Miami Heat Beat the San Antonio Spurs: Now It is Time for Us to Exercise!

Unknown Author: Thank You

Congratulations to the Miami Heat for winning the Basketball Finals in the NBA 2012-2013 Season!! This photo summarizes beautifully the end. I immediately think of Ray Allen's miraculous shot at the end of Game 6 that kept Miami from going home. But, since I have been watching a lot of basketball, I now need to get out there and exercise more. What excuse can I find today? 

What does this have to do with a podiatry blog you might ask? Plenty. Physical activity is one of the biggest secrets of life. My patients drive themselves to be more active. They continue to challenge themselves, to keep their hearts, lungs, muscles, bones all healthy. 

I mention that it is a secret of life since many of our children are not being taught this secret. Obesity is skyrocketing!! Diabetes is rampant!! And all of the other side effects of not taking exercise seriously. 

Below is a link to the President's Counsil on Fitness, Sports, and Nutrition. Read about the 60 minutes daily of exercise our children need, and the 30 minutes for adults. Yes, 60 minutes!! 

http://www.fitness.gov/be-active/physical-activity-guidelines-for-americans/

When you are starting a new program, remember it takes 30 days to make a new habit. So, just start moving more, gradually increase, plan to make the whole 30-60 minutes in 3 months. You will feel so much better about yourself, and your health will dramatically improve. If you can not run, walk, if you can not walk, bike, if you can not join a gym, watch YouTube videos on exercise routines. Make no excuses! As a sports medicine specialist, I try to take a patient and give them an athletic mind set whether they are an athlete or not. But, pushing through pain is not being an athlete, it is being an idiot!! Exercise in your comfort zone, gradually push yourself to new heights, and only very gradually set some goals. Goals can be a big reason people get frustrated and stop working out. Be kind to your self. But, Be Active!!!

Foot Strengthening After Multiple Foot Surgeries: Email Advice

Hi Dr. Blake,

I have had quite a journey that I never expected to deal with in my life time. I would like some advice about physical activity based on the surgical procedures I have had. When I was 20 yrs old, I had a routine bunion surgery on my right foot. Due to an ineffective surgery, the bunion returned and even had a bump on the top of my foot causing pain at the site of the bunion. I decided at the age of 30 to fix the problem so I ended up having another surgery where it was determined I had hypermobility and had the head of the metatarsal joint shaved down to fix the bunion. The surgeon also had two screws placed on the top of my foot to help with the hypermobility. Well, that didn't last long even though I was on non-weight bearing cast for 4 months as the problems returned 10 fold. I was running about 33 miles a week and general cross training. At the age of 40, I went to a Podiatrist and he could see several problems going on with my right foot. He determined that I do have hypermobility, hallux valgus and my sesamoid bones were completely destroyed. He had to go in and replace the greater toe joint with a Hemi toe implant, fuse the second toe joint, remove the sesamoid bones and remove the screws as they were causing extensive pain as they rubbed against my shoes. Ultimately after 3 surgeries, my left foot ended up having a collapsed arch and I had to have surgery to fix that with pins and a cast for 2 months. I have a bunion surgery for the left foot next summer (As a result my left foot is now 3/4" longer than my right foot!). So, I have had some problems with my feet you could say. =) I am a really active person, I use orthotics, hapad metatarsal pads, and I did receive physical therapy. So far, my right foot has been feeling good, however, I did have extensive discomfort while it was healing. My right big toe is stiff with limited mobility and it's difficult to move and PT helped in a limited amount. Due to my biomechanics in my feet have changed how my weight is distributed I do see some calluses on the outer edge of both feet, but is very minimal. I have curtailed my running and now use an elliptical trainer, I do engage in weight training and watch my diet.
What kind of activities do you recommend with all of the surgeries I have had? What other kinds of foot strengthening exercises can I do to continue my healing process and any recommendations do you have for me at this time? I have tried to find your blog on metatarsal doming, but with no luck. My podiatrist is excellent but I would like other opinions as well. I appreciate your time in reading about my extensive surgeries and you providing advice on my case. Thank you!

Dr Blake's comment:

Hey, Thank you so very much for the email. You are right to think about focusing more on non impact sports like elliptical, cycling, swimming, and moderate running. Sounds like your orthotics or changes in biomechanics have gotten you to the outside of your foot. Continue to work with the orthotic maker to try to keep you centered. The better your core, the less collapse into your arch you will have. The better your foot strength, the less stress on your bones and ligaments. You could easily improve your foot strength by a magnitude of 2 or 3 by daily going through 3 exercises each evening. I will place in my labels all the foot strengthening posts in a minute. I will also place under this email that I will officially post within the hour. I hope this helps. Rich

Ball of the Foot Pain: Email Correspondance

Dr. Blake,

    I have been dealing with left foot pain for over five months. I was placed in a boot for five weeks for stress reactions in the 1st, and 2nd, and 3rd metatarsals, followed by six weeks of physical therapy. During the physical therapy, the pain on top of the second metatarsal and bottom of the 1st metatarsal got progressively worse and the physical therapist ended up cancelling half of my sessions because of the pain. I also ended up wearing the boot again for two weeks and then a surgical shoe for two weeks during the last four weeks of the physical therapy.

    In the last two months, I have worn athletic shoes full time, minimized the amount of time on my feet, and started experiencing constant swelling over a two inch area down the entire length of the top of my foot. If I spend more than a few minutes on my feet, the pain on the bottom of the 1st metatarsal gets worse and worse. I have also periodically had shooting pain over the 2nd metatarsal when walking.

    I recently had an MRI, which showed marrow edema in the plantar and lateral margins of the 1st metatarsal head and nonspecific marrow edema in the hallux sesamoids. When my doctor initially reviewed the MRI images, he said it looked like I had an extra outer sesamoid. After reviewing other images, however, he decided that this was not the case as he did not see it in those images. There is a black jagged horizontal line through the outer sesamoid in three of the MRI images. Other images of the same sesamoid show no line. Is it possible that this is a partial sesamoid stress fracture? The doctor determined that I have sesamoiditis and told me to wear a metatarsal pad in my shoe for the next six weeks to off-weight the sesamoids. I tried the metatarsal pad, but it has made the pain significantly worse.  

   What do you suggest? 

                                          Thank you!

Dr Blake's comment:

    Hey, thank you so very much for the email. Typically, you have one source of all this pain (say a fractured sesamoid or first metatarsal head) and when treated improperly, the pain and swelling magnifies to involve a larger area. Swelling alone is no big deal since it is a reflection of a healing response of your body. Pain and swelling means you have not stabilized things well enough and healing is being somewhat compromised. Remember stress fractures are tiny cracks in the bone, hurt as much and as long as true fractures, and normally may not be seen other than the bone edema (swelling) noted on the MRI. Thus, the confusion of whether a black line is seen or not probably means stress fracture vs true fracture. Stress fractures on the bottom of your foot take a long time to feel better since first the fracture and then just the resultant bone edema hurt. 

    The things you need to do in the next 2 months are: make sure the inserts have maximal off weight bearing padding (called dancer's pads), make sure you have high and tolerable arch support, ice minimum 3 times a day for 10 minutes to keep cooling down the area, do a full 20 minute contrast bath daily and twice on weekends, learn to spica tape to stabilize the big toe joint, keep your legs strong with biking (you can rest the arch area on the pedal), weight bear to tolerance (all immobilization and non weight bearing can increase the swelling in a foot/weight bearing great for moving swelling, make sure your Vit D and Calcium are normal, eat healthy, use crutches, get a new MRI 3 months after the first, and hang in there for some of these injuries to completely heal can take several years and your job is to create a pain free environment to allow healing. Another 3 tests that could give alot more information are CT scan, bone scan, and CT fusion (which is a combination of the above). If insurance allows, and the way you are struggling, I would try to get more information also with one of these tests. I sure hope this helps. The information on all of this (like contrasts) is all within the blog. 

                                                                    Rich

Sesamoid Stress Fracture: Email Advice

Hi Dr Blake,

I am a 22year old British female 100m sprint hurdler and have represented my country internationally at various competitions both home and abroad. In September 2012 I switched my training group. 

The training load increased massively to what I was normally use to and within 3months my testing results had improved greatly my sprint times had dropped by half a second and lifting in the gym had gone from an 75KG PB for clean to a 90KG PB. However, January 3rd 2013 I woke up and was unable to put any pressure through my foot, a week later I was put in an air cast and 2 weeks after that I was diagnosed with a stress fracture in my sesamoid bone.
I was in an air cast boot and crutches for 9weeks in total adapting my training and doing aqua jogging, upper body and abb circuits only. After 9weeks the doctors felt it was time to come out of the boot and start walking but continue with Aqua jogging and introduce Watt Bike sessions and progressing to jogging/low intensity running on the grass.

4weeks ago I had specific insoles designed to off load my sesamoids which have helped a lot and I'm also working closely with my podiatrist using a monitoring sheet to write down my pain scores each day after sessions and throughout the day.
After doing grass sessions my foot always reacts 2days afterwards reaching pains of 5-6 and settling again after a further 2days. On average I always have a constant pain of 2-4 and randomly will get sharp pains every now and then. On Sunday 9th June 2013 we decided to progress my training from the grass to the track but still at an intensity of 70% and 2 days afterwards my foot reached a pain of 8 with throbbing/ swelling and as of yesterday it has only really settled properly again.

I feel that I haven't really ever completely rested and given my foot chance to heal as the doctors have said its fine to do bike and pool sessions, and I just feel so confused as what is the right thing to do. I know that I do not want surgery on removing the sesamoids but I feel that I'm stuck and my foot isn't completely heeled and I fear that I'm not letting it has its always at a pain level 2-4. I'm not sure if the right thing to do now is have a complete month off it and don't do any training wise at tall and the only loading will be daily activities on it with my insoles in my trainers or if infact what I'm doing now isn't making it worse and is still helping the heeling process.

I asked a close family friend who is the Head Radiologist and a Consultant for Professional football players and he replied saying;

Hi, sorry to hear it has not settled yet . Have spoken to a couple of professional physios and they also think you can't do much more to let it settle down than you are already doing . Another scan will not help, if you are in pain then it has not heeled up yet. Also follow up scans can be very difficult to interpret, because the sesamoids will look very odd. The only option if conservative management doesn't work is surgical removal , which is seldom done or necessary. Maybe complete rest till Sept may be the best option, given that most activities produce pain. I suspect you have done an Internet search, which offers similar advice.
Good luck

After coming across your website in the early hours of this morning and reading your blogs and advice I decided to email you to get your opinion on what you suggest I do. The winter season starts in September and I want more than anything to be able to train almost pain free. Should I have a month off and see how it reacts, carry on with what I'm doing now or is there anything different I can do?

Please could you help me.

Dr Blake's comment:

     Thank you so very much for your email. I am sorry to hear about the stress fracture, and unfortunately, they can remain sore for months and months after they are healed and strong enough to run with. That is because of the bone remodeling that occurs for up to 1 year from the time of the complete healing. That bone remodeling leads to bone swelling which hurts. The patient and doctor and physio are always perplexed at how much healing has occurred during this time. 

     These are the essential things you can do for the next 3 month segment of time. Train with all the great strategies except barefoot running (non-orthotic) as much as possible. Bike, Bike, and Bike some more for great leg strength. Run with shoes that fit your orthotics and have them make a pair with more arch and more dancer's padding to see if that is better protection. Ice, Ice, and Ice some more. 10 minutes of ice pack while you do something else could be done 10 times a day, 3 minimum. I like at least 1 session of contrasts per day. You must get rid of the bone inflammation as best as possible, so that the pain you are experiences is fracture pain. Just this tends to bring the pain down 2 to 3 levels, so your 2-4 hopefully will become 0-2.

     Make sure that your Vit D3 and calcium are all great, and your diet healthy. If you are not a red meat eater, our clinic recommends two 4 ounce serving of red meat weekly. 

     If you have had an MRI, you really should wait for 6 months to get another to check healing. I am happy if you send me a copy of some of the images T2 weighted that look close to the ones on my other posts. I get an MRI to confirm the diagnosis, check if there is anything else wrong, and have a baseline if I need it in 6 months. 

     You definitely need to Listen to Your Body and create that pain free (0-2) environment for the next 3 months. Follow the advice above, learn to spica tape, run if you can (sounds like you were smart except for the barefoot part), and give me a monthly progress report. As you begin to run in spikes, remove the one directly under the sesamoid please.

     Sure hope this helps. Rich

Post Sesamoid Removal with a Unusual Twist of Cartilage Removal: Email Advice

Dear Dr. Blake

     I had to have a sesamoid bone removed, the one where the incision is on the side of my foot. I also needed to have cartilage removed because it was dead or dying due to the injury. I had to wait 6 months after the injury for the surgery to get approval.

    Now, it is very painful to walk and my great toe joint is bending back and to the left. I use my hands to move it every night. But every morning it is so stiff and it is painful when I am bending it. Is it possible that during the surgery one of the tendons was accidentally cut? 

    I had the surgery in march 2013 and I still do not have normal sensations in the toe. It is partially numb and feels tingly when I touch it. If I am on my feet and fairly active it swells up, turns a bluish color on the top of the great to joint, and the pain gets worse. I always ice it in this case. MY question is I have a job that requires me to be on my feet for most of the day. I must wear boots as well and I dont think my foot would even fit into my work boots. Are these symptoms normal for the surgery ? When can I anticipate being 100 % Thank you for your time Doctor.

Dr Blake's response: 

    Thank you so very much for the email. You had major surgery on your big toe joint that may take several years to mend. Since you had cartilage also removed, the healing pattern is not as predictable as just removing a sesamoid. Basically you have an arthritic joint, and everyone is hoping you can walk on the damaged bone afterwards. See if you can push to get an MRI and send me the disc or email me some images. If you get to that point, I can help you decide which ones to send, but you can look at typical MRI images for Hallux Rigidus in my blog. 

     Start working with the podiatrist/orthotist to get boots 1 size longer so you have ample room to fit a protective orthotic device in there. Ice for 10 minutes twice daily the bottom of your foot, and do contrasts baths once daily to remove deep swelling within the bone. Massage into the area Neuro-Eze twice daily to help with the abnormal nerve sensations. I hope this helps some. Rich

PS We always must assume that the surgery was done correctly and that the expected outcome is for full recovery. However, complications of some sort occur in 10% of all surgeries (mostly minor). If your surgeon did not paint a doom and gloom picture after surgery, they are expecting complete recovery. However, you need to respect your symptoms and gradually increase activity, as you create a pain free environment, and work on the inflammation. Hopefully you are in shoes, removable boot, inserts that are protecting it as you walk. From there, you can safely and gradually add more motion and less protection, but you have to find out exactly what it takes to get pain free at this point. 

Nerve Sensitivity Bottoms of Feet: Email Advice

Hello,
I broke both heels six years ago and had pins and plates installed in the calcaneous.  I'm not having subtalar joint problems so far, but I'm having a lot of what seems to be nerve pain/sensitivity on the bottoms of my feet.  This sole sensitivity has increased over the past few years.  I'm not having numbness or tingling, mostly my soles are super sensitive.  I suspect I have nerve damage or irritation, and wonder what I can do to decrease the sensitivity.  I have even resorted to making my own shoes because I need very soft inner soles. Store-bought shes are too hard.  Thanks.

Dr Blake's comment: 

Brian, Thanks for the email. Nerves typically love some form of salve (I typically start with Neuro-Eze 3 times a day), gentle but firm massage, heat over cold (but there are exceptions), and motion over immobilization. Consider buying a 3 mm sheet of J-Gel from JMS Plastics to cover the insert you are wearing. This should get the nerve sensitivity improved. Hope it helps Rich

Article showing Effectiveness of 10% Efinaconazole for 48 weeks topical for Fungus Toenails

This is a very promising new medication awaiting full FDA approval for toenail fungus. 

http://dermatology.jwatch.org/cgi/content/full/2013/426/1?q=pfw-featured&eaf

http://www.podiatrytoday.com/could-efinaconazole-10-have-impact-onychomycosis

Wide Feet: Brooks Dyad 7 comes in 2E and up to Size 12 for Women

One of my patients is in love with her Brooks Dyad 7. They come in 2E and it really helps all the pain in the front of her foot (metatarsal area) from traditional width shoes. They are neutral athletic, so not for running if you are a pronator, but basically stable. Pronators or Supinators who run would want an orthotic device to neutralize those tendencies. I have also attached 3 videos that show various shoe lacing tips to help with fit or stability or both. 

Sesamoid Injury: Flip Flop Modification and Email Advice

This patient has had a sesamoid injury under the ball of the foot on his left side. We have had a few correspondences.

Hi Richard,

how are you? As agreed, here's some update:

doctor told me it was too early to start to run a bit so am still not running.

I now wear flip-flop with a hole in the sole. Much less pressure than in a shoe (see pic attached).

I did an MRI last week that showed less inflammation but still too much.

I had a PRP injection.

In 3 months time I will have another MRI. If it's still not sorted out, bone will be removed.

Would you have any thoughts/advice?

Tks and rgds, Paul (name changed due to witness protection).

Dr Blake's comment:


   Paul, brilliant idea about the flip flop!!! Over the next 3 months, gradually increase your activity each week slowly but progressively. Ice 3 times daily to control the inflammation. Start the Walk Run when your doc feels okay. Continue to stay in the Good Pain side of the problem. Give me monthly feedback. Stay good with your Vit D3 and Calcium. Rich 

Good luck!!!

Improving Pronation Control with Kirby Skives and Medial Column Corrections

When you dispense custom made orthotic devices, you should evaluate the stability they contain separately for the right and left feet. Be somewhat critical of your great prescription writing, and grade yourself on how well you have done. When you are trying to control pronation forces, and the orthotic device dispensed work well on one side vs the other, try to get the function as even as possible. The body loves symmetry. This image shows that the right orthotic device is being marked for 10-15% more pronation correction. The K means adding a Kirby Skive and the MCC means adding a medial column correction. Medial Column Correction stands for more arch support. These are plaster modifications applied before the plastic is heated and pressed. 

Compression Pumps: Source for In Home Reduction in Foot/Leg Swelling

So many of my patients have such swelling in their legs and need some elevation, some support hose, and a daily hour for compression with these compression pumps. Here is a great source I just learned about through a colleague. 

http://www.spectrumhealthcare.net/products/compression_pumps

Crazy Driving Through the Streets of San Francisco

http://www.youtube.com/watch_popup?v=LuDN2bCIyus&feature=related

Hi Rich,

The SF car driving was insane!!  Fun to watch though.  I was thinking “is he late for an appt. with Dr. Blake”? 

tami

Inverted Orthotic Technique: Preventing Cracking of the Positive Mold on Pressing

Here is the Anterior Platform being placed on the positive cast set at 25 Degrees Inverted. As the Platform begins to dry a wet tongue blade is placed into and will form a bridge across the platform/medial expansion.  A line is placed where the tongue blade will be eventually scored and cut off.  Tongue blades are also placed inside the plaster while making the positive cast. 

This image is the same as above but shows the tongue positioning better. The blade must be cut so that the shape of the medial expansion is normal. 

Here the tongue blades are allowed to soak in water before using. The soaking makes the tongue blades absorb water and be more consistent with the plaster they are trying to blend into. The harder and dry the tongue blade, the more it pulls moisture out of the adjacent plaster, making a potential area to splinter during the press. 

Lyrica: A Program to Gradually Get Used To This Neuropathic Drug

Lyrica (pregabalin) is one of the main drugs used in neuropathic pain. Neuropathic pain is pain from nerves, it is probably/is the worst of all pain, and the patients truly suffer with this type of pain. The pain, when originating in the nerves, have a direct path to the brain heightening the pain syndrome. Lyrica, like Neurontin (gabapentin) works to stop the flow of the nerve stimulus to the brain quite differently than opioids, and without the addictive qualities. Lyrica is normally twice daily, but can be used 3 times daily, and has a maximal dose of 300 mg per day. Below is a typical gradual process of getting use to the drug, although many go much faster. The side-effect of drowsiness is more prevalent as you get use to the drug in the lower doses than at the higher doses. Typically, if I can ease the transition onto the drug gradually, my patients can avoid much of the side effects. The AM dose should be done around 7 am and the PM dose as soon as you get home in the evening for good (latest 7 pm if you arise between 6-7 am). It is a 12 hour drug and you want the PM dose to be out of your system when you have to function in the morning. 

Week I (weeks can be changed into 4 day periods):       No AM dose                 25 mg PM

Week II:                                                                        No AM dose                 50 mg PM

Week III:                                                                       No AM dose                 75 mg PM

Week IV:                                                                         25 mg AM                   50 mg PM

Week V:                                                                          25 mg AM                   75 mg PM

Week VI:                                                                         25 mg AM                 100 mg PM

Week VII:                                                                        50 mg AM                   75 mg PM

Week VIII:                                                                       50 mg AM                 100 mg PM

Week IX:                                                                         50 mg AM                  125 mg PM

Week X:                                                                          75 mg AM                  125 mg PM

Week XI:                                                                         75 mg AM                  150 mg PM

Week XII:                                                                      100 mg AM                  150 mg PM

Week XIII:                                                                     125 mg AM                  150 mg PM

Week XIV:                                                                     150 mg AM                  150 mg PM

Of course there are many versions of this. At times, based on symptoms and symptom relief you stay at a certain level. Each new level requires time to see how it is helping the overall neuropathic pain. Since most of your healing of this problem, like so many other problems, occurs at night during REM sleep, the medication dosing until the last level is always more during the evening. Dosing like this one requires an initial RX of 25 mg to see if you can coexist with the drug, then soon after, two more prescriptions of 25 mg and 50 mg that you can mix and match to get the right dose. 

The goal of all this is to find a level of drug that reduces the neuropathic pain to a level 0-2 consistently. Whatever level that is, you stay at that level for typically 3 months, and then you gradually, every 4 days, go backwards down the slide. If you get to a level and the symptoms flare, go back up 2 levels and stay there for several weeks, and try to go down again. There are many versions of all this. 

You can see quite easily that making a decision to use this drug is quite a committment. If you get to the highest level, or the highest level you can tolerate without adequate pain relief, it is common to add other drugs to the mix. For those patients who can not tolerate Lyrica, Neurontin can be tried. Some patients respond more to one than the other. 

I hope this has been helpful. Lyrica has been a wonderful drug for so many of my patients, but getting on and off can be such a challenge that many patients stop taking it. It is common for patients to be started at 75 mg twice daily, and have such a bad experience, that the drug is stopped unnecessarily. This is an option to an easier way to get used to the drug.               

Beginning Yoga: Unbelievable Benefits for Healing Injuries

Practice one pose a day and you will get stronger, more flexible, and more centered with your injury.

Inverted Orthotic Technique: Current Research Project

I will be working on a research project that involves the Inverted Orthotic Technique. It is of course my privilege and honor to study this orthotic modification I invented 32 years ago. I use it daily in my practice, but have never had the finances to teach more than a handful of orthotic laboratories or keep them up with all the changes to prescription writing that has occurred in the last 25 years. 

What is the Inverted Orthotic Technique? It is a wonderful way to control pronation of the foot when the amount of pronation is considered either abnormally too much, abnormally too fast, or the pronation just places the foot in an abnormal position. Following a brief introduction of the technique in Australia, 17% of all of the orthotic devices prescribed were this technique. That was in 1990, so who knows now?

Here are some photos from my first patient in the study. This patient is a severe pronator. I will never see the patient, and my technique is being compared with another technique, and being critiqued on how well it stabilizes the patient. During the research design, those involved decided on 25 Degree Inversion Correction, 35 Degree Correction, and 50 Degree Correction as the 3 orthotic devices to be made for this patient with the 2 techniques. It is a double blind study, or at least single blind, since I will never see that patient. These degrees of correction are equivalent to 1/4" correction, 5/16" correction, and 3/8" correction of the foot. If you use standard beliefs, the knee position of this patient walking would be corrected 1/2", 5/8", and 3/4" (so very significant). I developed the technique working on knees. 

Here are the 3 sets of casts from the same patient.

These 3 sets of casts are set to Invert them 3 different degrees.

The nails used set the casts at 25, 35, and 50 degrees of Inversion.

Good Foot Strengthening Video

This is a great exercise to strengthen your feet. You can actually use rubber bands, but some width to the band makes the exercise more comfortable. Please add this to the other foot strengthening exercises I have on this blog. 

Integrated Solutions to CRPS Conference Notes Part IV

This is a continuation of my notes from the wonderful healing conference on CRPS (Complex Regional Pain Syndrome)

Muscle relaxants typically do not help

Neurotropin

Made and Used in Japan

Helps with allodynia (where you touch the skin and it feels very painful to the patient)

Service dogs are a major help for these patients in chronic pain

When  performing Surgery on patients with CRPS

Gabapentin or Lyrica starting 2 weeks pre surgical and minimum of 8 weeks post surgical

Synera patch should be placed for 30 minutes over IV area (before the needle stick)

Minocyline after with the gaba or lyrica for 8 weeks

Hospital Chart must be marked to be very careful in handling the involved extremity

IV ketamine Infusions should be done with chest port, PICC line not good

Child  with CRPS you need to rule out behavioral disorders first

With RSD, they may have ED, mitochondrial disease, nerve entrapment

Everything on website

http://www.rsds.org/index2.html

Netherlands Guidelines for CRPS: Severe Neuropathic Pain

You can see I have alot of information on CRPS (Complex Regional Pain Syndrome). I have 5 patients with it and I am trying desperately to help them. At a recent conference, this treatment guideline protocol from the Netherlands was highly recommended.

http://pdver.atcomputing.nl/pdf/CRPS_I_Guidelines.pdf

Biomechanics of the Foot: My Love of Teaching

     I have practiced the subtle art of podiatric biomechanics within the world of sports medicine and injury rehabilitation now for 32 years. I believe I have helped most I served, with some exceptions. After my podiatric medical school, I did a one year medical/surgical residency and then a fellowship in biomechanics. I earned my Master's Degree in Education teaching podiatry students the art of the biomechanics. I would have fun walking across the front of the auditorium with ping pong balls taped to various body parts so that I could teach the normal motions that occur in gait.

     My basic need to teach has brought me to this blog in 2010, but started in 1979 with teaching Biomechanics III to sophomore students at the California College of Podiatric Medicine (CCPM) in San Francisco. From 1981 to 1992, I taught the Sports Medicine Spring Semester course also at CCPM. From 1981 to present, I have lectured on podiatric biomechanics and sports medicine throughout the United States, and internationally in Australia, Canada, and England. I have wrote over 50 published articles in this field and attempted unsuccessfully to write a full text book. In 2011, I was honored to be given the chance to teach sports medicine again to sophomore students at Samuel Merritt University in Oakland California. I just finished my third year and it is great to be back with the students. 

    My legacy will always be a type of orthotic device I invented in 1981 while beginning to work at Saint Francis Memorial Hospital's Center For Sports Medicine in San Francisco. It is called the Blake Inverted, the Blake, or the Inverted Orthotic Technique. I have worked there for 32 years now attempting to understand alittle more each year how the foot works and how to fix it when broken (not necessarily literally). While frustrated over helping a patient with knee pain, I changed the orthotic RX forms forever. The standard maximum correction of the foot was 4-5 degrees of varus (arch is raised) forever that we know. Over that amount would cause the foot to roll outwards too much (excessive supination) and produce a variety of injuries. This was an accepted fact. To help my patients with stubborn problems, I have gone past 60 degrees of correction. 1000's of patients have been helped, most did not know the historical significance of the type of orthotic they received, or the name attached. They were just getting their orthotics. 

     Even though the Inverted Orthotic Technique is part of me, and now part of podiatry history, it is only a small small part of what it means to have a biomechanically based podiatry practice. When you practice biomechanics, it means you are always thinking of the possible mechanics behind every injury, every pain, every surgery, every bump on the foot or leg, every step that the patient takes, every move they make on the reformer in pilates or the basketball court. Why do they hurt themselves? Poor mechanics are sometimes the sole source of the problem, or a slight contributory factor affected the rehab. 

     I hope in the weeks and months ahead, in these postings on the Biomechanics of the Foot, to begin to share with you, my readers, the subtleties of this art. I love the art, some hate it. I make 400 pairs of custom orthotics for patients each year, some podiatrists none (because they hate them). Podiatrists are trained to treat the biomechanics of the foot and ankle. This is so much more, so much more, than orthotics. It is toe separators for bunions to align the joint, the proper biomechanically sound way to stretch a tendon, or strengthen a muscle, the proper taping technique, or the mechanics of dunking a basketball (one feat I will never do until it is worth 3 points). What about the mechanics of various athletic shoes that must be considered? So many things. 

     I hope this is interesting. I hope to help my patients to think about why they hurt and can they be part of the problem. Can they do things (training, shoe selection, diet, icing, etc) differently to improve their chances for long term activities and a much better quality of life? Thanks for walking with me.

Neuroma Injections: Questions regarding Alcohol shots

Hello Dr. Blake,
I have a neuroma in my right foot. Had three cortisone injections and they did not work. I will be getting my fifth alcohol injection this afternoon. The pain is about 75% gone. What would you recommend I do next if today's injection doesn't get me to 100% relief? And how long should I wait to judge the overall effectiveness of the alcohol shots?
Thanks very much.

Dr Blake's comment: 

     Thank you so very much for your comment on my blog. Whereas cortisone shots are typically done as sparingly as possible (three is a good number to try), alcohol shots are done in series of 5 one week to 10 days apart. The goal of the alcohol shots are to decrease the nerve sensitivity and hopefully destroy the nerve (in this area you only lose a small amount of sensation between the toes and no motor function loss). 

     The goal of any treatment modality (and this applies here) is to reduce the pain 80% where the pain level can be maintained day to day between 0-2. 80% better is where you can increase your activity gradually. You still need protective inserts to off weight the nerve (some form of orthotic device or one of the many variations of metatarsal pads). It sounds like you are probably there, or close enough. I would continue icing 3 times a day for 10 minutes each, and continue not to go barefoot. Give the month of June 2013 as a test to see what really happened with those 5 alcohol shots while you gradually increase your activity and give the tissue injected a rest. 

     When you go through the month, you should also consider Neuro Eze or another compounding gel to massaged 3-4 times daily to keep the nerve calm. By 7/1/13 you will have an idea where you are at. If you are alot better overall, but the pain level has gradually increased, you are a candidate for another series mid July to late August--lucky you. In my practice, when I am using alcohol 50% need a second round, and 10% need a third round. And, the bigger the neuroma on MRI, the less likely the shots will work totally--but I would always do before considering surgery. 

     I sure hope this helps. Rich

Fractured Sesamoid And Possible Avascular Necrosis: Email Advice

Hi Dr. Blake,
I have a fractured left tibial sesamoid. It probably started as a stress fracture from running in a new pair of shoes last September. I didn't get an x-ray until January, at which point it was shattered into 3 pieces. My first doc (sports med) told me it would never heal and that I'd need to learn to manage the pain. I pushed back against that a little, and he suggested no running for 8 weeks and a follow up x-ray. The follow-up showed it still fractured, so he sent me to a podiatrist for orthotics for pain management. 

The podiatrist put me in an air cast and prescribed an exogen bone stim machine. Unfortunately, insurance made me wait until the 90 day point to get the bone stim machine. So, I wore the cast, partially non-weight bearing (anything outside the house I did on crutches) for 6 weeks, and waited for the bone stim machine. Got the the 90 day x-ray and it showed, "further deterioration." I've now been using the bone stim machine for 30 days and got the follow up x-ray to see if it's working. The bone is still further deteriorating and my doctor suspects avascular necrosis.

I'm scheduled for an MRI on Monday to get a better look at what's happening. But, he's saying that the chances of healing are minimal at this point and that the best case scenario is that my body absorbs the dead bone and I can avoid surgery. 

Thoughts on that?

I don't have direct access to my x-rays, but I have seen them and there is a clear progression of the sesamoid becoming fainter and fainter on x-ray, to the point that this week's x-ray it's hard to see the contours of the bone.

Thanks for any feedback.

Dr Blake's comment:

     Thank you so very much for the comment. You are doing all the right things right now. The bone stimulator should be used for 9 months total, while you continue to ice, wear orthotics, spica tape, and gradually increase your activities (keeping the pain between 0-2). In this case, you may have lost the sesamoid, or it may be just demineralized due to non weight bearing (like the astronauts!!--bad joke sorry) and surrounding fluid can make it look non existent. Take it one month at a time continuing to see what you can do to increase your activity painlessly. Give it the full 8 more months. Don't keep getting more xrays, they lag behind in the actual healing. The MRI is better right now, but it is only the baseline for one 6 months later to check progress. Good luck Rich.

BTW: How is your bone density and Vit D3 levels? Probably a good time to get this checked out. 

Hallux Limitus: Successful Conservative Treatment Email

Dr. Blake,

I am only commenting on your blog because i want to simply say thank you. Why? Well, you seem to be one of the very few physicians willing to comment on hallux limitus and rigidus without a pre established agenda. No offense, but I went to see an orthopedic and two podiatrists each of which were selling me a surgery and had me under Anesthesia before the xrays lights went off. Neither suggested any of your conservative approaches before surgery was offered. I found that terribly odd. My pain was bad but i felt there should have been something else said/suggested. After reading your blog and your YouTube videos i learned more about limitus (which i realize i have) and ways to calm the joint down etc. As you said, "it should be treated as a sore joint. Nothing More."

http://www.drblakeshealingsole.com/2010/08/hallux-rigidus-surgery-or-no-surgery.html

I have full Motion in the joint with the small "bump" on the big toe but inflammation after running and power walking etc, Stiffness in early mornings etc. But Spica taping helps as well as whatever else i learn from your info. I think my initial battle was accepting that my body was actually getting older and that's the hardest thing for me. Truly. I'm 39. If/when my condition gets to an unmanageable/intolerable point I'll fly to SF from Chicago and give you a visit without hesitation. Meantime I'll continue following your blog and implementing the advice. Again, thanks.

Dr Blake's comment: 

     I am so happy to hear wonderful responses. Thank you very much. There are too many protocols and cook books, and by gradually applying the sports medicine principles of creating a pain free environment, protection (like with the spica taping), anti-inflammatory like 3 time daily icing, off weighting the sore area, etc, so many problems can be minimized. When there is pain, and our ability to participate in the activities we love, it is sometimes very hard to make a good decision and avoid surgery. You were so smart to get 3 opinions, and very unlucky that they didn't give you options for conservative treatment. I am so happy and proud my blog helped. I wish you the best. Rich