Thursday's Orthotic Discussion of the Week: Pouring the Negative Cast and Building the Anterior Platform for the Inverted Technique

Dear Dr. Blake,

Thank you very much for your blog and for this post ! I've read with great interest your post from Podiatry Arena and, as a self educated person [in my country doesn't exist podiatric schools] I want to tell you that your post is one of the best, expecially from a practical point of view !

 I have a question which maybe seems stupid for you and I apologies for this. I personnaly have difficulties with anterior platform building so I kindly ask you to give me some instructions regarding the composition of the pink plaster from photos. In my practice I make it either too fluid or too rigid and simple I didn't succeed to build the anterior platform in the way you have described here !

I'm expecting with great interest March, when you'll post your manual !

Thank you for your kindness !
Respectfully,

Robert (name changed)
Romania

Dear Robert,
     I am always honored by getting emails and compliments, and especially from so far. Thank you so very much and I hope I can help. Here are some photos that I hope will help. More questions are encouraged.

Here is the initial set up for pouring of the negative casts to make them a solid positive cast. The most important part of the photo is my coffee cup since it is 6:30 am on a Saturday morning. One basin is for the soap solution and one basin is for the casting plaster to be used in making the positive cast. 

For 2 feet I am pouring the plaster to make a positive cast I use 5 cups of plaster and 3 cups of water. There is the 1 cup volume rubber pouring bowl. For 2 pairs of feet, 4 total, I will use 10 cups of plaster and 6 cups of water. The basin I use holds up to 15 cups of plaster. 

This is the Casting Plaster I use with 30 minute Set Time. 

It is also called Red Tag 30. 

I use a one cup bowl, but you can buy these bowls that hold 5 or 10 cups at once to make life easier at times. Here the plaster is in the bowl and will be emptied into the basin to begin the process. 

I have fillled the basin with 10 cups of plaster good enough for 2 averaged sized pairs of feet. If both your casts are for sizes 12 or greater, consider 12 or 13 cups of plaster. The water ratio is still 60% approximately the plaster amount.

I buy a soapy concentrate and dilute with water 50%. This is poured into the negative cast to saturate the bottom and sides. Any extra soap is allowed to drip out and returned to the bottle. This makes it so much easier to get off the negative casting material once the positive is dried. 

Here are the negative casts after having been soaked thoroughly with the soapy solution and then being tipped over to allow the soap to drain. 

The negative casts are then leveled so that the heel bisections stand perfectly vertical when poured. This is done with every cast so that the top of the cast represents a parallel with the ground. 

Here my talented brother Bob is pouring water in a 60% ratio to the plaster with some colored dye to make the plaster solution for pouring. One pair of casts typically need 5 cups of plaster and 3 cups of water. 

The plaster (mud!!) is mixed thoroughly to get out any clumps of plaster so that the solution is a uniform consistency. 

Plaster clumps are completely broken apart

Then the very smooth consistent liquid plaster is poured into the balanced to heel vertical negative casts.

My great brother Bob skillfully pours the plaster to make the positive casts set a heel vertical.

Here the negative casts sit after the plaster is poured

Typically you can pour up to 3 pairs of casts in one basin. That basin would have 15 cups of plaster and 9 cups of water.

Once the negative casts are poured, it is important to recheck the heel bisection to make sure it has remained vertical. 

After pouring, sticks are placed into positives to minimize breakage with the high pressure vacuum press. 

Once you remove the casting plaster, the first and fifth metatarsal areas are marked to define the anterior platform borders. You find the contact point on the first metatarsal (lowest point) and then place the line 15 mm closer to the arch. I like to then even the 5th metatarsal platform with that line, but the fifth metatarsal is normally a little shorter. The vertical lines are in the space between the first and second metatarsals and the 4th/5th metatarsals.

Here you can see the proximal line 15 mm from the contact point. This will be where the plastic of the orthotic device ends. You do not want the plastic to run under the weight bearing surface when walking or running. 

Here the nails are placed on the platforms to make the angle for Fettig Modification of the Inverted Technique. Here the medial nail under the big toe joint will set the overall inversion and lateral nail under the fifth metatarsal head for the forefoot valgus correction.

When I am working with plaster, I typically have 2 or 3 bowls going at once. The plaster has to be right, not too runny and not to solid, to apply and shape. It takes time to learn your plaster. I try not to stir it much, for stirring will make the plaster harden faster. I try to pour off the excess water once the bubbles stop, for too long with excess water makes the plaster to take forever to dry. 

I use wooden sticks soaked for 10 minutes or so for making the transition from anterior platform to the medial arch fill more solid during vacuum press. The high pressures can break the platform away from the medial arch without the sticks in place.

After the nails are in place, and the plaster the right consistency, place a piece of paper down to make the anterior platform. 

Gently stir the plaster to check the consistency

It is so important to play with the plaster and know it's consistency

and play some more!

And more

I place dye into the plaster to make the various parts of the positive cast stand out

Mix it in well

When the plaster is ready, place it on a piece of paper and press the positive cast gently down. It is important not to push too hard to distort the nails. It is important not to push too lightly and lose the angle set by the nails.

Here the anterior platform area of the positive cast is coming in contact with the plaster mound

Gently, but firmly, I press the positive down into the mud

Then I use a spatula to make the medial and lateral edges straight up and down.

It is important to check your angles, if off from what was ordered, immediately knock off the platform and start all over again.

This photo is out of order but shows the positive casts, after being poured, drying for 1 hour in the sun. 

Here the wooden stick is placed into the anterior platform to set further strengthen the area before pressing. The total length of the stick coming out of the platform and into the arch will be 1 and 1/2 inches in general.

Another view of the stick

The platform is being formed following the lines on the positive cast.

When cutting the anterior platform, keep the spatula moist with water to allow easier trimming.

Do not lose focus on the shape of the platform desired and outlined by those lines 

The medial and lateral sides will still need to be trimmed to go straight up and down from the positive cast.

Another view of the 20 degrees Inversion with 6 degree forefoot valgus in the Fettig modification of the Inverted Orthotic Technique.

Trimming of the sides with scrapper

Final product with anterior platform with medial and lateral expansions.

Wednesday's Article of the Week: Possible Future of Synthetic Cartilage Injections in the Big Toe Joint for Hallux Limitus/Rigidus

The article below discusses the complex world of research around Synthetic Cartilage injections for Hallux Limitus/Rigidus. Every Podiatrist is waiting anxiously for approval of a synthetic substance to act like a new cartilage pillow within the big toe joint when injured. In this proposed study, intra-articular Hyaluronan (Synvisc) would be injected into every other patient and sterile saline (salt water) into the other 50%. Everything else would be equal. It would be the only treatment for a 6 month period. Patients would be evaluated many ways:

• pain levels
• function levels
• pain with walking and at rest
• amount of stiffness in the big toe joint
• amount of measured big toe joint dorsiflexion
• plantarflexion strength across the big toe joint
• global satisfaction to treatment
• overall health related quality of life
• magnitude of symptom changes throughout the day
• use of pain relieving medications
• changes in measured pressures in walking of the ball of the foot

Data will be collected at baseline, 1, 3 and 6 months

Up to 3 shots will be given each patient based on symptom relief

Data will be analyzed using the Intent to Treat Principle and other common forms of objective testing.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2636797/?report=classic

Dancer's Pads used to off weight Hallux Limitus/Rigidus when it is sore to put weight on the big toe joint.

Tuesday Question of the Week: Fractured Fibular Sesamoid under the Big Toe Joint

Dr. Blake,

Thank you so very much for your willingness to hear my story!  That alone means more than you know.  Here it goes.

I picked up running in 2011, ran my first half marathon in 2012, and did two more by May 2013.  I started having slight discomfort from the arch of my right foot up to my big toe (mostly when I flexed it) in December 2012. It felt like a sore muscle, so I chalked it up to bad shoes (changed them) and ran through it.  I never expected to be told there was a fractured bone in my foot.  The discomfort was intermittent at best, bothersome but not very painful.

I finally saw a podiatrist in September 2013 as a precautionary measure before training for another race.  He took x rays and told me my fibular sesamoid was fractured. 

The sesamoids are two little bones under the first metatarsal head in the ball of the foot that consistently get injured. In this MRI image (not this patient), you can see how they stand between the ball of the foot and the ground. The arrow is pointing to a bursitis (fluid sac) which was misdiagnosed as sesamoid pain. 

 I was put in an aircast for 6 weeks.  At my second follow up appointment he told me the bone had healed and cleared me to run and wear heels again. 
Dr Blake's comment: Rarely, maybe this fast, but typically 3 months in removable boot, and 1 to 1 and 1/2 weeks to wean out of the boot into protective orthotics and shoes. 

 He gave me no instructions regarding how to safely get back into running. I tried to ease into it slowly by run/walking short distances with a stiff soled shoe insert he gave me and an ace bandage with a gel cushion under the ball of my foot. 
Dr Blake's comment: I like dancer's pads much better, minimal under the sore bone, and more under the 2nd to 5th metatarsals. 

 That was late October.  I ran a little here and there throughout November and early December 2013.  The dull discomfort was less noticeable than before the boot, but it came back after I'd run a mile or so.  I stopped running and decided to see a different podiatrist.

The new podiatrist took x rays the week of Christmas 2013.  She could tell the bone was cloudy looking but couldn't say whether that was calcification or something else.  She suspected avascular necrosis and ordered an MRI.  Upon reviewing the radiologist's finding (my understanding is that she never reviewed the actual images), she said the bone was beyond healing and that my options were surgery removing the bone now or surgery later, whichever was more convenient for me.  She told me to run my heart out and that it would eventually bother me enough to want the surgery.

Dr Blake's comment: It is so hard to make that ascertain. I would start you on a bone stimulator from Exogen, get your biomechanics in order, and see how the next 9 months went. 

To get another opinion, I saw a well-regarded orthopedic surgeon in Dallas on Jan 23, 2014 who specializes in foot injuries.  He took an x ray and said the bone looks unhealthy.  He also reviewed my MRI but mumbled something about the cuts being 4millimeters apart and not terribly helpful.  He said that unless I stop running entirely, surgery is likely inevitable.  He said I could go back to running now because I won't make the situation worse (what?! how is that possible?).  He gave me no instructions for caring for the injury and said to call him if/when the bone bothered me enough for surgery.

Dr Blake's comment: Yes, you can make the problem worse. Fractured sesamoids can produce damage to the underside of the first metatarsal leading to a hugh mess, and a longer recovery time. Spend 2014 trying to get this injury healed with activity modification creating 0-2 level pain, orthotics to off weight, bone stimulator daily, icing twice daily, contrast bathing once daily, spica taping when you are going to be athletic to protect, 1500 mg Calcium daily, and 1000 units Vit D3. 

Dr. Blake, I have never experienced the pain many of your patients have.  My pain is minimal at best, and basically non-existent at this point, as long as I'm not running on it or wearing heels.  Surgery seems dramatic and it scares me, both because of the initial pain involved post-op and the unpredictable nature of the outcome.  But I miss running, and being inactive is weighing on me.  

Dr Blake's comment: The athletic part of your rehab program should not emphasize impact sports or too much toe bend. But, you should run every other day with good orthotics and dancer's pads, even if it is only 5 minutes to develop a baseline. You must stop running if the pain comes on during the run meaning you hit the threshold of injury. Pushing through that type of pain can injure you further. Cycling, swimming, and swimming should all be good, with a little modification if necessary. 

My questions for you are:

1. What is your assessment? Dr Blake's comment: Listen to your body for we need to protect these bones. I am happy to look at your MRI by mailing to Dr Rich Blake 900 Hyde Street, San Francisco, CA, 94109. 
2. Can a sesamoid bone with supposed AVN be healed?  If so, how? Dr Blake's comment: An AVN is still fixable if the bone does not collapse. Bone collapse can be helped with bone stimulator, pain free protected weight bearing, calcium and Vit D3, contrast bathing and icing daily. 
3. Will a bone stimulator help at this point? I had not used one before seeing any of these doctors, but a co-worker offered to lend me her Exogen device.  I started using it 20 min-daily a few days ago. Dr Blake's comment: Definitely 2 sessions of 20 minute with the Exogen for the next 9 months.
4. Even though the doctors say I can go back to running, I have chosen not to in hopes that my bone just needs more time/care.  Is there any benefit to be gained from staying off my foot, or am I wasting my time with a dead bone that will not heal? Dr Blake's comment: I will try not to discuss Lazarus from the Bible, but no one can be certain that this bone is dead. Treat it as if it were dying due to lack of blood flow and go from there. As long as the MRI shows that the bone is not fragmenting and degenerative, you have a good chance a saving it.   I downloaded the xray image below and it showed a fracture, but the MRI will be a better way to interpret. The radiology report of the MRI talked about AVN (dead bone) and fragmentation, so let me see how severe. 

I have a hard copy of my MRI disk that I am glad to send you.  The report is attached, as are the x rays I have from the first doctor who suspected a fractured sesamoid in Sept 2013.  I can request the most recent x rays from both follow up doctors if you'd like to see them.

Thanks again for your time.  It is much appreciated.

All the best,

Monday's Image of the Week: Accommodation Par Excellence!!!

Pain in the Metatarsal area is a prime location to try various off weighting pads. These vary from metatarsal pads to dancer's pads to toe pads. Here is a great example of one of my patient's very successful attempts at off weighting the sore area of both feet. I gave her the 1/8 inch adhesive felt from www.mooremedical.com and she found a metatarsal pad. By pointing her in the right direction, and her spending time at home placing pads in various positions, she is feeling better than she has felt in several years. Bet you can tell where she is sore by the pattern of the padding!! 

Sunday's Video of the Week: Introduction to the Bar Method (not the lawyer kind of bar or the Irish Pub!!)

The Bar Method is a form of workout that combines toning exercise with flexibility. It originated in the San Francisco Bay Area and so is very popular. I believe they have developed 4 videos for home use, and I believe it is a great way to condition yourself. Check it out in this weeks: Video of the Week.

Saturday's Exercise of the Week: Metatarsal Doming or Arcing

Metatarsal Doming or Arcing exercises for the foot are perfect for re-strengthening those small intrinsic muscles in our feet. These muscles are not really exercised properly when we stand, walk, or even run. They can slowly weaken with injuries, periods of inactivity, but also shoes and orthotic devices can allow them to stop working. Consider adding Met Doming or Arcing to your daily home or gym workouts and you will feel more power in your feet. A simple set of 10 reps daily can keep these muscles in tone to protect your foot. You can start doing 3 times daily to begin to catch up, then after several months decrease to twice daily, and then in 4 months decrease to once a day. Of course, all exercises are to be done painlessly. 

Friday's Patient Problem of the Week: Narrow Men's Dress Shoes

One of my nice patients today reminded me that he has very narrow and long feet: 11A. He has found that only Alden and Allen Edmond shoes fit him. He does have one pair of Rockport that works okay.

Dr Jane Denton at our office checking out shoe fit and stability.

http://www.aldenshoe.com/DrawProducts.aspx?Action=GetDetails&CategoryID=6&ProductID=94&PageID=8

http://www.allenedmonds.com/aeonline/cati2_Shoes_1_40000000001_-1_____120552____1000_?facet=Width:A

http://www.shoes.com/en-US/Mens/_/Rockport/Casual+Shoes/Width+Narrow_B+or+N/Products.aspx

http://www.onlineshoes.com/mens-shoes-narrow-shop-x-nar-list_ct1,wd4,as54

Thursday's Orthotic Discussion of the Week: Fettig Technique

The Fettig Technique is a specific modification of the Inverted Orthotic Technique designed by Dr Mathias Fettig while practicing in Montana. The classic Inverted Technique ignores the forefoot to rearfoot relationship in preparing the positive cast. Dr Fettig felt for his patients with forefoot valgus/plantarflexed first rays, where he wanted the correction of that everted forefoot deformity, but also wanted the heel inversion, he could combine the 2 techniques. And they have worked well together stabilizing the forefoot and rearfoot components.

All positive casts are poured vertical heel as a reference point no matter what correction you are going to do to the cast. 

Here is an example of a left foot cast that once poured vertical heel so that the top of the cast was parallel with the floor, the cast captured 6 degrees of everted forefoot deformity (inverting the top of the cast 6 degrees).

The front of the cast needs to enclose the first and fifth metatarsals in making what is called the Anterior Platform. 

The first and fifth metatarsals should be marked at their lowest points to the ground, and then a border 10-15 mm proximal to that point marked for the edge of the Anterior Platform. This is due to the need for the plastic to end behind (towards the arch) the weight bearing surface. The 10 to 15 mm leeway is an estimate with longer feet needing more and shorter feet less leeway or clearance. 

Here is a bottom view of the foot with the lines initially drawn between the first and 2nd metatarsals and then the 4th and 5th metatarsals. The low point on the first metatarsal is relatively easy to find with the line towards the arch dropped down the side of the foot and 10-15 mm from that low point. Unless visualization of the 5th metatarsal is obvious, I love to leave this line even with the first metatarsal line. This makes a square and stable leading edge of the orthotic device. 

Here the line for the 5th metatarsal is dropped down. 

Now the fun begins. This image is of the 2 nails needed for the Fettig Modification of the Inverted Orthotic Technique. If the FF Valgus measurement is 6 degrees taken from the top of the cast seen in an earlier image, and 20 degree Inverted Orthotic Technique is necessary for pronation control, then the initial medial nail sets the cast at 26 degrees inverted. The second nail in the fifth metatarsal head then sets the total inversion back to 20 degrees. In essence, we have accomplished a 20 degree Inverted Orthotic with a 6 degree Fettig Modification. 

Once the nails are in place, the plaster to make the Anterior Platform is mixed. I always have 2-3 plaster bowls working, each with different consistencies waiting for one to be the perfect blend of solidity and liquidity to be ready to be used. You can see by this photo that I use color dyes. Also floating in the basin in the back are pieces of wood that I will use to make the anterior platform. These will be placed into the anterior platform under the first metatarsal head, and need to be super saturated with water so not brittle (more the consistency of the plaster). 

You can see from the above image that the wooden sticks (parts of wooden tongue blades) are saturated with water before utilizing. They are places into the anterior platform after making and before the plaster dries. Only a small part will be used that goes into the medial arch fill. This is important when pressing with high power presses to avoid breakage of the platform from the medial arch. 

You need to be patient with the plaster as it dries to a certain consistency before making the Anterior Platform. 

Here the plaster is stirred every 2 minutes or so checking on its' consistency. 

Once the plaster is ready, moldable but not runny, it is placed on a small piece of paper.

The positive mold is now placed on the paper in the area of the anterior platform. You place the positive mold with the nails down gently trying not to distort the nails. 

Here, my brother Bob, who is wonderful at designing these molds, works the plaster so that the sides are smoothed. 

Bob is cutting away excess plaster and making the side walls straight on the lateral side and slightly bevelled outward on the medial or arch side. 

The Anterior Platform is applied and the wooden stick to prevent breakage inserted. 

I wanted to show that mistakes are made. I am trying to set this Fettig at 20 Degrees but the placement of the plaster on the mold was checked at 24 degrees. Oh well, do it again!!!!

New plaster applied to make another Platform. 

Measurement shows a perfect 20 degrees. 

The Anterior Platform is roughly squared on all 4 sides.

If you are skilled at orthotic making, you can tell a 6 degree Forefoot Valgus correction (lateral side) and a 20 degree overall inversion have been designed into this Anterior Platform.

Another image of the Fettig Modification capturing all 6 degrees of Forefoot Valgus within the 20 degree Inverted Orthotic Technique. The wooden stick will be cut about 1 and 1/2 inches from the plaster.

The finished positive cast capturing a 6 degree Forefoot Valgus deformity and 20 degree Inverted Technique with the medial and lateral expansions left foot.

Same for the right foot.

Wednesday's Article of the Week: The Inverted Orthotic Technique and Changes in Biomechanics

This is the left foot and 55 Degree Inverted Orthotic that allowed a patient to get the heel centered under the leg. The original problem being treated was severe medial knee pain with over pronated feet. The heel is relaxed position was 13 everted or pronated and the 55 degree correction allowed the patient to get close to 2 everted (vertical). 

The article below highlights the Inverted Orthotic Technique. It is a method of designing the functional foot orthotic to help with foot, ankle, leg, and knee biomechanics. The article emphasizes the positive changes to the lower extremity produced by this technique. I designed the technique in 1981, studied it for 2 years before I first made my observations available, then introduced it in 1984. The cartoon on the home page was drawn by the famous cartoonist Dr Robert Hughes who was at my first presentation. The following are injuries that benefit from this technique over standard orthotic devices:

• Bunion Pain
• Hallux Limitus/Rigidus
• Plantar Fasciitis
• Posterior Tibial and Anterior Tibial Tendinitis
• Achilles Tendinitis
• Shin Splints and Medial Tibial Stress Syndrome
• Medial Knee Pain
• Patello-Femoral Pain
• Piriformis Syndrome

There are many orthotic laboratories that make this device including Allied OSI, Root Functional Orthotic Lab, ProLab USA, and Richey and Company.‎

http://www.researchgate.net/publication/8978040_Effect_of_inverted_orthoses_on_lower-extremity_mechanics_in_runners/file/3deec51891a54ae45e.pdf

Tuesday's Question of the Week: Multiple Pain Syndromes: Email Advice

Dear Dr. Blake, 

I have been following your blog for two years now.  I credit your blog for keeping me walking. The tips and advice I have read have helped me along this far.

I am a 41 year old very healthy female.  Until November of 2009 I was a runner, recreational athlete, and yoga instructor.  I woke up one day in November and noticed my knees were aching.  I had replaced running with using an elliptical trainer due to separating my shoulder 9 months earlier.  I thought maybe the elliptical was causing an imbalance, so I beefed up my hip strengthening at the gym.  My knees continued to hurt.  I saw an orthopaedic surgeon. I had an  Mri of both knees ( 3 times), went to physical therapy.  Physical therapy made things worse.  I developed quad tendonitis.  I could not bend my knees.  Sitting with bent knees was excruciating .  My knees burned and would get very hot and red.  I found a new doctor.  Then another doctor and a chiropractor.  Had RA labs drawn ( 3 times) .  All negative.  Found a biomechanics expert.  Started working with him exclusively. I made a little bit of progress. 

Two years later my left foot started to hurt and my entire lower leg. Then both feet and lower legs started to hurt.  Peroneals, post tib, calves, the ball of my foot. I could no longer stand barefoot ever. I wear shoes in the shower. I started going to podiatrists after ten days of unexplained pain.  I went to five different doctors in my area.  All found nothing.  All insisted I did not need orthotics. One went so far as to say he wished he had my feet. He said he thought I had fibro. He said orthotics are golden arches and to not to come back unless I broke my foot.   I had previously visited a physiatrist at University of Florida who ruled out Fibromyalgia. 

Dr Blake's comment: If you have pain in your foot, some form of orthotic device can help. There is a infinite range of devices to work with and all the variations of support and cushion and off weight bearing. 

I found your blog.  You advised a reader to look into Barry University.  I found a doctor a few hours from where I live.  The minute they looked at my feet I knew something was wrong.  They could not believe the atrophy of the balls of my feet for my age. They recommended orthotics.  Another option was sculptra injections in the balls of my feet.  My first pair of orthotics were made of hard plastic and the heel cup was too small.  I walked around on those orthotics for 3 months, then my heel fat pads started to thin, but my knees started to get better!   Orthotics were sent back and I was referred to another doctor to start sculptra injections.  New doctor made softer orthotics and injected sculptra.  The sculptra helps a lot.  It did take about 18months and several rounds to get to this level of comfort.  Sculptra is very expensive and does not last more than 6-7 months. The balls of my feet still get hot every night and sore.  I still have to where soft orthotics and soft tennis shoes.  I no longer hard limp all day which is a miracle. My knees no loner hurt every day.  Just every now and then. 

Dr Blake's comment: I am so proud of you for not giving up. If your doctor can send me a cast of your foot, I will make a Hannaford for you. But, I need a doctor/pedorthist to dispense/adjust. Hannafords would be the best design for your feet. 

http://www.manhattanfootcare.com/2013/03/sculptra-derma-fillers-for-treatment-of-foot-conditions/

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-31.html

My heel pads have started to thin again. I can feel the bones easily when I palpate my heels.  It hurts along the outer rim and along the back of heels.  It feels like I always have a blister when I do not have one. Hurts a lot.  Gets red and hot every night.  I use ice packs a few times a day, every day. I have to sleep with my heels off of the bed, because the pressure hurts.

Dr Blake's comment: Here is the links to two products you should buy.

https://www.mooremedical.com/index.cfm?/Achilles-Heel-Pad%E2%84%A2/&PG=CTL&CS=HOM&FN=ProductDetail&PID=166&spx=1

http://www.alimed.com/stay-on-heel-protector.html

 The orthotics I am wearing are slow recovery poron with spenco on top.  This worked for about a year. I have currently stuck a thin gel sheet over the heel portion.  Not perfect but helps. Thinking of buying J gel.  In October the spenco was replaced but not the slow recovery poron.  Spenco bottomed out in a few weeks.  Heels hurt.  the physician I currently see always keeps my orthotics for 4-6 months before I get them back. I never leave my current pair .  The adjustments have to be made when I am in the office.  I have been waiting for my new pair since October.  When they do come back the lab has usually botched them.  I have become my own pedorthist.    I have a dremel tool.  I make my own met pads . I add cushioning to my orthotics.  I wear my orthotics at all times,  except in the shower. 

Dr Blake's comment: Sounds like you deserve at least a honorary Podiatry degree. This is why I make my own orthotics. If only my patients really understood my dedication. Partially LOL!!!

I  need orthotics that will help my very boney feet to stop hurting so much.  I think that the right orthotics will keep my feet protected and comfortable and keep my knees happy.I worry that if my feet are this bad now, what will happen in the future?  I can come to California if needed to see you.  My exercise physiologist said I have 20 year old bones and 80 year old fat pads.  It would be wonderful to  get my life back.   So many doctors have turned me away.  I want to know if you believe you can help me? 

Thank you, 

Dr Blake's comment: I have since communicated with the patient and sending her a size 10 (her size) Hannaford. The wonderful part of a Hannaford is what you get back from the lab is just a little more than an insert with your foot length and width. The Hannaford is multi layers of memory foam and you do the molding during your first 30 hours of wear. They feel like walking on a cloud, but need big enough athletic shoes to fit them. If you are looking into Hannafords, I am happy to work with doctors and labs to learn how to make them. Read all the posts previously on Hannaford orthotic devices. 

http://www.drblakeshealingsole.com/2013/01/grinding-hannaford-orthotic-you-tube.html

Monday's Image of the Week: Temporary Kirby Skive for Pronation Control

This photo above is the left foot orthotic device of a patient that pronates excessively. Many times when I am dispensing orthotic devices, I fall short in controlling the excessive pronation enough based on stability required or continued symptoms. I have added in this image a 1/4 inch beveled wedge in the medial heel area of the left foot orthotic device on top of the plastic.I call this a Temporary Kirby Skive. It will give me more correction temporarily to the orthotic device in controlling pronation motion. Eventually I may decide to place that Kirby Skive into the plastic itself. The typical material used for this wedge is Korex, grinding rubber, or EVA. The top cover in the right of the image will be glued back on.

http://www.parisorthotics.com/hcp_lectures/STJA%20Loc%20and%20Rot%20Equil%20Theory_PAC2001.pdf

Recent Fibular Sesamoid Removal: Email Advice

I had a fibular sesamoidectomy 4 weeks ago and I am still having a ton of pain in the big toe joint. It is actually worse than before the surgery. My surgeon never taught me how to properly tape the area and I was wondering what the best way to support the toe was. Also what exercises could I be doing to help the area. I still don't have full range of motion.

Thank you for your help.

Dr Blake's Response:

     You are in the 3 month zone of the surgeon's responsibility before they release their patients back to people like me who will rehabilitate. Everything I discuss has to be discussed and agreed upon by your surgeon who has ultimate responsibility and first hand knowledge. My primary goal here will be to give your some normal guidelines on what happens and can be done. 

     After you leave the hospital or surgical center, you will have bandages and stitches and post op shoes/boots, and crutches. These will all be in part of your life until 2 or 3 weeks when the wound has healed and your stitches can come out. The joint is sore, swollen, very limited range of motion, and basically non functional at this point. The next 10-12 weeks you have to reverse all the swelling accumulation with icing twice daily, NSAIDs, contrast bathing each evening, and 2-3 times per week physical therapy. This is where you are at right now. Your goal the next 8-10 weeks is to reduce swelling, but get strong. 

     So, during this next 8-10 weeks, use crutches, removable boots, post op shoes, big tennis shoes and orthotics, whatever it takes to minimize the day to day irritation that will keep aggravating the swelling. You want 2 months from now to be in a great position to re-strengthen the foot and leg. The Immobilization Phase (now for you) lasts typically 3 months, and the Restrengthening Phase until your 1 year Anniversary. Don't let the inflammation linger into the 4th month by pushing it too much now. 

     The physical therapist goal in seeing you is to reduce inflammation, gradually increase range of motion, gradually teach you how to strengthen your whole lower extremity progressively, sometimes design dancer's pads and/or orthotics, make recommendations to the surgeon on your progress and changes in treatment, etc. 

After the 12th week post operatively, typically the swelling is down, the range of motion is better, and the Restrengthening and Return to Activity Phases are gradually blended. Some activities will take you 1 full year to get back to like cutting hard in basketball, whereas running with off weighting orthotic devices can be started at 3-6 months. Depends on the force needed for the activity. 

     It is important to understand about scar tissue maturation. At 9 months, the scar tissue produced by the surgery will begin to thin, and cause less interference with normal motion. By 12 months, the scar tissue is typically no longer a problem restricting motion and causing pain. Some activities require this normal scar maturation process to occur before they are comfortable. 

     So, in my practice, you would have the stitches removed, you would have little to no pain because you would be using crutches, removable boots, etc, whatever is needed, you would be icing 2 times a day, contrast bathing once daily, you would be going to PT 2-3 times weekly, you would have a healthy diet, you would be getting soft based orthotics (like Hannafords) to protect the joint, using dancer's pads (1/8th adhesive felt from mooremedical.com),  you would use spica taping when you feel you need it, you would be using the Blaine Scar Kit for twice daily massage, and the physical therapist would definitely have you on the stationary bike (arch on the pedal), swimming/running in place in the pool, taking NSAIDs orally or topically, doing Hallux Limitus Self Mob if allowed twice daily, walking progressively more and more, not trying to manually increase normal joint motion, and using intelligent activity modification principles. Memorize my post on Good vs Bad Pain. 

     I sure hope this helps some. Rich 

Knee and Foot Surgery Questions: Email Advice

Dear Dr. Blake:

I have a too short first metatarsal on my right foot and walking on this too short metatarsal for over 7 years has also damaged my knee.

Questions for you:

If I have the knee surgery first, will I need to be on antibiotics the whole time that I recover from my foot surgery if there are pins sticking out of my 2nd and 3rd toes, since these need to be shortened too?   Does having a total knee replacement with a metal implant complicate in any way a future foot surgery on the  on the same leg?  Are most knees able to tolerate a Rollabout after knee surgery?
Many thanks for the information.  Your blog is great!

Dr Blake's Response:

Thanks for the questions and the compliment. Definitely you need the knee surgery first, since it changes how you walk and may change the foot correction given. Typically there is a 3, but preferrably 6 month wait between surgery. Yes, the knee must be able to take the stress placed by the Roll aBout, so it is the physical therapist more than anyone that says it is time for the foot surgery. You should have a month practicing on the Roll aBout with good success before you undergo surgery. You do not need more than a peri-operative antibiotic (at the time of the surgery) for the foot surgery in general. However, the orthopedist in charge of your knee health, may think otherwise. I would be surprised if you had more than a 2 week course of antibiotics with the foot surgery. Have the 2 doctors talk, or consult an infectitious disease specialist prior to the foot surgery to have them discuss things and come up with a plan. The bacteria is stirred up at the time of the surgery and the skin is typically completely healed at 2 weeks. Topical antibiotics are placed over the pin exit wounds. Hope this helps. Rich Blake

Sesamoid Injury: Email Advice

Dr. Blake,

I am a 50-year-old woman and I work out 5 times a week. I run on the tredmill for 20 minutes each day and then end my workout lifting weights. I used to be a gymnast and 24 years ago broke a sesamoid bone in my left foot. After several trials of everything, I ended up having surgery removing the broken bone. Following my surgery I developed RSD. To remedy this I had daily injections as an epidural for a week. I haven't had any trouble with that foot since.

In October I noticed my right foot started hurting in a similar way as my left foot did. I have a high tolerance for pain and continued running on it, not to mention, wearing pumps and boots with a higher heel. It got to the point where I just couldn't take it anymore, so I went to a local podiatrist in Factoria, WA. He briefly looked at my foot, took a xray, and told me my sesamoid bone was broke into two pieces and was splintered pretty good. He put me in an air cast and scheduled a follow up to evaluate whether surgery would be required.

After that appointment, I just didn't feel confident in the diagnosis, so I decided to go to a top rated podiatrist in Bellevue, WA. Before I went I requested a copy of my xray from the previous doctor, but when I got to my second opinion appointment, no one in the office could open the xray on the CD. Having said that, the doctor had to take another xray. He gave me pads to wear and discussed surgery and available dates. I put my aircast back on and left. On the way home, the second opinion doctor called me and said he looked at my xray as well as his partner and did not see any break whatsoever or any splintering like the first doctor claimed. I have been back for a follow up with the second opinion doctor and have another appointment on Jan. 6th 2013 for a possible cortisone shot. The second opinion doctor doesn't have a clue what it could be causing my pain. 
Dr Blake's comment: This is why you get 2nd opinions to make sure surgery is necessary, but the difference is so enormous, you now need a 3rd. I once had 6 opinions on a personal health issue, and I am very happy I did. Is the Aircast a brace or removable boot? If it is a boot, and if it is not comfortable, use 1/4 inch adhesive felt from www.mooremedical.com to design a dancer's pad for the inside of the boot. 

Sesamoid pad to float the sore area placed into the removable boot. 

My foot still hurts off and on...more on than off. I have also noticed than when I cross my right leg over my left, the bad foot tingles terribly. I had a pedicure before Christmas and the girl working on me massaged my feet and pulled on my toes. It did feel quite a bit better after that, but a couple days ago the pain flared up again.

Today I downloaded a program (OmniVue) that allowed me to open the first doctor's xray. I now have a copy of both doctor's xrays. I compared the two and really don't know what I am looking at. I was able to export the first doctor's xray and save it as an image. Would you be willing to allow me to email the image to you so I can get your opinion on all of this? If so, I would certainly appreciate it.

We are meeting with the first doctor on Jan. 3rd to give him an opportunity to explain himself. I don't want any trouble. I just want to know if my foot is broke or not. My biggest concern is nerve damage and the possibility of developing RSD once again.

Thanks in advance.

Dr Blake's comment:

Thank you so very much for the comment. You can take photos of the xray images (as big as possible) and email to me at drblakeshealingsole@gmail.com.

 You should however not get a shot unless you have an MRI which is the best definitive test. You can send me the CD of the MRI and I will be happy to look at.

 If you can not get an MRI, and the xrays not are that definite, I would follow the protocol for a fractured sesamoid which includes 3 months in a removable boot, and a bone stimulator. 

Make sure you are doing well with Calcium and Vit D3 and icing twice daily with contrast bathing once daily. Hope this helps for now. Rich

Morton's Neuroma: Successful Surgery after conservative therapy failed

This was a wonderful comment to my post below on Morton's Neuromas and their Treatment Options. Thank you to the young man who wrote this. It does not change my mind on being conservative, but I do not think his first 2 podiatrists gave him an option of surgery. I do not do surgery, but we have 2 highly trained surgeons in the office who I consult frequently. If you have a solid diagnosis of Morton's Neuroma, you must be informed of your options, for it is the only way to make the best decision for you. You are the one feeling the pain, the doctors can not, but the doctors should help you stay objective and help you work through the treatment. 

http://www.drblakeshealingsole.com/2010/08/mortons-neuroma-treatment-options.html

I had MN in my right foot. I visited three podiatrists before finding one who was willing to perform the surgery - and he changed my life by doing so. I had orthotics, splints, injections - everything - over a 12 month period. Nothing helped and I woke one day wanting to cut off my foot (seriously, that is what I told my wife).

After changing from a PPO to Kaiser, I once again visited the Podiatrist. The doctor immediately said, "If you've tried other remedies, then you need surgery." I had the surgery two weeks later, and was walking with a padded covering the next day. The difference almost brought tears to my eyes.

I know of two others (also runners) who have had MN and the only remedy was surgery. The podiatrists I fired were all unable to perform the surgery, so they tried to offer every remedy under the sun except the only one that would help. Makes me angry even typing this.

I now have MN in my other foot (presumably years of running and years of marching are taking their toll). I see my doctor next week and I am quite certain that he will go back and pull the nerve. IT IS THE ONLY TRUE REMEDY IF YOU ARE IN PAIN.

Dr. Blake - saying that only 5% require surgery simply cannot be true and is certainly misleading to the patients seeking comfort in a very painful foot. I fear that they will follow the guidance and try to seek comfort with other treatments for at least one year (as you suggest) like I did. For the third of sufferers who have the pain in their foot, especially at the 8-10 on the pain scale, they will not be cured with orthotics, therapy, injections, etc. Surgery is their only cure.

Dr Blake's Response:

Thank you so very much for your heart felt comment. Most of my patients who have surgery for Morton's Neuroma feel the same way. When you need surgery for Morton's Neuroma, you should have it. This does not however mean that conservative treatments should not be tried before. 

There is typically a 3 month window of time after the patient first presents with MN pain that 2 things happen: A) an attempt at conservative treatment is initiated, and B) MRI documentation along with an evaluation of other causes of nerve pain. If by the end of the first 3 months, the conservative treatment is not working well, the MRI documents a MN, and other forms of nerve pain (like low back referred pain are ruled out), surgery is recommended. 

The gray areas come from patients where the pain is manageable, the MRIs are inconclusive, and there is some suggestion of low back involvement. 

So, I am very happy for you. I am biased to avoid surgery when possible, and that bias does come across strongly. I always feel bad when the patient and I work hard together to avoid surgery, but in the end surgery is needed. But, my patients know that if conservative treatment fails, surgery is our last resort option. How does conservative treatment fail? One way is that the pain level is not managed in the 0-2 range (Good Pain). During the first few months, while conservative treatment is being explored, it is imperative to do whatever to get the pain under control. This is more true for nerves than any other structure. Dr Rich Blake