Sesamoiditis: Email Advice

Email Received: 2/13/11 from Maryland

Hi Dr. Blake-

I just came across your information on the internet. I just had my big toe evaluated here locally in Maryland, and after I insisted to the podiatrist that it was swollen, an X-RAY was taken and the X-RAY showed that the outer sesamoid has fractured in two places – one a straight-through (not non-union yet according to the podiatrist) and the other hairline fracture. The podiatrist recommended that I wear a “boot” for about 6-8 weeks, but he didn’t have a size that would fit my foot (size 13.5 or 14), so I am waiting. The pain isn’t unbearable but I can feel pain when I walk or apply pressure. My characteristics: 40 years old, 6’2”, 255lb

Questions:

1. I do not remember a specific event that caused this fracture – I have been working out but not running – more ellptical, walking on treadmill, and doing weight-lifting upper body and lower body – so is it uncommon that a situation like this seems to spontaneously occur? My buddy’s father who is a doctor said that I should have a follow-up to check for “bone density, vitamin D, mineral density checks” with a rheumatolagist. Is that reasonable?

2. I just ordered a metasaral pad to wear underneath of my foot – recommended?

3. My podiatrist said that I could do elliptical exercises while I wait for the foot to heal, but when I tried yesterday my toe area seemed to hurt more – I tried elliptical and sit-down bike. Recommended?

4. Is swimming non-impact enough?

Any thoughts would be greatly appreciated ---

Troy

Dear Troy,
     First of all it is very difficult to make the diagnosis off xrays since many unpainful sesamoids are in two, three, or multiple pieces. These are called bipartite/tripartite sesamoids. The bone just never fully ossified in the teenage years. Of course, you have to treat the worse case scenario initially until you get an MRI or bone scan to document the fracture's existence without doubt. The removable boot sounds the right idea, and you can have it Fed Exed in two days from Alimed.com or mooremedical.com. I would get the low cut version, like the Anklizer.
     It is common to get sesamoid problems from elliptical machines since they are a solid metal unforgiving platform. It is common to get sesamoid problems from treadmill, especially if you are not used to it, have it on an incline, or trying to recently increase your speed. This being said definitely stay off these two machines until you can walk for 2 weeks without pain. The stationary bike is the drug of choice for sesamoid injuries since you can put pedal back into your arch and off the injured bone.
     The advice on getting Vitamin D levels and bone density screens is appropriate. Make sure you are at 1500mg Calcium and 1000 units Vitamin D until told otherwise.
     My blog has various posts on sesamoid injuries and you can see how easy it is to design your own dancer's pad and learn spica taping (both crucial). Swim only if you can swim, but avoid pushing off the walls. I sink!!
     Let me know after your MRI or bone scan what they found (ok to email a photo like the one below). Good luck. Rich

I received this 2nd email after I had typed the above response.

Thank you and I just came across your good instructions on the


http://www.drblakeshealingsole.com/2010/12/sesamoid-fracture-email-advice.html


I am afraid that if I sit here inactive for months at a time I won’t lose any weight—I was thinking of water acquatics for low –impact –hopefully I can do this – I just ordered the Kinesiotape   

Troy, spend 30 minutes on the bike tomorrow and gradually add another 5 minutes every 5th day. Lower the seat alittle to compensate for the change in pedal position. You should be able to burn a few calories. Rich

Top 100 Biomechanical Guidelines #38: Evaluate Negative Casts for Inverted or Everted Forefoot Deformities

     The negative impression cast of the foot is the foundation of all Root-based Biomechanic/Orthotic treatment. It is an extremely important technique that the biomechanics industry is trying to replace with laser impressions, foam box impressions, and other variations of arch supports. Now that we are entering the age of CAD-CAM systems of manufacturing, it is up to the biomechanics industry to do the appropriate studies to decide when another technique will treat the problem as well as the classic Root Balance techniques based on the impression cast. For the appropriate patient, the power of the impression cast vs other techniques can be equivalent to treating a 1 inch short leg with a 1/4 inch heel lift. In the right direction, yes, helpful at resolving the abnormal forces producing symptoms, maybe not. From the patient standpoint, a significant dilemma exists. Are my symptoms not improving because I am in the wrong orthotic device, or because I need surgery, etc? For many years, the Root Device has been a tried and true method used by thousands of podiatrists/some physical therapists/some chiropractors/some orthopedists on millions of happy patients. When patients came into my office with orthotic devices 10 years ago, 90% of those orthotic devices were stable and reducing symptoms. Presently that number is diminishing. Patients need to expect more out of the orthotic devices if they do not feel stable, and they are not helping symptoms. Technology is a strong force to influence, but let us try.

     This Guideline #38 deals with understanding what they negative impression cast shows us. Below is the impression cast for a patient with forefoot valgus. This is the type of foot that the Root Balancing Technique shines and has no equal. If you have foot and ankle symptoms, and you have this type of foot, you should have a pair of these orthotic devices made.

The photo below is of a patient (Carina) with the forefoot valgus foot type where the first metatarsal is lower than the fifth metatarsal on observation. You can see if the cast captures this deformity by laying it on a flat surface. The cast will lean to the outside if the deformity is captured like the photo above.

Forefoot Varus is the opposite tilt seen where the first metatarsal is above the 5th metatarsal in this evaluation. The casts for a forefoot varus will lean inward like below.

.

These casts only represent the relationship of the front of the foot to the back of the foot. They do not represent the foot to ground relationship ( a common misconception). I will have so much more on this concept. For biomechanics experts, I am intentionally not separating forefoot valgus from forefoot pronatus, plantar flexed first rays, and dorsiflexed lateral columns including dorsiflexed fifth metatarsals, for ease of this discussion.

In conclusion, I love when I find a forefoot valgus to support when I am dealing with many, if not most, foot and ankle problems. Forefoot valgus occurs in 40 to 60% of all patients. More on the more complex forefoot varus later.

The Famous Blue Dot for Heel Pain

I remember struggling once with a patient and her heel pain. It was before I really understood that when you design orthotic devices for patients with heel pain you must make sure the weight is shifted to the arch and the heel is cushioned and protected. This memorable patient returned for a followup visit feeling much much better. I was pleased. When asked what seemed to make the difference, she told me that on a recent visit to her chiropractor, she complained of her heel pain, and the doc placed a blue dot on her heel to cushion and lift her forward off the heel. It has worked with many patients ever since. You see in an artful practice like I have you learn more from your patients than textbooks and lectures.

 These blue dots can be of any color actually, and many materials are used to achieve the same effect. Here I am using Neolon, a Spenco knockoff of neopreme (which is wet suit material). It is very soft, but very durable. It fills in the deepest part of the heel on an orthotic device. I prefer placing it on both sides even if it only one side that has the heel pain.

Here the blue dot shows that the edges are skived to ease the transition. I normally turn this over so the flat side will be against the foot.

A further demonstration of the skived edges. I hope this helps.

Horseshoes are not Just for Horses: Try it for Ankle Sprains

Following an Ankle Sprain, Compression is essential 24/7 to reduce swelling as quickly as possible. Swelling is your enemy slowing down the speed of healing by reducing good arterial blood flow to the injured areas, floating the joint surfaces adding to the instability, increasing the pain which leads to more swelling cycle, limiting the range of motion, and making it difficult to walk (no walk, no activities for rehab). A horse shoe has a hole over the bone (does not matter if it swells there) and material to compress the swelling in the areas of the ligaments and tendons. This is held in place by the compression sock which has been folded down so that you can see the horse shoe. I use 1/4 inch felt, but even a rolled up sock, face cloth, etc will do. Be creative for once it your life!! Just kidding. Add contrast bathes, see link below, and you should be able to reduce the swelling dramatically in a short time. By the way, horseshoe patterns are much better than donut patterns since the hole at the top (hole towards the heart rule) makes sure the swelling moves freely away from the injured area.

http://www.drblakeshealingsole.com/2010/03/secret-of-contrast-bathing.html

Shoe Tongue Slippage: Try This Trick

There are many patients whom have the darnest time with the tongue of the shoe slipping down or to the side. The 2 photos below are from my long time patient Stacy. Stacy was getting some irritation at the top of her left foot from the shoe tongue of the shoe slipping to one side while she walked her dog Maggie. I used an old trick to stablize the tongue that any shoe repair store should be able to do. I used a scalpel to make a loop in the fabric so when she passed the shoe lace through it and then the nearby eyelet it held the tongue in place.

The scalpel is shown in this photo after the two slits are made to form the loop.

 A better photo demonstrating the shoe lace going through the loop and into the eyelet. Stacy immediately felt better when the tongue stayed in the right place. Imagine that!!

A San Francisco Sunset.

A Fix For Squeaky Orthotic Devices

When foot orthotic devices with some plastic, mix with modern day shoes with plastic or rubbery components, squeaking can occur. I have always recommended with some modest success that the patient apply foot powder under the orthotic device inside the shoe and around the sides of the orthotic device to act as a friction layer. For the shoes that this is not enough, you must find out where the squeak is coming from and apply leather to the orthotic device in this area.

Here the pen is pointing to a layer of thin leather (that any shoe repair store has) that has been glued/superglued to the sides and back of the rearfoot post on the orthotic device.

When the patient presented with the squeaky orthotic device, proudly walking for me to prove it, vowing on a stack of Bibles that powder had reduced but not eliminated the squeak. So I carefully put my hand on the orthotic device inside the shoe (yes, this is why I earn the big bucks!! What dangers lurk!?!), and attempted to move the orthotic device to produce the annoying squeak. It seemed to reside loudly in the heel area. Since this type of orthotic device had plastic posts, I covered the posts with leather and made Stacey walk. Wallah, no squeak!! Yes, it is hard to stay humble.

15 Harmful Things You're Doing To Your Feet

Dear Readers of drblakeshealingsole.com, I received this note from Ken and thought all the advice was excellent. Please have a look at the link below. And yes, I do recommend less shoe wearing in controlled environments for overall foot strength. Dr Rich Blake

www.nursingschools.net/blog/2011/02/15-harmful-things-youre-doing-to-your-feet/

Hi Richard,


We would love to share with you an article that we just posted on our own blog! “15 Harmful Things You’re Doing to Your Feet” (http://www.nursingschools.net/blog/2011/02/15-harmful-things-youre-doing-to-your-feet/) would be an interesting story for your readers to check out and discuss on your blog.

Thanks for sharing some great content through your blog. It has been a sincere pleasure to read.


Sincerely

Ken

Short Leg Syndrome: Modification of Midsole Lift

One of the problems I see with midsole lifts when treating limb length discrepancies is the inherent instability created by lifting that foot higher off the ground. So a pronator may pronate alittle more, and a supinator may supinate alittle more, with midsole lifts. The photos below illustrate a simple technique to eliminate most of this problem. The advantage of using midsole lifts, and not having to use them inside the shoe, does create a better shoe fit. Better shoe fit better stability and better comfort.

Here is a typical full length lift for the midsole of a shoe. These are made of a certain density (normally 30 to 40 durometer) for stability and cushion.

Here is a dual density lift. The black part is 30  durometer and the white part 45 durometer. This is designed to stop pronation. The opposite pattern can be used for supination problems. This is a more stable and predictable way to control these forces in contrast to placing a varus or valgus wedge on the lift.

Cycling Cleats: Wedging for Better Stability

Search Amazon.com for cycling cleat wedges

Check out the right knee of the cyclist with the white shirt. See how that knee pulls in (valgus) compared to the right knee on the cyclist with the pink shirt. This inward pull of the knee causes a syndrome called "biker's knee" or patello-femoral dysfunction. Pain develops around the kneecap (patella) and can get quite annoying and disabling.

There are many reasons for that inward pull of the knee, and one of the common solutions is cleat chimming, wedging, or canting. Above are the yellow wedges, thicker on one side, that can be gradually introduced to the base of the cleat. These are the specific wedges used for Look Pedals.

Here you can see the bottom surface of the cleat with around 1/4 inch total wedging applied. See how the lateral side (5th toe/pinky toe) is thin and the arch side is thick. This is how the wedge cants the whole cleat, inverted the foot, and decreasing knee valgus (internal rotation of the knee).

Here a side view of that same wedge showing the thicker arch side.

Here is the side view of the thinner lateral side (pinky toe).

Here I am using the Look wedge template as a pattern and attempting to use thicker 1/16 inch polypropylene from JMS Plastics company.

Here 4 polypropylene wedges have been made and placed on the bottom of the cleat. This design has the 3 holes for the screws and skived to make the inverted cant.

Here the wedges are placed  in the right position and the screws are put into the 3 holes created. I am attempted the same degree of wedging as with the yellow Look chims, but hopefully they are firmer stronger and more durable.

Here are the initial 3 holes seen on the bottom of the cleat.

My good friend Marc Evans, world famous triathalon coach talks in this upcoming video on the biomechanics of arch line, heel line, and knee line.



These next two short videos show the change of the knee with these type cants.






Critical attention to the biomechanics of cycling can avoid many injuries. I hope this introduction to cleat wedging has been a useful introduction.

Ganglions: Soft Tissue Masses often seen in the Foot



Patient presents with painful swollen big toe joint

  Patient Carleen presented to my office yesterday with a swollen big toe joint. These first two photos show how swollen the area looked. Compare the swollen right big toe joint with the uninvolved left big toe joint seen in the third photo.



Side View of the Swollen Right Big Toe Joint



Non Swollen, yet prominent, uninvolved left big toe joint

MRI showing Probable Ganglion Cyst not involving the Joint

MRI Image of the Sideview of the Big Toe Joint

After getting the MRI imaging, I drained the cyst of 5 ml of bloody fluid and sent it to the lab. The lab did not identify any bacteria. Hooray!! Carleen was started on icing and contrast bathing to reduce the swelling (minimum of 3 daily of the combination). She was given a hapad arch support to transfer weight into the arch and dancer's pad to float the painful toe. See the padding used in the following post link.

http://www.drblakeshealingsole.com/2010/09/sesamoid-fractures-advice-when-not.html

 I will follow her in two weeks. Ganglions may resorb, but some have to be surgically removed. I would inject 3 plus times with cortisone before considering surgery. She will need some form of orthotic device designed for her shoes to prevent pressure. The biomechanics of her foot is of a plantarflexed first ray which sticks out like a sore thumb and gets easily bruised. This bruising over time can lead to the gradual development of a cyst.

Carleen first felt symptoms 3 months ago, but does not recall bruising her foot. It is probably her biomechanics coupled with unpadded shoes, or the normal stress of activity, that causes the tissue to be initially traumatized. Ganglions are normally produced by normal joint or tendon fluid, that due to a weak spot in the lining of the joint or tendon sheath, allows the fluid to begin to seep out of the joint/tendon and into the surrounding tissue. The body attempts to wall off the fluid, but the hernia formed causes a gradual cyst formation. The biggest cyst of this type is called a Baker's Cyst off the back of the knee joint. Hopefully, with Carleen, we will be able to prevent surgery.

Shin Splints: Basic Treatments

Shin splints is so common, and normally responds so well to basic treatment, that most clinicians do not get too involved in its complexities. The basic treatment of shin splints involves:

• Reduce activity to pain free levels for at least one week.

• Ice the involved area for 30 minutes 3x/day.

• Change your athletic shoes if they may be worn down.

• Minimize your speed workouts and hill workouts.

• Consider if levels of Calcium and Vitamin D may be low.

• Attempt 3 to 4 days/week alternative exercises as long as it is pain free (i.e. cycling, elliptical, walking, swimming, court sports, etc.)

• Stretch the achilles tendon 2 positional (knee straight and knee bent) for 1 minute each 3x/day.

• Experiment with an ankle brace or ankle taping if it is painful to walk.

• Wear tie-on supportive athletic shoes full time while the shin is healing (although you may experiment with clogs as an alternative).

• Attempt pain free muscle strengthening of the muscle group involved. More on this in a later post.

Several videos on this subject.

Pointing to the Anterior Tibial Shin Splint

"Not On My Watch"---website to eliminate Healthcare Associated Infections

Since I am on the Infectitious Disease Committee at Saint Francis Memorial Hospital I would be remiss at not publishing this important message.



Hi again Richard


I sent you an email last week but hadn't heard back so I wanted to try you again. As you may be aware, the Department of Health & Human Services recently released its annual report on the quality of health care Americans receive. While there have been some improvements, hospitals still have work to do to put an end to the ongoing - but solvable - problem of Healthcare-Associated Infections (HAIs).

Caregivers and other healthcare professionals know steps need to be taken to protect patients from HAIs, but it will take strong leadership to make the changes necessary to reduce the likelihood of these life-threatening infections. To help achieve this goal, Kimberly-Clark Health Care launched "Not on My Watch" (www.haiwatch.com), a website that provides tools and information to help facilities eliminate HAIs.

I hope you will help in this effort by informing the readers of Drblakes Healingsole.Com about this initiative. I've created a useful site that you're welcome to grab resources from:

http://haiwatchnews.com/

Please let me know if you have any questions or need more information. If you are able to post about this, I'd love to get the link to your post.

Thank you,

Barbara

Hammertoe Advice

Email sent to drblakeshealingsole.com on 1/20/11

Question, currently I suffer from hammertoes on one foot, it is the second toe next to Big toe. It is completely dislocated, now on my right foot for the last year I'm having a lot of pain and my foot is swollen and the second toe is starting to turn under some. My biggest issue right is I have this sore foot and shin splints, I can't walk very far anymore because of it, I can't shop for long or do any standing in one place very long. Do you have any suggestions?

Gloria

Dear Gloria, I am imaging that you have a hammertoe that looks like my patient Paula below.

Here her toe is dislocated with the big toe now moving under the second toe. As the 2nd toe goes up, the 2nd metatarsal is pushed down against the ground much more than normal allowing for stress to build up in the tissues. The soft tissues under the second metatarsal/toe joint begin to scream bloody murder and pain starts. This pain causes swelling which causes more pain, and a vicious cycle is created.

The top five self treatments that you can easily start are:1.Budin Splint (either single or double loop)

http://www.drblakeshealingsole.com/2010/04/pain-in-front-of-foot-possible-help.html

2. Start wearing YogaToes or a knockoff

http://www.drblakeshealingsole.com/2010/07/help-for-bunions-and-hammertoes.html

3.  Ice massage three times daily

http://www.drblakeshealingsole.com/2010/04/ice-or-cold-therapy-helps-in-injury.html

4. Avoiding bending the toe joints as much as humanly possible (ie. stay flat footed on the ellyptical machine).

http://www.drblakeshealingsole.com/2010/07/arch-support-with-otc-hapads-help-for.html

5. Begin using Hapad Small Longitudinal Medial Arch self adhesive pads in most shoes.

When you are in alot of pain, I would probably try to rest the foot in a removable boot and try to get an MRI to find out what is going on. If finances are an issue, the removable boots can be purchased online and try to wear for 6 to 8 weeks while you ice three times daily.

I sure this helps you.

Posterior Tibial Tendinitis/Dysfunction Improved with Inverted Orthotic Technique

The posterior tibial tendon is one of the main supporters of the arch. For many unfortunate patients, the tendon tears leading to significant arch collapse. I will have many posts on this very disabling injury. I am very happy to use the Inverted Orthotic Technique (aka Blake Inverted Orthotic) for this injury. The pronation is so severe that a corrective orthotic device is necessary, and sometimes medial shoe wedging and/or ankle bracing. Many of these patients do need surgery, but some can avoid surgery with the Inverted Technique. This is a brief introduction.

     Let's start by watching this great video on a posterior tibial dysfunction patient on both sides.




So how can this patient be helped. Let us focus on the right foot. I measure the heel position from vertical (heel straight) with a goniometer. Here the ruler is only being used to show how much this 10 everted (valgus) is off from that vertical heel position.

Impression Casts are taken of the feet. In this case, the casts show the valgus heel and can be measured. The goal is to correct the heels back to vertical.

From the measurment of heel valgus standing, the Inverted Technique uses a 5 to 1 ratio to set the cast in an overcorrected position with the goal to straighten the heel back to vertical. If the heel is measuring 5 degrees of valgus, the positive cast would be set at 25 degrees inverted. I never go above 35 degrees initially due to the radical change that the patient will need to make. I will talk later about how you increase the correction based on the patient's response.

In the positive cast above set at 35 degrees of inversion see the amount of space under the medial heel area. It is this part of the cast which will attempt to control the pronation by placing supination forces into the medial heel and midfoot.

In the above example, a 35 degree inverted orthotic device was initially used to correct a 10 degree valgus position. The correction was true to the 5 to 1 rule. The 10 degree valgus position was changed to a better 3 degree valgus heel. If necessary, further simple mold adjustments will be used with Kirby Skive and Medial Column Correction to obtain the remaining 3 degrees.

I hope this is a good introduction.

How much of a short leg is enough to cause injury?

Here is the standing evaluation of the pelvic landmark for measuring for a short leg. The examiner should remember to keep the hands parallel to each other and the ground. The examiner's eyes should be at the level of the hands.

When treating leg length discrepancies in athletes, as little as 1/16 inch can cause a definite overuse of one side of the body. I highly recommend correcting for any leg length difference in a highly competitive athlete, and definitely in chronically injuried patients. It is a relatively easy treatment to observe the effects on a treatment. You may be surprised at such small differences, if corrected, can make such a large difference in symptoms.

Definitely pull out the lifts if you notice no change or a worsening of symptoms.

APMA Sponsored Video on Diabetes

The American Podiatric Medical Association sponsored this video on Diabetes. Very important for diabetics to always stay diligent about their foot care. Check their feet daily. See their podiatrist regularly. Take every sore or pain seriously. Monitor their blood sugars. Know your HbA1c.

Heel Pain and Orthotic Devices

If you are having heel pain and wear custom made orthotic devices, consider having 1/8" to 1/4" gel sheets applied. You can get them at Alimed. See the link below.

http://www.alimed.com/Alimed/product/Silipos-Gel-Dots-and-Squares,23076,165.htm

For walking the 1/4 inch is great, but for sports 1/8 inch is normally perfect.

Rebuttal New York Times Article on Orthotic Devices

http://www.nytimes.com/2011/01/18/health/nutrition/18best.html?ref=science

First of all here is two comments from my patients.
Patient #1:

They just never wore the ones you make! Signed Shirley to me!!

Patient #2:
Dear Dr. Nigg:


Orthotics are the greatest invention since corn flakes! I may very well be one of the first people to wear them, having obtained a set in 1959 (they were made from plaster casts of my foot of 100% cork in those days and suggested by my Podiatrist Dr. John Pagliano, of Los Angeles. His son, Dr. John W. Pagliano, DPM, is a famous sports medicine Podiatrist in the greater Los Angeles area).

My current pair are state-of-the-art orthotics made by Dr. Rich Blake, DPM of St Francis Memorial Hospital (Catholic Healthcare West) in San Francisco. They have cork heels. They aid in preventing of my previous lower back problems and sore arches.

Sincerely,

Richard

      I want to thank Shirley and Richard for bringing the New York Times Article to my attention. I have been practicing for 30 years, average making 200 pairs of orthotics per year, giving me 6000 pairs of orthotic experience to bring to this table. And I am Past President of the American Academy of Podiatric Sports Medicine, and Past Editor for Sports Medicine of the Journal of the American Podiatric Medical Association.
      Orthotic devices are shoe inserts prescribed for a specific function, normally to relieve pain. And the orthotic devices must make the patient walk or run more stable, more fluid, with less stress at heel impact, produce better alignment at pushoff, be comfortable, and so on. These are heavy demands placed on the prescribing doctor/therapist/orthotist, but the sophisication is there to accomplish these goals. The advances in the orthotic industry have been so immense in my 30 years in practice that I find poor orthotics only made by those disinterested in the process. The patients demand success. And success is normally delievered by the health care system. I am very proud of my podiatric colleagues for their work in this regard. There are podiatrists, like myself, that specialize in orthotic devices. But, great orthotic devices are being made all over.
     Much of Dr Nigg's comments (and I respect him immensely) show he does not dwell in the world of foot pain. My last patient of the day Toni will never ever take Dr Nigg's comments (and I hope he was just misquoted). Toni had severe foot pain, 4 years ago orthotic devices eliminated that pain, and you can not convince her to not wear her orthotics. And I do not blame her!!
     In my practice, I make routinely probably 20 different types of orthotic devices. And I take very seriously my need to get it right since many insurance companies will only pay for one pair a year. I do not have the freedom of a researcher to experiment away with every patient. So I try to analyze what type of orthotic device is appropriate for this patient with these symptoms at this time. It does not mean that this patient could have 10 reasonably different pairs made for them, each doing something alittle differently, each affecting different change at their feet, ankles, knees, and hips.  But that would be so confusing to the body. I am glad I do not have to research these changes from subjective data from the patient.
     Orthotics Work Wonders!! I believe that because I have see that every day in my practice. Many patients can not consider walking a step without them due to nerve damage in their foot that no strength gain in their foot could ever compensate for. Who is Dr Nigg to send negative energy into this realm? Medicine is all about healing, about hope, about positive energy. Orthotics, even in the most challenging patient, with the most difficult symptoms, are a symbol of that hope. I know enough about the world of orthotic devices to know that if they fail to help a patient it is because I am not understanding the situation enough. It has nothing to do with orthotics, it is the imperfect humans prescribing them. I ask Dr Nigg to do research on how long it will take a patient with nerve damage to strength their feet so they can avoid orthotics all together?
     Why do patients get orthotics? They are in pain, and their mechanics seem to indicate that some change produced by an orthotic device would be helpful. So they get orthotics. The pain goes away. Some good research should be done on how long should the patient remain in orthotic devices after it cures their problem. The average patient does not want that pain back. They may be very happy to wear orthotics forever, like I wear my eye glasses. Yes, I should do some eye exercises, but I am taking the easy way out. Yes, I need to have all my orthotic patients doing 2 to 5 minutes every evening foot strengthening exercises. So, they won't be so frail.
     So, I applaud the New York Times for bringing this to the forefront. Being from San Francisco, where William Randolph Hearst made yellow journalism famous, I understand how you want to sell papers. But, why don't you give hope, because orthotic devices have stood the test of time in medicine, and deserve praise for how well they have helped millions over the last 40 years since modern day orthotics were introduced to the world by Drs Root, Weed, Sgarlato, and Orien. Boy, have they changed the world. I, and my patients, salute you gentlemen.
  Thank you. Dr Rich Blake    
    

Top 100 Biomechanical Guidelines #37: Major Stability can be Attained with Full Root Balancing of Forefoot Deformities

Taken from Root Lab brochure. Dr Mert Root, my teacher, my mentor, my friend. I miss you. Passed away after a long illness in 2002.
http://www.root-lab.com/about.htm

Dr Mert Root, along with several other brilliant doctors (Weed, Orien, Sgarlato), revolutionized the treatment of foot problems with their theories in the 1960s and 1970s. A Balanced Root Orthotic Device is the standard that all orthotic devices are modifications. To design a balanced orthotic device, you are eliminating the intrinsic tilts in the foot, the forefoot varus, forefoot supinatus, forefoot valgus, forefoot pronatus, plantar flexed first rays, plantar flexed fifth rays, etc, etc. Being a purist, Dr Root preached full correction of these corrections. Disciples followed that espoused modifications for comfort, sometimes they were right and sometimes they ruined the technique. Most labs will make the classic Root Balanced Orthotic Device if asked, but their standard is their version of a  Modified Root Balanced Orthotic Device (normally function loses to comfort). But, the debate will rage for decades whether the purest 100% correction of these natural tilts in the foot is that important, or whether 80% correction is okay. Or 70%. Or 60%. I believe it is important when using the Modified Root Balanced Orthotic Device to clearly document what type of correction you are using. If the symptoms are not improving, further correction towards the classic Root Balanced Technique can be ordered. I know this works, and will dedicate a few posts to this topic. I use so many types of orthotic devices, but the Root Balanced Orthotic Device is the best for many conditions. These include:

1. Morton's Neuromas
2. Hammertoes
3. Midfoot Sprains
4. Metatarsal Fractures (including Jones type)
5. Metatarsalgia
6. Tailor's Bunions
7. Pes Cavus Problems

I hopefully will be able to introduce you to Root Balancing. I owe it to Dr Root, an unbelievable giver, and healer. His son Jeff, and daughter in law Kathy, run his lab still, even though Dr Root passed away in 2002. A terrible loss.

These are forefoot varus impression casts of the foot. When you stand them up, they lean inward. A Root Balanced Orthotic Device will attempt to place these heels straight up (heel vertical)

These are forefoot valgus impression casts. When you stand them up, they lean to the outside. A Root Balanced Orthotic Device will attempt to stand them straight up (heel vertical).

This is simply an introduction to a hot topic in podiatry. As more and more labs go computerized, and the health care provider has less and less control of the final product, the consumer may have to be more demanding. I have made a good living converting modified Root Balanced Orthotic Devices to classic Root Balanced Orthotic Devices to achieve better stability and better symptom relief. Talk to your podiatrist whether they use classic Root or modified Root techniques. Root technique is like the paint brush however, the individual provider must have the freedom to paint.

Philosophy: Is your health care provider really seeing the whole picture?

http://www.dreamstime.com/stock-photo-woman-behind-mirrored-beads-rimagefree1306683-resi2565486

I love this image of a health care provider looking into a patient's problems. I can work with patients for a long time and realize I am only seeing such a small part of who they are and what ails them. Health care providers learn to look through the stuff that separates, but only as a patient opens up. I am afraid modern day medicine is retreating behind a thick wall to some degree. The beautiful art of medicine lies in the decoding process of all the pieces we are given. I have been recently treating a patient named Stephanie. Because of how serious her injury, I am really getting to know her. She has a nerve injury we are trying to sort out. She is getting many opinions on my recommendations. We talk, we email, we explore. I am so impressed at her strength, but understand her fear. Most health care providers want to see their patients face to face for every exchange, but it is not practical. The fragmented images are more fragmented on paper, or phone, or internet, but it is just a new learning curve. I have learned to love the ease of the email. But, since I am from San Francisco, I miss the hugs (probably why I got into medicine in the first place).

Today I had a great visit with a patient named Robin. Very complex spirit, but very centered, and easy to be with. I am sure I am seeing her through a peep hole, or a crack in the fence. If her health requires alot of investigation, I feel she will be fun to work with.

The world is crying out for health care providers to be primary care doctors (where the buck stops!!) Not triage doctors which hear a complaint, and always just swish you around to various specialists. Every specialty should have super specialists and general care specialists. I feel I do a decent job as the primary care podiatrist for my patient's foot and ankle problems. By being the foot primary care specialist, the buck stops with me!! Even though I am sending Stephanie to various specialists, I gladly take full responsibility to help her decide her options, to wade through the complexities. If you have a foot injury, you should have a primary care foot specialist who takes care of you--and that can be a physical therapist, podiatrist, orthopedist, chiropractor, etc. Someone who is committed to know what every one is saying, and to see you through the injury to the end. Someone who will be priveleged to see you at a deeper level.

Big Toe Joint Pain: Email Advice

Good Afternoon, Dr. Blake.

Hope you had a great holiday. :)

It was fun, but definitely a blur.

I want to thank you for giving me a call this afternoon to let me know that you received
the X-Rays from my HMO. I really appreciate it, because I know you have got to be
a busy person, especially during this part of the year.

After my visit with you earlier in September, (when you didn't have the X-Rays) I went back
for my consultation with the HMO podiatrist.

She definitely said that it wasn't a bunion, but after viewing the images said it was a bone spur.

Originally, pre-imaging the doctor said that fusion of the big toe joint was an option, but after imaging said that wouldn't be

a good thing.

So I'm in agreement with both of you in that I don't want to fuse anything. I have more motion

by not doing so.

What I'm wondering, however, is if you would be in agreement that it is a bone spur and if you would

also agree that going in and smoothing out the surface, (which is what the podiatrist proposed) would be

a good option. If it would at all alleviate some of the pain I've been having when pressure is put on that area.

Also, if there is a chance that it would give me back a little more motion.

She said it would be probably around a two-week rehab with the smoothing out process.

Right now, my foot definitely lets me know when I've worked it too hard or am in the wrong kind of shoe.

All my shoes are pretty much flats, (supportive flats) but it still bothers me with all the dancing I do.

The orthotics were declined by the HMO, so I won't be getting those anytime soon.

Let me know if I should call you back today or tomorrow

or make a follow-up appointment to see you in person at St. Francis.

Thank you so much for your time.

Best Regards,
 
Heidi
 
Dear Heidi, Thank you for allowing me to answer this email on my blog. I have even changed your name to protect you. When you first saw me the podiatrist had been talking about fusing your big toe joint as a primary surgery and I was quite appalled. I am so glad that opinion has changed. You definitely need surgery, but good rehabilitation of the toe joint will take a few months, and you will have to be good to the toe for about one year.
 
Why do you need surgery? Let us look at your xrays. Here are the straight images from the top of your foot noting arthritic spurs and irregularities in the joint suggesting Hallux Rigidus with degenerative arthritis.
 

You can see part of the joint does not look healthy at all.

Here is the 2 links in which I discuss Hallux Rigidus that I know you have already seen. The 2nd one where you will be following surgery, and the same treatment will be needed (immobilization to some degree with anti-inflammatory, following by a restrengthening phase to return you to activity). Every one goes at a different pace.

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

http://www.drblakeshealingsole.com/2010/09/hallux-rigidus-initiating-conservative.html

This is just a zoomed out version of the above photo giving you more perspective on the arthritis in the big toe joint (irregularities) not seen in the 2nd joint next to it. This view however shows nothing that guarantees you need surgery (we see it in the side view called the lateral view).

It is this side (lateral view) of the big toe joint (first metatarsal-phalangeal joint) that shows why you should have surgery. See the large piece of bone wedged in the top of the joint. It is an arthritic spur that may have broken off at some time, but definitely you can not co-exist with this for your life. Surgery (called a cheilectomy pronouced ki lec toe me) would clean out this and all the other spurs and irregularities and give you an arthritic but less painful joint. The surgery just sets the stage for the rehab. The rehab of  your toe and physical fitness can not begin until this is cleaned out, and the doctor you mentioned has a good reputation. But, this is not To Cut Is To Cure, the surgery is 50% and the rehab is 50%. I would feel comfortable with you having surgery, if I felt comfortable that you will get all the right physical therapy, orthotics, taping, castings, etc that you need after. That should be your next big discussion with the surgeon. Without good rehab, you will get even less motion in the joint afterwards.
Heidi, I hope this has helped you. Rich



Putting the Pieces Together

http://www.dreamstime.com/stock-images-eze-17-roofs-rimagefree1305105-resi2565486

I had a great discussion today with a patient Valerie. She appeared from the onset to have Hallux Limitus (limited range of motion of the big toe joint) as her primary source of pain, but as we discussed her situation and the onset of pain it seemed like her symptoms correlated more with nerve irritation. The nerve that runs on the top of the instep can get irritated from shoe laces and eyelets real easily. So again her and I as a team will try to Put The Pieces of the puzzle Together. Today was her initial visit, so we had the first rock today. Not sure how high it will go. We started by icing the big toe joint 3 times daily with a 10 minute ice pack and avoiding activities that bend the toe too much (lunges with her trainer, and high heels). But we also started with lace skipping to remove pressure on the eyelets that are the most painful, tongue padding with felt to spread out the pressure over a larger area, and gentle nerve stretching with ankle range of motion movement. I told Valerie to email me in 2 weeks to see how she is doing, and we can add another rock if needed.

Ultimate Frisbee: Email Advice

Email sent 1/3/11

Dr. Blake,


Happy new year!

I have a question that would probably be a great one for your blog. I joined a competitive beach ultimate league and will be going to a beach tournament in two weeks. I haven't played a lot on sand, so I'm trying to figure out what equipment I need.

First of all, do I need to wear the braces on sand? It seems harder to get injured by the surface, but there's still a risk of stepping on another person, which is how I got the high ankle sprain in the first place. I also sometimes get the sensation that something is 'giving' in my ankle in certain positions (just moving around the house, not in athletics) when unbraced, and I wonder if sand allow it too much freedom.

Editor's Note from Dr Blake: Sasha had a really bad sprain, actually a high ankle sprain which she is getting better from, but I would protect it in unstable environments like this for a year longer than you think you need to. And during that whole year do ankle strengthening emphasizing fast twitch and proprioceptive strength.
Second, if I have to wear the braces, can I wear sand socks as well? Over or under the brace?

Editor's Note: It would be preferrable to wear the Sand Socks against your skin and the ankle brace on the outside. I do know a few patients that wear an extra Sand Sock on the outside to protect the brace from the sand. You would have to get 1 or 2 sizes larger for the outside layer of sock (ie medium inside and large or extra-large on the outside).

http://www.sandsocks.net/product.cfm?gclid=CImj__fhn6YCFRNSgwodFxfwnw
 You asked me to report back about my HMO. It was very difficult to get that initial appointment, since they wanted me to go through a general practitioner first (with a 3-week wait for an appointment) and then make an appointment with a physical therapist (another 3-week wait). I did some complaining and luckily got through to the Sports Medicine department, which is entirely separate from the Physical Therapy department. I left a frustrated voicemail for the department supervisor and she called me back offering me an appointment the next week! So I learned early that it pays to be an advocate when you are not the default case the System is expecting. Since I was at the end of my rehab, I had two appointments with a physical therapist (who is herself an elite ultimate player!) to show me more aggressive and sustainable strengthening. And I've been OK since. Wearing braces on both ankles when I play sports, but not when I run or bike or walk. And free of other sprains and pains in that ankle!

Editor's Note: Hooray!! Most patients following an ankle sprain just play lip service to the restrengthening phase from 3 to 12 months post sprain. It is not hard, but takes an effort and discipline, since you are normally feeling great at that level. Sounds like the physical therapist did great by her.
Thanks again for the great care when I had my last insurance. I've recommended you to several acquaintances. And thanks for considering my questions!

-Sasha