somewhat different than last year's injury.  With that one, I was able to walk without limping.  This one causes me to limp.  I was not in motion when my ankle rolled, but I was standing on an elevated surface, and rolled down from that (if that makes sense :)

Please let me know if I should come in to see you.  I'm pretty sure it's just a sprain.

Thanks, 

Roberta

Roberta, 

     Thanks for the email and I am so sorry about the sprain. Until the swelling is gone for 2 straight weeks, you should use compression 24/7. Those compression socks will help you, along with the horseshoe padding. I am going to use your email for my blog tomorrow, but will remove your identity (probably call you Roberta). Ice for 96 hours, then begin the contrasts at 1 min hot, 1 min cold for 20 minutes. When you ice you can remove the compression. Schedule with me for Wednesday on, but cancel if it is getting better and better. I will try to be even more thorough in my blog. Rich

     When you sprain your ankle, you need to immediately control the swelling. The more PRICE you do over the first 4 days, the assault and battery days, and the less swelling you have by the end of those 4 days, the faster your ankle will recover. Now, Roberta's (identity removed) ankle looks more like a high ankle sprain (the ligaments above the ankle called the tib-fib ligaments), and it could be a distal fibular bone fracture. So the next few days will tell us if we should xrays. Ankle sprains get better and better, ankle fractures go much slower. So, if Roberta is not feeling a significant improvement with the ability to weight bear on the 5th day post injury, we should definitely be xraying her. I always recommend weight bearing xrays on the foot and ankle since sometimes how the bones line up to the ground and each other can make a difference in diagnosis and/or treatment. To summarize PRICE for you, it is:

Protection: crutches, bracing, removable boots,etc

Rest: Restricting motion of the ankle just enough to not stimulate the pain response

Ice: All the wonderful Anti-Inflammatory measures we have available including avoiding certain foods.

Compression: Remember Compression should be tighter below the injury and looser above the injury

Elevation: Even 1 inch off the floor makes a difference, but get it up as much as you can for the first 4 to 14 days.Control that swelling.

I will leave a Rx for ankle xrays on my asst Kathy's desk. If you feel you should get an xray, call her, schedule an appt, and go to xray 1 hour before. Rich

More on Gout

From: Peter Vannucchi, DPM

One reason why there are no high quality evidence studies for gout is due to the fact that the complexities of effective management make it difficult to treat. In Dr. Purdy's community of southern Louisiana, I am certain that primary physicians see lots of gout. Their lack of aggressiveness is not from a lack of understanding the disease, but from the difficulty of getting patients to abstain from the obvious, namely beer. Beer has guanine in it which is rapidly metabolized into uric acid. Beer is the major culprit. So when a patient has a six-pack on Saturday night, you can almost predict that the patient will be in your office or in the emergency room on Monday. 

Patients also eat shellfish (namely mud-bugs and shrimp) as well as organ meat, and lots of red meat. Forget about high-purine vegetables - it turns out they are not a problem. Dairy products  tend to decrease uric acid to some extent. This is all relatively new data that has come out in the literature.

Chronic Metatarsal Pain in a Runner

Hi Dr. Blake,

I saw you about a month ago.  I have chronic ball of foot pain (had been present for 3 months) that although lessening is still stubbornly persisting.  The budin splint you suggested I get has helped.

Budin Splint with Metatarsal Pad attached to limit motion and re-distribute weight around the 2nd Metatarsal.

  The pain is has "moved" and is now below my second metatarsal.  I've been running on it 3 days a week and this definitely aggravates it.    Do you think the Neuro-eze cream might help me?

Do you think that cortizone could help (oral or injection)?  I would like to keep training.  

I will make an appointment to see you again if you think it would be beneficial.

Thanks in advance for any comments/advice. Tom

Tom,

     Thanks for the email followup. Neuro-Eze may help if the symptoms are neurological. Probably more inflammatory. I could give you a Rx for Voltaren Gel to massage in 3 times daily. I will leave with my asst Kathy. Call her Monday with the pharmacy number.

     If the Budin Splint is working, tighten it alittle each week. 

 Definitely continue to ice massage for 5 minutes three times daily. Stay away from cortisone since we are probably dealing with a slightly injured ligament and cortisone can weaken it further.Come back after 2 weeks with the Voltaren gel and bring in your running shoes. When you say that the running aggravates it are you back to the same level of soreness when you run again? Very important, and no limping. Read my blog post on Good Pain vs Bad Pain to make sure you are staying in the Good Pain part. Hope this helps.And, it is normally great when the pain begins to move, as the original problem is being isolated by the treatment prescribed. Rich

Hi Rich,

Thanks so much for your prompt response.  It means alot to me!  I will call Kathy in the morning for the Valtaren gel.  I tightened the splint today and felt some more relief so I think that is a good sign.   The soreness after I run is managable and does not affect my gait and definitely no limping or anything like that.   It's very stubborn though!   I'm trying to balance the running with cross training and I'm being as conservative as I can without losing my fitness.   I will review your good pain bad pain post.

Thanks again.

Ganglion Cysts

Many patients present to my office with lumps on their foot that either appeared suddenly or gradually grew. These are normally ganglion cysts, formed by fluid leaking from tendons or joints. They are totally benign, and occasionally have to be surgically removed. But most patients are told to ice massage them in a circular manner 2 times per day to see if they can break them done. Before any thought of surgery, the ganglions should be drained in an office setting, one or two times. If the ganglions are not superficial, then cortisone can be injected after the draining to further increase the chance that they will not return. If you do get them drained, you need to spend one month with a compression wrap and extra padding over the ganglion to help prevent it from refilling up again. Here is an example of a ganglion from a recent patient. Like some patients, this patient also had a ganglion on his wrist that did need surgery. Ganglion patients can get other ganglions. 

These benign lumps are not attached to the skin, are soft to pressure, and can only be documented on MRI or ultrasound. X-rays should be negative. Since ganglion cysts can develop from herniations in the ligaments of an arthritic joint, X-rays may show boney changes under the ganglion. If you can use ice massage to shrink them, routine ice massage 2 to 3 times per week may help keep them from coming back. 

Insole Wear Patterns: A Biomechanical Treasure Chest

These inserts tell a wonderful tale about this athlete. See if you can find all these clues, and find Waldo while you are at it. The foot functions more to the lateral heel (inverted) on the left. The left has a more dramatic push off. The pronation is a little more to the right, but both sides are fairly centered. Pushoff is more explosive on the left. 

Sports Medicine Quiz: Biomechanics 3 at Samuel Merritt University

The following questions cover the in-class presentation from Dr Rich Blake at Samuel Merritt University on Jan 24th and Jan 31st 2012. The students are encouraged to review the entire lecture material within the blog post below for more in-depth self study. 

http://www.drblakeshealingsole.com/2011/01/biomechanics-3-sports-medicine-summary.html

Questions for 1/24/12

1.   How does Sports Medicine differ from the regular approach to injuries in orthopedics?

2.   What does the C stand for in RICE?

3.   With contrast bathing, what are you trying to accomplish?

4.   What is the 80% Rules for function and pain scale?

5.   What does KISS stand for and how is it used in medicine?

6.   What is the difference in a 2nd degree sprain vs a 3rd degree sprain?

7.   What are common modifications to increase level of difficulty in the single leg balance exercise?

8.   In the treatment of any tendonitis, what does the initials BRISS stand for?

9.   What does Vit D3 do for bone metabolism?

10. What are the 3 phases of Injury Rehabilitation?

11. Name 3 common forms of strengthening exercises?

12. In Turf Toe is the primary injury dorsally or plantarly?

Questions for 1/31/12

1.   What are 5 common mechanical problems seen in gait?

2.   What is limb dominance in gait?

3.   When watching someone walk or run, where should your gait evaluation begin?

4.   What are 3 orthotic modifications used for over supination?

5.   Bonus Question: What are 3 potential benefits to the much maligned high heel shoe to the patient?

When Do We Begin to Save Our Joints? More Musings from my footstool

This post is dedicated to Lynne.

     Just saw Lynne several days ago. Lynne brought up the age old question at her young age of 59 "do I stop running now to save my knees for the future?" Her knees have some X-ray and MRI findings of wear and tear. Lynne has never had any pain. She did have an episode of knee swelling and sought medical advice. Age old probably sage advice is to stop running since it is the most stressful of her activities on her knees.Lynne is high level triathlete. Yet is it the best advice for Lynne? Does running chew up your knees and hips and ankles silently until you wake up one day and can not walk? What do we know about the Nutritional Theory of cartilage health? What protects joints? What breaks them down? So many questions to be individualized for each of us. 

     My bias for recommending to Lynne to keep running comes from 5 factors. #1 Joint Cartilage is feed from pressure created in the joint from activity (nutritional theory of cartilage health). #2 Pain is our friend and will normally tell us way before severe damage is created that we must start limiting certain activities. #3 Sports Medicine for podiatrists evolved from being able to get injured knee patients to run pain free when the medical establishment was telling them to stop running forever, and I come from that time period of the mid 1970s.. #4 I personally want to keep exercising until I am 100 and I will continue to find ways to exercise (my last 3 orthopedic injuries found me at odds with surgeons wanting to cut, and I was able to successfully rehab each one, and am back playing full court basketball painfree). #5 When you break away from generalizations like stopping running to avoid knee wear and tear, you must own your knee more directly and do positive things daily for it. 

     So, Lynne had been running for 40 years, never had knee pain, did get swelling and her images showed classic wear and tear of a 59 year old. She did not have the knee joints of a 90 year old, so all the running she has done has not been bad for her knees. There was a famous study from Sweden or Norway (way up there) in the 1970s. Twelve 90 year olds who had died had there hip joints examined. All 12 never had hip pain. 6 of the 12 were very active their whole lives. 6 of the 12 were very inactive their whole lives. Guess who had the hip joint cartilage of 20 year olds--yes, the active group. The 6 individuals who had been inactive had hip joints of 90 years old (and not a day older). This study helped secure the global recognition that the cartilage in our joints needed pressure to drive the synovial fluid into the cartilage (a form of forced feeding). 

     Lynne stopped running to save her knees, but may be actually speeding their demise. Lynne can sure be smarter and try not to run down hill frequently where the force that your knee must absorb is up to 10 times body weight. And Lynne can get her knees strong with daily quad sets, straight leg raises, and short arc quad leg presses. Since most of her problem with wear and tear is behind the knee cap, and the load on the knee cap increases dramatically over a 45 degree knee bend, Lynne should do her activities and exercises in a 0 to 45 degree flexion range. Running is perfect for that, some parts of biking may not be. Let pain be your guide.  Lynne should ice her knees with swelling or pain after activities, she should wear a knee brace (I love the Bauerfiend GenuTrain for this problem) when she runs to see if it helps. She could also learn the many ways of taping her knee like McConnell Taping. She should take glucosamine daily. And lastly, Lynne should listen to her body and get back out there, and not listen to general rules that may not apply to her. And as Sue Sylvester on Glee says: And that is how I C it!

Bad Sores: Top Podiatrist Recommends this Product

I recently sent a diabetic patient to a top wound specialist for an opinion. His recommendation to her was to use Winvivo Healing Balm. She definitely looked a lot better in the three wounds I had been trying to help her with. It can be used for superficial or deep wounds. It should not be used in the face of a possible infection. I believe the product has some great potential, but it is always trying to find out who it is beneficial for. 

http://www.winvivo.com/healingbalm.html

Wound in a diabetic after I scraped the callus and dead tissue away (called debridement). Careful debridement is always the number one treatment for these injuries/sores.

Application of Winvino to the wound bed.

Closeup of the wound bed after application of the product. I like it because it can penetrate into a wound. I love another product called Acticoat when the wound is superficial. 

Electronics for Heel Pain: If this works, the Stock is definitely worth buying.

http://www.marketwatch.com/story/bioelectronics-study-on-plantar-fasciitis-to-be-published-in-the-journal-of-foot-and-ankle-surgery-2012-01-19

Brown Fat for Anyone?

My good friend Dr Karen Langone from Long Island, New York, posted this great article on her Facebook page. You should not need any more reasons to exercise. After you study the article from the New York Times, I will give you a quiz on PGC1-alpha, brown fat, and irisin. Does two irisins make one PGC1a or 2 PCG1a s make one irisin molecule? 

http://well.blogs.nytimes.com/2012/01/11/exercise-hormone-helps-keep-us-healthy/?ref=health

Dry, Cracked Heels

http://www.alimed.com/heel-so-smooth-heel-sleeves.html

This is one product available for dry, cracked heels. Works well. 

REFLARES OF PAIN: UNFAIR, BUT PART OF THE PROCESS

This is an email from a typical patient expressing her frustration over a recent reflare of her symptoms. The symptoms are in the front of her foot, and a recent MRI showed no sign of fractures or neuromas.

Hi Dr. Blake,

My foot has been flare up since Sunday after a yoga class, I have been using the contrast bath, but not too much ice though, according to the acupuncturist, she thinks that I need more blood circulation to improve the nerve problem. Icing is not a good option in Chinese medicine.

Last time (Thursday) I visited her, we had a very good acupuncture session, she attached electrodes to needles to provide continued stimulation (like the Stim unit). After the treatment, I felt good, walked without any nerve problem for a while.

Sunday morning I went to a yoga class, I felt OK during the walk from my home to the gym, but there were several standing poses in the yoga class that required strong foot position, then I felt a lot of nerve activities. After the class, I went home to apply a contrast bath, and it seems to quiet down a little.

But yesterday and today, I can feel the nerve problem all the time even when wearing my MBT shoes or sneakers (on a better day, I can almost feel normal in those shoes).

So now I'm applying ice, hoping it will not get any worse.

I forgot to ask you if you have a diagnosis report that I can bring with me when I visit my Physical Therapist and my Acupuncturist. I went to my PT office on Friday, but they were not sure if it's OK to treat me with massage and ultra-sound, so they asked to see the doctor or MRI report and maybe your recommendation for PT. 

Also I want to ask you if it's OK that my Acupuncturist massage my foot, in her opinion, she thinks there is scar tissues developed, so she wants to deep massage them to break down the scar tissues. 

I forgot to ask you if you have seen any possible fracture in my MRI? These two days, I started to feel "similar feelings" as when I had the stress fracture on my metatarsal two years ago. Am I starting to get paranoid or is it really a fracture? 

Can you see it from the MRI if there's any fracture line, since we did not looking for fracture but neuroma, is it possible the MRI might miss a fracture line?

I still have my immobilizer boot from two years ago, should I start to wear it, will that help to improve my condition?

Sorry to ask you tons of questions, I was feeling better last week and felt the condition might be improving, but now I feel the problem again, it really brings my spirit down again and my mind starts to go crazy a little........

Thank you very much in advance.

And here is my response:

 Thanks for the email and sorry about your flareup. Flareups are quite common, and you have may a few more until we get this under control. One of the secrets to not going insane is in quickly controlling the symptoms of a flareup. Definitely the boot and icing are wonderful to do right now. Wear your removable boot 24/7 for three days longer than you need. If it puts stress on your back, go to our sports shop and get an EvenUp for the other shoe. Ice for 10 minutes 3 to 4 times per day. 2 Advil 3 times per day for 5 days on, followed by a 2 day rest is appropriate. Since it is nerve pain, absolutely no deep massage at all. Accupuncture is great. PT is rarely helpful at this time. The MRI shows no fractures. When you know it has been irritated by the yoga, only ice for 48 hours. The contrast bathes may have heated it up too much. Hope this helps. Finished your orthotics today!! See you soon. Rich

Balance: An extremely important exercise for sports and daily activities

Here I present 2 videos on the importance of balance and ways to improve your balance. First, Coach Marc Evans discusses the importance of balance in running. Marc is a world renowned expert in Triathlons. Then, I present my own past video on single leg balancing: the Most Important Exercise in the universe. 

Hip Function with Lifts for Short Leg Syndrome

Dr. Blake, 

When one has a lower leg length inequality, have you measured the effects it has on the hips when one goes into 

a heal lift verses a whole foot lift? I am curious to see what you observation is. 

Tim

Hey Tim, Thanks so very much for leaving a comment on the blog post entitled "Heel Lifts vs Full Length Lifts for Short Leg Syndrome". The schematic below is normal hip function in green and various motions or positions considered abnormal in purple. I see that there is a misprint which should read Hip Motion Asymmetry indicating different motion on the right and left. Over the years I have observed more Hip Hike with heel lifts vs full length lifts and more difficulty in general stablizing the hip height difference originally seen. For athletes who spend a lot or a bunch of time (just to irritate my high school English teacher) on the balls of their feet, the role of a heel lift is lessened in effecting change at the hip level and the base of the spine. 

Normal and Abnormal Motions/Positions of the Hip Area

     All this been said, experimentation with each patient is important. Every doctor/therapist that uses lifts goes off some general rules initially. There has to be a starting place. I like to start with full length lifts (normally stop just before the toes). As I watch a patient walk with lifts, I want to see easy, fluid hip motion, a lessening or elimination of limb dominance (lean of the body to one side), no hip hike (jerk upward), no knee instability which could be a sign of hip instability hiding under the clothes, and for the patient to tell me that they feel more stable and centered. Compromises have to be made when there are toe fit issues, or when stability is not being obtained.

     Another doctor/therapist may want to start with heel lifts. As they treat the patient, they should evaluate in every shoe that the patient uses the lifts whether there is hip stability, hip evenness, elimination of limb dominance and no hip hike at heel contact. There are so many shoe styles, that patients often find that the same lift in one shoe that was working well, has some issues with another shoe. In general, the nuances can be worked out, but most just do not wear the lift in those shoes it does not seem to work with.

    So, to answer your basic question, I normally see smoother, more equal, less jerky motion at the hip and knee with full length lifts than heel lifts. But, if I was starting with heel lifts in a non-athlete that was not on the ball of their foot a lot, I probably could find some shoes out there that worked well for the patient in terms of these issues. I hope I was able to answer your question.

Is Ankle Replacement Surgery on the Horizon for Ankle Arthritis?

http://www.doctorslounge.com/index.php/news/pb/25944

The article above shows that there is hope that good ankle replacement surgeries will be part of the future. There is so much research in this area that I try to tell my patients that have advanced arthritis in their ankles to get cortisone shots as needed, wear high tops and ankle braces if helpful, and do daily ankle strengthening and anti-inflammatory measures (like ice packs). Occassional trips to the physical therapist or accupuncturist to control inflammation can also help. Get multiple opinions before agreeing to a fusion or replacement. Have a conservative podiatrist if possible be your ombudsman to sort through the information available from the surgeons.

Navicular Pain: Accessory Bones and The Right Xray Views

This patient has 6 months of arch pain right where the posterior tibial tendon attaches into the navicular in front of the ankle. The 2 X-rays demonstrate how standard foot X-rays, commonly ordered in emergency rooms or by standard protocols may not reveal the problem. 

This is a standard oblique foot X-ray which shows the outside of the foot better than the inside. Even though the pain was the inside of the foot, and even though I ordered an oblique view to isolate the inside of the foot, I still got the standard oblique view since it is ordered 1000 times more than other obliques. The marker highlights where the pain is, only it is hidden behind the bones.

After sending the patient down to X-ray again, and writing more on another prescription pad,  I was able to get the correct oblique. The marker shows clearly an accessory navicular bone, demineralized, and probably the cause of  pain. Of course, I am now ordering an MRI to look deeper at the 3 Dimensional and tissue activity components. But, this example clearly shows how standard X-rays may not always show the problem, especially when specialized X-rays are needed and not routinely done at any institution. X-rays are normally correct when positive, but may be wrong when read as negative in the face of chronic pain. 

Email Advice: Calf Atrophy, Bunions, Foot Swelling

This is an email I just received with many interesting points to discuss.

Dr. Blake,

     My name is Robin and I just made an appointment to come in to see you. I wanted to reach out and see if there is anything I can do to help my foot until then.

Here's my situation:

      Last night, I started feeling like I have a splinter in the ball of my right foot, especially when I'm walking, when I press the foot on the floor or when I lift my toes up. I'm nine weeks pregnant and wondering if I perhaps have developed planter faciitis.

      Since April, I also have developed a bit of atrophy in my right calf near my knee that I wanted to get checked out as well (I've had an MRI of it and have been to an orthopedist and the conclusion was that it's just atrophy, possibly from sitting cross legged).

      I also have a bunion developing on my right foot, however, and I believe I also have a bunion developing on the top of my right foot under my big toe so I'm wondering if I perhaps am developing hallux rigidus (I've read that calf atrophy can be a sign of this) or if the atrophy is from my patella femoral syndrome.

Here's a bit about my history: 

     I used to wear orthotics (got them about six years ago) for my patella and one foot being longer than the other (I was in pain at that time and wanted to be able to run again, which I eventually was), but I stopped wearing the orthotics earlier this year when I was worried they were worn out and potentially causing other problems. 

     That's about the time I started developing the calf atrophy. I also have stopped running and doing major aerobic/weight lifting activity (outside of walking) since becoming pregnant so I'm wondering if that is contributing to what's happening with my foot.

     In sum, I'm wondering if there is anything I can do in the next week before I come in to help my foot (I started wearing the orthotics again today). I really appreciate the help and look forward to meeting you.

Best,

 Robin

Dear Robin, Thank you for the email and I look forward to seeing you. 

     1. Plantar Fasciitis tends to feel sore in the am when arising and primarily in the heel, although there are cases of it in the arch, and sometimes in the metatarsal area. Starting using an ice cube to massage the area in circular motion 3 times per day to reduce the swelling. Use can also look on the blog for the rolling ice massage technique with a frozen sports bottle. If there is swelling, use could try contrast bathing (also listed in a separate post) to reduce the swelling once per day. It is a 20 minute soaking process. Because it is an usual place for plantar fasciitis, it is more likely a bone bruise or stress reaction to one of the metatarsals. See the video on the KISS principle in designing a float or accommodation for the sore area. You can go straight to my youtube channel drblakeshealingsole. Check that area in all the shoes you normally wear to see if there is any rough spots. Do you think it is sports related? If you are right handed, and a tennis player for instance, you may pivot across this area more than on the left. Check the wear in old shoes on the shoe insoles to see if this area tends to always wear down faster. Check the skin for signs of the callus, wart, corn, etc.

     2. In regards to the atrophy, it usually a sign of low back disc problems or muscle injury. A neurologist or physiatrist or chiropractor can evaluate this for neurological cause. Since you are pregnant, they will not do a low back MRI. The muscle involved should be weaker than the opposite side. Does it affect strength in any way? Look at the post/video on 2 positional calf strengthening and test the strength of the gastrocnemius and soleus on both sides. See if by doing straight and bent knee heel raises you can can find a difference that can be worked on. Use a tape measure and measure the calf size in the same place below your knee on both sides. See if you can record the difference to use as a reference point. If you have calf atrophy now of unknown cause, we have to assume it may get worse before it gets better. Atrophy can be from lack of use like with pain, or with abnormal function (like produced with hallux rigidus).

     3. I will have to evaluate the bunion area for you. Do you have stiffness in the right big toe joint that is not in the left big toe joint? Do you have a history of pain near your big toe joint? Definitely wear your orthotics as much as possible until I see you to give me an idea how they work and feel for you. Read my posts on what to do for bunions, like toe separators and yoga toes. Definitely the pregnancy could cause some symptoms, but you would think that they would be symmetrical. It will be fun playing Sherlock Holmes, definitely one of my heroes. 

I hope this helps you a little. Rich