Quiz Answers #2: Answers to Daily Sports Medicine Quiz

Here are the answers to yesterday's quiz.

#1 True

http://www.drblakeshealingsole.com/2010/12/plantar-fascial-tear-possible-cause-of.html

#2 YogaToes place a very natural stretch in the direction of straigthening all the toes. It would be difficult to hold the stretch long enough with your hands to get the same stretch. Like all stretches, there should be no pain. It can take time to get used to them.

http://www.drblakeshealingsole.com/2010/03/tips-on-bunion-care.html

#3 4 Heat to 1 Ice

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

#4 Full Length Lifts

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-20.html

#5 L4

http://youtu.be/E0E60NpOSHg

#6 The 7 generalizations of stretching are: hold each stretch 30-60 seconds, no bouncing, deep breathe, alternate between sides, warmup before stretching, stretch after exercise, and never stretch through pain.

http://www.drblakeshealingsole.com/2010/07/video-7-generalizations-for-stretching.html

#7 Outside or baby toe side (lateral)

http://www.drblakeshealingsole.com/2010/06/help-for-supinators-lateral-shoe.html

#8 Adequate plaster fill to ensure first ray allowed to plantarflex

http://www.drblakeshealingsole.com/2010/09/inverted-orthotic-technique-determining.html

#9 HbA1c

http://www.drblakeshealingsole.com/2011/01/apma-sponsored-video-on-diabetes.html

#10 Rest
        Ice
        Compression
        Elevation

http://www.drblakeshealingsole.com/2011/05/rice-therapy-following-ankle-sprains.html

Quiz #2: Daily Sports Medicine Quiz

As with all the upcoming quizzes, answers will be posted the next day.

Quiz#2

1. Tears in the Plantar Fascia normally require 3 monthes in a removable cast/boot. True/False
2 Why are YogaToes (or the knockoffs) helpful for bunions?
3. What is the ratio of heat to ice in contrast bathing to reduce swelling? (with the most amount of heat).
4. In treating short leg syndrome, are heel lifts or full length lifts preferrable?
5. What lower back nerve root may be involved with pain on the outside of the big toe joint (bunion side)?
6. What are the 7 generalizations of stretching?
7. What side of a running shoe is a valgus midsole wedge put into?
8. In designing an Inverted Orthotic Device, what precautions need to happen under the first metatarsal of the positive cast?
9. In a diabetic patient, what test is very crucial and should be under 7.0?
10. R.I.C.E. stands for what?

Gradual Process of Weaning Out Of A Cast/Removable Boot

Dr Blake's Note: This patient is recovering from a broken sesamoid bone under her big toe joint (first metatarsal) and is beginning the process of weaning out of the removable cast.

Hello, Dr. Blake,

I hope you are well! I still read your blog faithfully, even though I am getting much better.

I am resending a message from about a month ago, since I have discovered that some of my AOL account messages are not getting through to people so you may never have received this. It basically asks about how to wean out of a boot; also curious about your thoughts on rocker soles.
I also want to tell you that I think your site may have changed health care for many sufferers in Seattle and Washington; I found the "Even-Up" there, and no one here has ever seen one-- I've been introducing it to this area singlehandedly. Well, I just got a call from the Orthopedics Dept here where I work asking where I got my EvenUp! Now their patients will be told about them!

EvenUp seen on the left foot with the Removable Cast right foot

Dr Blake's Note: This is what it is all about in the evolving health care system. Spread the word when you hear of people with health issues. The internet is opening up new horizons. Bravo to this wonderful patient!!
Thanks again for everything,

Ann
 
Ann, Thanks and I am very proud that I can make a difference, and you too. We are a team together trying to help the health of foot sufferers.

 I think the rocker shoes, especially when you are having foot problems, are too unstable, and too unpredictable. So I would avoid them for the forseeable future.

 Golden Rule of Foot: Weaning from the cast needs to be painfree.

 Golden Rule of Foot: You can wean out of the cast if you are painfree in the cast for at least 2 weeks.

 Most people begin to wean out of the cast after work, evenings and weekends when they can think about their foot and be extra slow and careful. Many times the work environment is too busy, and you just can not think about your foot as much.

When they have accomplished this initial painfree transfer from cast to no cast, they begin weaning off at work. You begin weaning by starting with 1 hour in your shoes, inserts with accommodation, spica taping.

You gradually add 30 minutes to 1 hour per day of time out of the cast as long as there is no increase in pain.

Many patients need to level out at a certain level if pain begins after a certain amount.   Stay in the painfree zone. This is why the typical weaning process can take from 2 to 8 weeks.

Read the posts on the Magical 80% Rule and Good vs Bad Pain, since as we increase function, pain may be slightly increased.

http://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html
http://www.drblakeshealingsole.com/search/label/Good%20Pain%20vs%20Bad%20Pain

 Do Not Experience Bad Pain (pain over level 3), pain that you would want to limp.

 Hope this helps. Email me at drblakeshealingsole@gmail.com if i am not clear. Rich
 
And here is the immediate response from the patient.
Hi, Dr. Blake,


Once again, THANK YOU. These specifics and ideas and estimates of time frames are SO helpful (and very clear), and I have not gotten that level of information from my care providers here so I've sort of been making it up (and overdoing it, as it turns out). I am now thinking I'd better go to see one of the Seattle folks you recommended to me, since it's not really fair to keep asking you for specifics like this! I'll let you know how it goes.

Dr Blake's Note: It can be hard to give specifics without all the information, but I hope some the generalizations I present can be helpful to patients.



I am so grateful. And hope you have a wonderful weekend!

Ann
 

Answers to Daily Sports Medicine Quiz #1

Quiz #1 Answers




1. No

http://www.drblakeshealingsole.com/2011/05/achilles-tendon-ruptures-dont-forget.html



2. 2nd Stage

http://www.drblakeshealingsole.com/2010/03/tips-on-bunion-care.html



3. Hunter's Response

http://frank.mtsu.edu/~wwhitehi/atep/497/ch4.html



4. No

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guideline-10-know.html

5. Cortisone and Alcohol

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

6. Mechanical Changes, Flexibility, Anti-Inflammatory

http://www.drblakeshealingsole.com/2010/03/treatment-of-plantar-fasciitis.html

7. Relieves Pressure 1st Metatarsal (Ball of Foot)

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

8. 35 Degree Inverted

http://www.drblakeshealingsole.com/2011/03/inverted-orthotic-technique-arch.html

9. Doppler Ultrasound

http://www.drblakeshealingsole.com/2010/08/calf-cramps-common-causes-and-diagnosis.html

10. Tendinitis

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Quiz #1: Daily Sports Medicine Quiz

All answers to the upcoming daily quizzes will be posted the following day.

Quiz #1

1. Complete achilles tendon ruptures always need surgical repair. True/False

2. In what stage of bunion development do you start to see the big toe drift towards

    the 2nd toe?

3. What is the name of the intense vasodilatation phase when using ice therapy?

4. One of the common compensatory patterns of short leg syndrome is early heel

    lift of the long leg. True/False

5. What are the 2 most common types of therapeutic injections for Morton's Neuromas?

6. What are the 3 general categories in the treatment for plantar fasciitis?

7. What is a Dancer's Pad?

8. With a relaxed heel position of 10 degrees heel valgus, what is the initial inversion Rx

    for the Inverted Orthotic Technique?

9. What test should be ordered when a patient presents with calf cramps severe enough to 

    interfere with sleep?

10. The acronym B.R.I.S.S. is used in the treatment of what condition?

Good Luck. Dr Rich Blake

Heel Pain and Physical Therapy Modialities

The following video briefly goes over some physical therapy modalities commonly used in the treatment of heel pain, such as plantar fasciitis and plantar heel bursitis.





Ultrasound is commonly used as a source of deep heat.

Ultrasound is typically used for 5 minutes.

Ultrasound must be kept moving to prevent burns.

Interferential is used to reduce pain, swelling, and muscle spasm.

Interferential must be diagonally crossed.

Interferential is typically used for 15 minutes.

Deep tissue work is used to breakdown scar adhesions. A skilled manual therapist can even break down a bursae, but it is very tricky to not inflame the bursitis further.

Stationary Bike Seat Height for Injury Rehabilitation

The following video demonstrates the principles of starting a patient on a stationary bike during injury rehabilitation.






With many foot injuries, the stationary bike is an excellent rehab tool. No matter where the pain is normally the foot position on the pedal can be adjusted to find a comfortable spot. With many ankle injuries, the seat height can be lowered so that the ankle does not have to bend. When you do lower the seat height, the knees are bent more than normal, and the gears should be eased up abit to have less resistance.

Achilles Tendon/Plantar Fascia Injuries: Role of Calf Tightness

Calf Tightness is an often missed as the cause of achilles or plantar fascial injuries. This short video demonstrates one of the techniques used in breaking down tightness in the calf that can cause achilles tightness. Self massage with ethaform roller, rolling pins (yes used for cooking), or other devices like the Stick should be implemented if you note that the sore side is also tighter when stretching the achilles tendon.

http://www.amazon.com/s/ref=nb_sb_ss_c_1_9?url=search-alias%3Dhpc&field-keywords=the+stick&sprefix=the+stick

http://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Dhpc&field-keywords=ethafoam+roller&rh=n%3A3760901%2Ck%3Aethafoam+roller&ajr=0

Anatomy of the Posterior Tibial Tendon

Injuries to the posterior tibial tendon on the inside (medial) aspect of the ankle include: posterior tibial shin splints, posterior tibial tendinitis, posterior tibial tendon dysfunction, os tibial externum syndrome, and arch pain. In fact, the posterior tibial tendon can even be involved with tibial stress fractures. It is the body's strongest defense against over pronation and arch collapse. When a patient pronates excessively, the weakest link in the chain is affected. It is very important that the anatomy of the posterior tibial tendon from origin to insertion is understood when treating pain along its course, since other structures with different treatment regimens can be painful and many misdiagnoses occur. I hope this video clearly demonstrates the anatomy of this frequently injured structure.

Taping for Posterior Tibial Tendon Dysfunction/Tendinitis

This video presents the use of 2 inch Kinesiotape to help support the arch relaxing the pull of the posterior tibial tendon. The various injuries associated with over pronation and the posterior tibial tendon are helped with this taping technique. The injuries include (although not exclusive): posterior or medial shin splints, posterior tibial tendinitis, os tibial externum syndrome, arch strain, and tibial stress fractures. This form of taping is a common adjunct to stable shoes, orthotic devices, and power lacing. For those of you unfamiliar with power lacing, the video below shows this powerful stabilizing technique.

Posterior Tibial Tendon Dysfunction: Important Muscle Testing

The following video demonstrates the 4 muscles/tendons that need to be evaluated for pain and/or weakness in the treatment of posterior tibial tendon dysfunction.



Pain in this area commonly generalized as posterior tibial tendon soreness must be differentiated from the other tendons. Plus, in strengthening the posterior tibial tendon, it is very important to truly isolate it from the other possibly stronger tendons. See the video below on the 4 common ways of strengthening the posterior tibial tendon.

Taping for Achilles Injuries (Longer Version)

The following video discusses how to tape for achilles tendon injuries. This is a common modification of a previously shown version (link below). When trying to rest the achilles tendon, tape immobilization, orthotic devices, heel lifts, braces, heel shoes/boots, and removable or permanent casts are all part of the treatment arsenal.



The previous video on another version is featured below.

Achilles Tendon Injuries and Zone of Ischemia

This short video introduces the importance of immediate treatment of achilles tendon pain especially when swelling is noted. The area 2 to 5 cm above the attachment of the achilles tendon in the body of the tendon is called "The Zone of Ischemia". It is an area of relative poor blood supply. When an injury to the achilles tendon occurs, if there is swelling in this zone of ischemia, the normal circulation is cut off and healing potential comes to a halt rather quickly. This is why athletes fear achilles tendon injuries since they can be so chronic. It is vital to work on the swelling with physical therapy, accupuncture, ice packs, heat in careful amounts, and contrast baths.

Evaluation of Heel Pain

Dr Rich Blake demonstrates the typical evaluation of heel pain with emphasis on area of plantar fasciitis, heel bursitis, achilles tendinitis, heel stress fractures and localized or referred nerve pain in this video.

Taping for 2nd Metatarsal Pain

Many patients develop pain in and around the 2nd toe and metatarsal. Along with Budin Splints (see separate posting), kinesiotaping can be used well to immobilize the second and/or third metatarsal joints.

Posterior Tibial Tendon Strengthening Exercises

Dear Dr. Blake,


Please post the link to the specific exercises that isolate and gradually strengthen the posterior tibial tendon. Any exercises (resisted adduction, e.g.) that I've tried hurt.

Thanks! Yvonne

Dear Yvonne, Thanks for the email. I hope the above video helps you understand the 4 basic forms of strengthening exercises used in the treatment of posterior tibial tendon dysfunction. Gradually the patient is progressed from Active Range of Motion to Isometric to Progressive Resistance to Functional. Heat (in the form of warm water soaks, heat linaments, or heating pads) is used often to loosen up the tendon before exercise for 10 minutes. If walking is not painful, 5 minutes of walking can get the blood pumping. Ice should be used after for 10 minutes, normally an ice pack over the sore area. NO Pain can be experienced during the exercise. If you are still having trouble strengthening without pain, try the numbing effects of ice. Ice the area for 5 minutes, then let the tissue unthaw for 20 minutes, and then try the exercise. Should work until the tendon is significantly damaged. Then ice 20 minutes afterwards. I sure hope this helps. Rich

Fatigued?? Overworked?? No Time for Friends??

The Medical Board of California is encouraging overworked physicians, like myself, to read a good book entitled: The Fatigue Prescription: Four Steps To Renewing Your Energy, Health, and Life by Dr Linda Hawes Clever. After some review, and after personally failing the Renew-O-Meter, I felt it probably applies to alot of my readers also. Please look at the 2 links below and take the test to see where you stand. If you are recovering from an injury, you need to get some balance back into your life to heal well. If you have upcoming surgery, you will need some balance to handle the demands on your life. If your kids are growing older, and you are only watching from a distance, renew now!!! If you are planning an important event in one or two years that will consume alot of your time and energy, get in balance now. Hope someone, maybe even me, is helped by Dr Clever's thoughts.

http://www.thefatigueprescription.com/
http://www.renewnow.org/

Taping for Achilles Tendinitis

ELASTIKON Elastic Tape One Roll: 2'' x 180'' Stretched - EachMcDavid Two Pack 30-Yard Rolls Underwrap, Green
ATHLETIC TAPE- ROLL, WHITE

     Taping for achilles tendinitis is coming back into vogue with the use of kinesiotape. But, since I presently have no experience with this version of kinesiotaping, I thought I would show you several tried and true methods to tape achilles tendons (this video has one of those versions). The treatment of achilles tendinitis from a mechanical standpoint is to limit some of the ankle dorsiflexion (forward bend of the ankle/not pointing downward like a ballerina). The 4 methods commonly used are: heel lifts, orthotic devices (not full length), taping, and running shoes for everyday wear for their extra heel lift over cross trainers, flats, etc. Of course, most boots, clogs, heels, wedges also have this characteristic.

     The three products you would have to purchase are: 3 inch elastikon, 1 and 1/2 inch athletic tape, and prewrap (see links above) which are all readily available. You would tape for athletic activities, or prolonged walking, but some tape all day long. I will have another video soon on a slightly different version.

     Remember with achilles tendinitis you need to ice, stretch, strengthen, and protect. See previous post on achilles tendinitis (often spelled tendonitis).
http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

Posterior Tibial Tendon Dysfunction: Email Answer

Dear Dr. Blake,


I have searched your informative blog and not found much on PTTD. I really enjoyed reading your tailored approach to each patient in your blog comments, and I am hoping you can give me some useful insights. I do like and trust my podiatrist, but I am in a quandary and want to explore every avenue before summitting to surgery.
(Dr Blake's comment: PTTD stands for Posterior Tibial Tendon Dysfunction. This is the most important tendon for supporting the arch. Complete tearing of that tendon always leads to complete arch collapse. So this is a very serious problem).
I am a 40 year woman in excellent shape, trying to avoid surgery for PTTD. . I found you in reference to your use of inverted orthoses and I am wondering if I consistent use of them might help me. I have consulted with two podiatrists and both have agreed on the PTTD diagnosis, now I just need to figure out my plan.
(Dr Blake's comment: The Inverted Orthotic Technique is the most sophisicated foot orthotic for arch support and is always used for PTTD. There are only a handful of orthotic labs in the US that may them, but a relatively easy technique to learn).
HIstory and background:

I sprained both ankles in my early 20's, the left ankle was a more severe sprain.
(Dr Blake's Comment: this probably left her with some weakness in her arch).
I have had pain in the arch ankle area of my feet for the past six or seven six years, always when wearing improper footwear (heels). The pain always stopped when I went back to supportive/comfortable shoes.
(Dr Blake's Comment: this is the classic presentation of PTTD where the symptoms begin gradually in the arch and/or ankle areas).
I work-out in the gym  four times a week (weights, elliptical, stair climbing machine) and have always hiked for exercise (usually once a week).

My problem became severe when, on a two-week trip in SE Asia in the Nov. '09, I wore flip-flops almost exclusively. We did tons of walking, and at for the first time I noticed my feet burning and tingling in the evenings. I did not connect this sensation to my other painful flare-ups, because I had always assumed it was my high heels causing it. It did not occur to me that I could hurt my feet wearing flip-flops.
(Dr Blake's comment: Again, the symptoms of PTTD gradually begin to change affecting other activities, although one day of aggressive walking in flip-flops if you have a predisposition can cause symptoms).
Over the next six months I experienced increasing pain in both feet upon getting out of bed and standing up first thing in the morning. My left ankle and arch started to look slightly swollen, but I did not see a doctor.
(Dr Blake's comment: This is probably the first mistake, if you see swelling, the body is actively trying to heal something, and may need some help and guidance).
I finally sought treatment when, after a run last summer (August '10) , I was in so much pain in both feet that I had trouble walking. I experienced shooting pains up the calves up both legs at night and my left ankle and arch was red and painfully swollen.
(Dr Blake's comment: Here she is in the Immobilization/Anti-inflammatory Phase of Rehabilitation. You must create a painfree environment and allow the tendon time to heal. You normally need a removable boot, followed by brace, followed by orthotic device. You normally need to combine immobilization with ice and contrast bathing to reduce swelling in the tendon. You normally begin strengthening the tendon painfree from the first visit. Emphasis on the painfree).
First podiatrist diagnosed stage 1 PTTD and prescribed orthotics. Second podiatrist concurred and added ice/anti-inflammatory therapy and in addition put me in a walking boot until my inflammation subsided. After six weeks in boot I went to just wearing the orthotics and sometimes Dansko shoes. My right foot felt 98% better, and my left foot was improved to the point where I could often walk with no pain (always wearing orthotics).
(Dr Blake's comment: Stage 1 the tendon is inflammed, but fully functional. Stage 2 the tendon has some tearing, and begins to not support the arch well. Stage 3 the tendon tears enough to not be functional, and the arch begins to collapse. Stage 4 the tendon completely tears and the arch completely collapses).

Which brings me to my present situation; I am in pain a lot of the time once again, as sometimes want to be barefoot (live at the beach, have a six-year old daughter), wear an attractive (flat) sandal with support, but find that I cannot do so without incurring a lot of pain in my left foot. As I write this I am back in my walking boot as left inside ankle/heel area is throbbing with a dull pain. I wore shoes without orthotic devices yesterday and I'm now paying the price!
(Dr Blake's comment: Golden Rule of Foot: Create a Painfree Environment or else the problem will not heal. This is especially true with PTTD. You need to create a painfree environment. You must stay in that boot until the pain goes away).

Upon hearing all of this from me, my podiatrist has finally recommended surgery. He is of the opinion that that is the only solution for my particular situation. I tend to agree, but I feel overwhelmed when I hear the reality of the recovery. Is there any chance he is wrong? Could I religiously wear the inverted orthoses and "heal" my left foot the way my right foot was improved? Or should I just "suck it up" and do the surgery so I can have a chance for a real recovery and a lifestyle that will resemble "normal" again?
(Dr Blake's Comment: yes, yes, maybe)

Dear Joann,
     Thanks for the email. When patients present to my office with this scenario, I just try to start over. Pretend the injury just happened. Try to put a healing environment together for them to hopefully end with a successful rehabilitation. Sometimes the decisions are hard to make, but we make them and stand by them.
     So, what must you do now? What will allow you to heal? First of all, surgery is only needed 100% for Stage 3 and 4. Does not sound like you are there. Your focus must be immobilization, anti-inflammatory, and restrengthening. Nothing from this point should hurt. The activities should not hurt, the strengthening exercises should not hurt, and the physical therapy should not hurt. Definitely read my post on Good vs Bad Pain and live by it.

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html
     Since the posterior tibial is the strongest arch support tendon, help it out as much as you can to do it's job. This is accomplished with taping techniques, the Inverted Orthotic, stable shoes, wedging of shoes, power lacing, and bracing. Your podiatrist/therapist and you need to create a stable environment, whether it is pre or post surgery. So if a surgeon does not know how to create a stable environment for your tendon, if he/she does surgery, they most likely will not know how to rehab it after.
http://www.drblakeshealingsole.com/2011/01/posterior-tibial-tendinitisdysfunction.html

     Here are so many strengthening exercises for the posterior tibial tendon that is normally easy to gradually build up the strength. Remember, if you try to strengthen a muscle/tendon, and you produce a pain response, the tendon is the end gets weaker.
http://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html
     What helps control inflammation? Icing (if they is no swelling or after activity), contrast bathing if there is swelling, physical therapy, accupuncture, many topical creams (some by Rx and some OTC), and oral medications. I like to stay away from months and months of oral medications, but short courses when the inflammation is flared is fine. 

So Joann, I will try to dedicate alot of my blogging over the next month to this issue. My recommendations for you right now:

1. Stay in the Removable boot for the left side until you can walk without pain for 2 weeks.
2. Purchase an Evenup for the right side to protect your back.
3. Begin icing 3 times daily for 10 minutes both sides. The left should have evening contrast bathes starting at one and one due to the throbbing. 
4. Get an Inverted Orthotic Device for both sides, or some type of orthotic that does not allow your foot to pronate at all. You will need this to gradually wean off the cast.
5. Begin some posterior tibial tendon strengthening each evening followed by 10 minute ice bath.
6. Get bilatteral ankle MRIs to document June 2011 status of both your tendons.
7. Find out the stage of your posterior tibial tendon disease and comment on this blog. I will reply.

I sure hope this helps. Rich

Low Dye Taping Modifications

This video is a sequelae to the recent video on Low Dye Taping. Here common modifications to the Low Dye Taping for arch/plantar fascia pain or just overall reduction in pronation are presented by our Athletic Trainer, Aphrodite.

More on High Heels: So What do you think of Flatforms?

http://www.irishtimes.com/newspaper/health/2011/0531/1224298131741.html

This article talks alot about the inherent dangers of very high heels, stating that 2 inches is a reasonably safe heel height for normal wear. The tightening of the calves can be balanced by daily stretches. I hope Lady Gaga hears that.

But,  this article also introduced me to the Flatform. I hope this can become a strong fashion trend. Looks safer!!

Low Dye Taping

Dr Ralph Dye, a podiatrist, invented a way of taping the arch which is called the Low Dye. The High Dye was his version of an ankle taping. Both of these techniques are widely used now 50 plus years later. This video demonstrates a version of the classic Low Dye used for a variety of foot complaints including plantar fasciitis, foot strain, metatarsalgia, foot arthralgias, etc.

Lady Gaga May Need Our Help!!

I must announce to the world that I love Lady Gaga's music. I was saddened today by the fact she hurt her foot and needs medical care. Her music videos must go on and I pray that her podiatrist/orthopod that sees her gives her great advice. The Gaga Show must go on!!!! She the article below.

http://www.contactmusic.com/news.nsf/story/lady-gagas-foot-problem_1222165

One of my previous posts linked below talks about the need for stretching when you live in heels. Hopefully Lady Gaga will not stretch through pain, since that makes the tendinitis worse. Also, if you are close to her, tell her not to do any negative heel stretches, feels great, but can tear fibres apart that are trying to heal.

http://www.drblakeshealingsole.com/2010/08/high-heels-fashion-accessory-with.html

http://www.drblakeshealingsole.com/2010/08/high-heel-wears-need-to-stretch-often.html

http://www.drblakeshealingsole.com/2010/08/plantar-fasciitisachilles-tendinitis.html

If you have other comments for Lady Gaga, post them on my blog, I am sure she will read it.

Avoiding Blood Clots after Surgery

http://health.usnews.com/health-news/family-health/bones-joints-and-muscles/articles/2011/05/29/take-steps-to-prevent-pulmonary-embolisms

Here is a good reminder article to move those legs after surgery or while flying long distances. Learn if you are a high risk for this: obesity, smoking, family history, diabetes, etc.

Ankle Sprains: Taping Technique

I hope this video gives you an idea on how to self tape your ankles. You need prewrap, 1 inch and 1 and 1/2 inch white athletic tape. There are so many modifications that if you get the main idea of what you want to get accomplished, you do not have to do it exactly as the video.

Sandals: Get Good Support This Summer

Hooray summer is here, I think?? Rain rain go away!
A great supportive sandal for this summer when your feet are craving sandals, yet support, is the Orthaheel Wave Flip Flop.

See this product at footsmart.com and amazon.com Also, check out the post below on sandals that can fit custom orthotic devices.

http://www.drblakeshealingsole.com/2010/07/orthotic-devices-for-sandals-more.html

I have many patients who love the Your Sole sandal. Check out http://www.yoursole.com/

Evaluation of Possible Morton's Neuromas

This video discusses the typical physical examination of a patient who may have Morton's Neuroma. This nerve problem is normally between the 3rd and 4th metatarsals and can be difficult to diagnosis and treat. Please see also the links below from other posts on this subject.

http://www.drblakeshealingsole.com/2010/08/mortons-neuromas-which-shots-to-get.html

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

http://www.drblakeshealingsole.com/search/label/Morton%27s%20Neuromas

Foot and Ankle General Strengthening Program

Strengthening exercises for the foot and ankle are numerous with some helpful and some possibly harmful. I hope that these exercises will give anyone looking to strengthen their feet and ankles a good start. After 30 years of being a podiatrist, the word is finally out. People need to strengthen their feet and ankles. The video shows the basic program taught by our physical therapy staff at Saint Francis Memorial Hospital in San Francisco. Patients can monthly increase the number of sets and reps done, and change the exercises to make them more challenging. This is a great 3 to 4 time a week program when you know you should be building up the strength in these poorly often neglected feet of ours.

Taping with Kinesiotape for Bunions

Bunions produce instability in the foot that can lead to pain in the foot, ankle, knee, hip or back. They are a weak spot that need to be addressed, often times quite simply. What do we have at our disposal? Foot strengthening exercises, toe separators, foot orthotics, surgery, shoes, and taping. The video below will show you how to use taping of the big toe joint to stabilize a bunion. If you tape for a week, you may find some of your symptoms that you thought were separate from the bunion are actually related. I have links below to the foot strengthening exercises and toe separators.













http://www.drblakeshealingsole.com/2010/12/foot-strengthening-exercises-who-has.html

http://www.drblakeshealingsole.com/2010/04/toenail-clippings2bunion-care-101.html

http://www.drblakeshealingsole.com/2010/03/tips-on-bunion-care.html

Inverted Orthotic Technique: Heel Contact Point

Hi Dr Blake,


I am an orthotist working in Ireland,

Hope you dont mind me dropping you an email, I have a query regarding your inverted device.

On the website you make reference to marking the lowest point on the heel (on positive cast).
What exactly do you mean by this, is this the most convex point on the heel (fatty pad) when viewing laterally?

Looking forward to your reply

Kindest regards

Declan

Dear Declan,  Thanks for your patience with my response. I hope these 7 photos explain. If not, please comment and I will give it another try.

For those who do not know, I invented the Inverted Orthotic Technique in 1981. Most of my patients over the last 30 years are in some version of this technique, although Root Balance Technique and the Hannaford Technique are also used quite frequently.

Here an uncorrected left foot positive cast with no forefoot to rearfoot abnormality is resting vertical on a platform.

A grease pencil is used to mark up a surface and then the heel area of the positive cast is rubbed over the area with the foot being held vertical.

Here is the mark that was transferred to the positive cast of the lowest point on the heel with the heel in a vertical position.

Here is the same mark on the bottom of the left foot showing the more of the foot for better visualization.

Here is this same foot with the anterior platform nail to set the positive cast to a 30 degree Inverted position.

Here the left foot heel area of the positive cast set 30 degrees with the lowest point on the heel now moved laterally.

Here the lateral mark is demonstrated (further right in the photo) by the same method above.

Declan, I sure hope this helps. Rich Please send more questions about orthotic techniques.

RICE therapy following Ankle Sprains

     Following an Ankle Sprain, it is important to create a painfree environment. The keys components have been taught in High School and College Health Classes forever.

R----Rest
I-----Ice
C----Compression
E----Elevation

Rest is a four lettered word to most athletes, but crucial in minimizing the re-aggravation of the ankle. Rest is created by whatever it takes to make the ankle painfree. This may be crutches, removable cast, ankle brace, limited activity, and/or completely getting off the foot involved. The first 4 days after a sprain is the most crucial time to chill out. Yet, since no one can really be sure 100% of the time what is wrong, the first 2 to 3 weeks following a sprain should be relatively painfree.

Ice for 96 hours following a sprain is crucial. You can refer the previous link on application of ice below. Yet, ice is used for months and months in a typical sprain, it is just knowing when to use it.

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

Compression is also crucial. The product seen in the video is Tubigrip, but a common substitute is an Ace Wrap. The secret to compression is to put more compression below and less compression above the ankle. This may require some tape of some type to hold on the wrap above the ankle. Make sure this tape is not wrapped all the way around.

Elevation even 1 inch off the floor is very beneficial. As long as it is comfortable, and as long as there is swelling, try to elevate the foot and ankle as much as possible. Super Elevation once a day for 30 minutes is very important. Super Elevation is where you lie on the floor and elevate your foot on the wall or couch 3 feet above your heart. Combine this with compression and gentle nonpainful range of motion of the ankle and the swelling will improve the most.

Short Leg Syndrome: Email Advice

Good Afternoon Dr. Blake,


I saw one of your videos on You Tube and finally felt that I was NOT crazy. I hope you can help me.
(Dr Blake's note: please see my You Tube channel entitled drblakeshealingsole)
I had surgery on my left knee at the age of 8 to remove a benign bone tumor. Of course, as you can guess, my left leg is now longer than my right leg. I am 46 years of age and have suffered from a sense of clumsiness, no coordination, “can’t dance”, falling into walls and down stairs most of my life.
(Dr Blake's note: surgery in a young child can either stimulate bone growth so that side becomes longer, or stunt growth so that side becomes shorter).

I had an MRI of my left knee back in March, 2011 to check for medial meniscus tear. Thank goodness, there wasn’t one. Just a week later, my left foot swelled up and started hurting. I saw a local podiatrist right away. Had two sets of foot x-rays about 9 days apart to check for stress fracture. Again, none found.

I was told I needed orthotics since I have a much shorter right leg. Wore a heel lift for about 10 days waiting for the orthotics (which I now know from watching your video is a NO NO!). My symptoms kept getting worse even after I got the much hated orthotics. They make my knees and feet HURT so bad even though I broke then in according to the schedule (1 hour the first day, etc.).
(Dr Blake's note: heel lifts for the treatment of short legs is not the best way, full length lifts are much more stable. Also, you never need orthotics (some version of an arch support) for the treatment of a short leg, only lifts. The orthotics are for the treatment of something else and usually go in both shoes). The pressure from even a good orthotic on a swollen painful foot can be very painful.
I have been in physical therapy for the past three weeks, but the pain keeps getting worse. I am being treated for weak ankles and now knee pain. The left inside of my knee is weak due to the right foot pushing out when taking steps, I am guessing?
(Dr Blake's note: Orthotics and Lifts work the best in the Restrengthening Phase of an Injury. You, on the otherhand, are in the Immobilization/Anti-Inflammatory Phase. You are breaking the one of the Golden Rules of Rehabilitation: Create a painfree environment to allow healing to occur. You should be on crutches, removable boots, rest, etc, along with anti-inflammatory measures. The lifts and orthotics will be important in a month or two. Get the pain under control. Read my post on Good vs Bad Pain).

I’m seeing my local podiatrist this coming Friday and am going to tell him to “stuff” his stupid orthotics. They are causing major gait issues and compounding the knee, foot, and ankle instability problems. Apparently, I also have extremely flexible ankles which is not a good thing.
(Dr Blake's note: They could be the wrong orthotic, but they may be just the wrong timing. Spend the time talking right now about getting the pain under control. Xrays are so poor at recognizing a more subtle soft tissue injury, discuss with him or her about getting an MRI).

I am wondering if I can purchase one of those “3 step” sole inserts you showed in one of your videos. After watching your procedure, I am pretty sure it would make my life much less painful.
(Dr Blake's note: see my You Tube video on Manufacturing of Full Length Lifts. I am happy to mail you 3 but first have the podiatrist review the video and see if he/she will make it for your short side. If not, it will be my pleasure).


PLEASE, PLEASE, PLEASE help me. I don’t think I can live like this; I can’t walk, can’t exercise, and my quality of life has gone down the drain.

Any information you can provide would be most appreciated.

For the record, I am 5’5”, 149 pounds, and wear a size 7 or 7 ½ shoe depending upon the manufacturer.

If you can’t sell me the inserts, can you please let me know where I can purchase them? (Dr Blake's Note: You can always buy 2 pairs of Spenco Inserts in your size. Stand on each one and mark between your toes. Cut out the toe area, since it is most important to lift the heel and ball of the foot only, and not crowd the toes. The third one will have to be a left flipped over (place that one on the bottom).

Many thanks!
Thank You.

Lisa

Hands Free CPR: Effective and The Life You Save Could Be Very Important to You!!!

http://handsonlycpr.org/

Please check out this exciting new form of CPR which has shown to be helpful in preventing deaths.

Plantar Fasciitis?: Email Correspondence

I live in San Francisco and am a 59 year old woman in great shape. I retired a few years go because my mother's Alzheimer's

had gotten bad enough that she had to go into assisted living. She is pretty happy now. Before I had her hospitalized, she had been bipolar all my life, and it had caused a lot of problems for me.
Once hospitalized, her bipolar disease was diagnosed, and she was put on meds that instantly controlled it. In the past three years,

she has never been mean or angry once. I visit her daily, have her living near me, and we have become close and she is always kind and affectionate, even though her memory is shot and she often forgets I am her kid.

I have always been otherwise healthy. I am pretty athletic and go to the gym three to five times a week, or more, until this foot problem began. After a month in France the last few years, I came back with my feet suddenly hurting. The first time, the pain went
away after a few weeks. I had worn Crocs the whole month in France. This past year I also wore Crocs the whole month, and the pain started when I returned.


My doctor said it was plantar fasciitis and I saw a podiatrist who sent me to a guy who made me orthotics. They only seemed to make the pain worse, and I found it really hard to ice them often, especially after first getting up. I did a minimum of the exercises they told me about, but didn't go to the gym because it made it worse, especially the elliptical machines.

I got the special shoes they told me to get and so far have had the orthotics adjusted twice, but now the pain is terrible in my ankles and above. When I go down stairs, I suddenly scream sometimes because the pain is so bad.

I saw my internist while my podiatrist was away and he told me to stop using the orthotics which I have, but the pain is still there.

My internist looked at my feet and said the plantar fasciitis problem is caused because I have hallux rigidus. He made me an appointment with my podiatrist to discuss surgery on each foot.

I've been reading about the surgery and it sounds awful and not with very great odds of it curing the problem.

Please tell me what to do???? I have pretty high anxiety because I am my mother's trustee and have a lot of responsibilities andit is very difficult to watch her getting much worse, and I am close to many people at her home because no one visits them, so I have taken them on as friends. I'm living on a teacher's pension which is pretty amazingly low.





So I especially need to exercise to fight my insomnia and stress. These two foot problems are making working out hard, and I am due for my yearly vacation in July, because I need a break from Alzheimer's once a year or I start getting too depressed.

I was planning to do the hallux rigidus surgeries in the fall if I have to do them, but I just read your article about not doing the surgery. How do I know what to do????

Should I come in to see you?Janis
 
 
Janis, Hopefully we can initially start communicating my email until I get a handle on this. Do not even consider Hallux Limitus surgery if you have no pain in your big toe joints!! Please read the post on medical history taking and answer, then email, all the questions back to me. That will give us a better beginning focus. Go to REI and purchase a pair of the soft athletic red Sole inserts, heat them up if they bother you. If I do see you, they are extremely easy to adjust. I am putting this on my blog tonight. And we update with each email I receive from you. Let's get your feet back, or at least working in the right way again. Rich

http://www.drblakeshealingsole.com/2010/06/giving-good-medical-history-for-pain.html

PS Is there anything that does not make sense when you are contemplating Hallux Limitus surgery, on the most important joint in your foot, when you have had no conservative treatment on it?

Sesamoids: Broken or Normally Just in Pieces




 

Here the inside or medial or tibial (same name for the same bone) sesamoid appears broken into 2 pieces, but is it? Sometimes, these sesamoids never completely become whole, and they are in 2, 3, or 4 pieces. This can be there natural condition and can make the diagnosis of a broken sesamoid difficult at times. With this preclude, here is a recent email I received.

Dr. Blake,


Here is a fun one for you... debating on tripartite sesamoid vs. sesamoid fx.

Personal history, I'm a 28yo female who is fairly active. I danced from childhood through college. Within the past year I have started running and completed my first half marathon on April 10, 2011. I am also a chiropractor who is on my feet most of the day and in various squat and lunge positions when I am adjusting patients. Needless to say, I'm hard on my feet.


While training for my half marathon the only foot problems I had was blisters. After I finished my half, I had pain all over my feet, I attributed this to blisters (since I had SEVERAL). I did not run any the week after my half. I teach dance one night a week, and did not notice any unusual pain during this week. One week after the half I ran a 5K, after this I noticed some soreness under the ball of my foot on the medial side. This was mainly a pulling/stretch then I extended my toes. That following Thurs, I trained with a running group, and we sprinted hills. I pushed it! We sprinted up hill forward 5 times and backward 3 times. I'm not sure exactly when I noticed the pain changing, but a couple days later I realized that standing in releve' (on the balls of my feet) was unbearable (I could only stay there for about 2 seconds, typically it's doesn't bother me at all).

Since then I have not ran, and I am very careful while teaching dance and adjusting. Since it is not getting any better, I have started to play around & look up more things. I have pinpoint tenderness under the fibular sesamoid, the rest of my foot is normal. When I passively extend my toes it hurts but not unbearable. If I flex my 2nd toe against resistance (while keeping my big toe neutral) I have intense pain right at the sesamoid in question. I have had to alter the way I adjust because one of my typical stances has my right foot in a lunge behind me, and can't get enough power from that foot due to the pain right now. (I'm just under 5'4", so I have to use my entire body to adjust some of my patients.) Tuning fork on and around the affected area is negative.


I have attached 2 different pics of the AP x-ray. I apologize they are not the best pics. Due to the fact that tripartite sesamoids are typically bilateral, I will take a XR of my left foot to check that. (I have to get back to our main office to take the x-ray.) Other things I have came across are that bipartite and tripartite sesamoids are typically on the medial sesamoid, while mine is on the lateral. I do have some other congenital anomalies in my spine, so having them in my feet wouldn't surprise me.

I have been icing, trying different taping, and not working out. (However it's not getting any rest when I'm working.) I did your kinesiotaping this morning, however it really didn't restrict my big toe extension. Any suggestions?

While researching this topic, I came across your page, and decided I'd share with you my story. Have a great day!

Tiff

Tiffany's lateral or fibular sesamoid appears to be broken, but is it? The question drives radiologists and doctors crazy at times.

Tiffany, Thank you for the great email. Yes, it is a complicated question? Tripartite or broken? But what about both? You can break the cartilaginous bond between the sesamoids and it must be treated as a fracture. You can break the fibrosis bond between the sesamoid pieces and it must be treated as a fracture. You must treat the most dangerous possibility, because all docs live with patients that the misread the sesamoid injury, thinking it was just bipartite or tripartite, and were wrong. These end up needing surgery, which could have been avoided. These may end up with some disability, which could have been avoided. My protocol now, and it has taken me 30 years of practice to get here, is to get a MRI of possible sesamoid fractures. If this is still questionable, then get a bone scan to look for hot spots. If this is still questionable, get followup xrays in 6 weeks. Fractures tend to show a changing pattern in the bone, even on xray. Since it is the fibular sesamoid, get an Oblique and Plantar Axial xrays which show it well.

     Tiff, you have a classic pattern on long 2nd metatarsal. Are you sure it is not the lateral capsule of the 2nd MPJ that is injured? Please please email any photos of subsequent tests you get.

     If I were you, until you are 100% sure, I would treat it as a fracture. The big toe joint is the most important joint in your foot. Err on being extra careful with this injury. Rich

Morton's Neuroma: Email Advice

Email received 5/5/11


Dear Dr. Blake,

I'm going to preface my question with a thank you that you have probably received many times in response to your blog: "I'm so glad I found your website!" Thank you for presenting your knowledge to people in pain, searching for answers. I wish I lived in California so I could come see you directly and get some help! Instead, I wonder if you'd just tell me what my next steps should be.

I have a Morton's neuroma. I've probably had it already for a year. The first time I went to the podiatrist, she thought I only had a collapsing (hammer?) 4th toe and prescribed the purchase of a soft gel cuff to cut to size and wear on the toe when exercising. This I did. And it did help a little, even though the area still felt numb.

About a year later, I was back, this time the pain having become so acute that I couldn't even walk my dog around the block without hobbling. She did another exam, heard the clicking and pronounced the neuroma diagnosis, and told me that immediate care involves 3 cortisone shots. If that doesn't work, excision or chemical killing of the nerve. So, not knowing any better, I had 2 shots (I don't know one type of cortisone from another, so I'm afraid I can't tell you what it was), each of which relieved the pain entirely for 1 month. At the end of the 2 months, I woke up one day with a pain on TOP of my foot, and a bright red bruise, slightly below the point where the foot bones come together at the top of the foot. For this she took an x-ray because she suspected a fracture -- but she couldn't find any fracture. She prescribed a pressure boot anyway, so I wore that for 6 weeks (!!). Even when she re-x-rayed she did not find any evidence of fracture, but insisted it was not related to the neuroma. Of course everything felt better in the boot because the foot was immobilized, but now that I'm not wearing it, the foot hurts again, this time both the neuroma and the ankle hurt -- I think because of simple weakness.

So now, with that secondary pain healed, we are back to treating the neuroma. Her chosen course of action is immediate surgery.

My first reaction was to say 'no', but of course it is very painful. I happened to mention the condition to an MD friend of mine who is in family medicine and he says he never prescribes surgery first thing but rather starts off with metatarsal support. What?! I asked myself, NOT surgery? He said surgery is only needed in about 20% of cases!

I was surprised, so I began to do a little Internet searching. The first thing I found was that most websites agreed with my DMP's traditional course of treatment -- they describe neuromas more of less popping up out of nowhere (or from high heels, which I don't wear, I wear things like Danskos, Birkenstock, Think, and Nikes, and hiking boots and Uggs in the winters here), and being treated with cortisone or surgery.

Then I happened across your blog and for the FIRST time I read that my neuroma might have other causes that could also be addressed and that I could start first by trying some other things before resorting to surgery. You write that it might have something to do with sciatica or ankle problems... well I had broken both bones in my ankle on black ice (--Minnesota!, in the spring of '05) and have 9 pins holding it together! About a year after that I had some physical therapy for pain in my left SI, which improved a lot after treatment but has never gone away -- I just live with it because it isn't debilitating. Is it possible that the ankle is causing both the SI pain and a neuroma that is also possibly treatable?! Your website was a huge relief to find.

So -- now I come to my questions...

*I read on your site that there are some things I can do first to self-treat -- so first I went out and got a metatarsal support (I could only find one kind at the clinic's shop, there is nothing at Target or Walgreen's, so I may have to go online, but at least I found one pair I can use in the immediate term). That helped quite a bit right away, I tried it on a short walk with the dog and there was only numbness but no burning sensation.

*I stopped going barefoot in the house but now wear my Birkenstock clogs as slippers.

*Should I try alternate warm-cold foot baths even though my injuries are not recent?

*Should I try Neuro-Eze (again, I'll have to order), even though my pain is not constant, but only hurts when walking?

*Tylenol, not Ibuprofin?

*Massage?

*What would YogaToes do for this, anything?

But here's my biggest question: Who do I see to analyze my gait? I don't know if I pronate or supinate, I can't see it. I don't know if my ankle function is harming my nerve- - I do know that when I tried some of your exercises for foot strength, I realized for the first time how small the range of motion/stretching is in my previously injured left foot. Could that be contributing my neuroma and my SI pain?

I guess what I'm asking is if I've already been to a DPM and she insisted that the neuroma had nothing to do with my previous ankle surgery, who can I ask about my gait and who can I get to help me treat the neuroma? I thought I was going to a reputable clinic here, it's large and has a great reputation but I don't know who I would need to see now....and if not a DPM, then who?

Thank you for your time, thank you for your blog! How can I repay you for the hope you have given me that I might be able to get this condition under control and better yet, perhaps even address any underlying cause?!

Sincerely,

June
 
Dear June, 
 
     Thank you so very much for your kind words. Your questions are all valid ones, and most doctors gradually learn all the treatments available for certain injuries (sounds like your doc is early in the learning curve, which is okay and no slight to her, just her reference point right now). In todays medical world, you do have so many choices in treating that surgery should be the last resort.
 
     If you want to try to avoid surgery, and surgery is done on less than 1-2% of our neuroma patients, you need to get 3 or 4 opinions from podiatrists and find one that is willing to team up with you. I do not know where you are at, but asking around for a conservative podiatrist is a start. If you are in the US, you can go to the website of the American Academy of Podiatric Sports Medicine (http://www.aapsm.org/) and check for local members.You need someone to analyze your gait and design orthotics to stablize that gait and off weight the neuroma. Without that, you will need surgery. But the orthotics are more important after the surgery than before for many reasons, so you have to have orthotics even if you are going to have surgery. Shoe stores, running clubs, and physical therapists may give you a recommendation for a podiatrist. And if that fails, start checking into physical therapists and chiropractors that make orthotics.
If you email your city, I can help find a doc if you are having trouble. But, in the end, you will have to go to the appointment and find out if they want to play on your team.
 
     One of the best things you said is that the cortisone shot lasted for 1 month. That really has made the diagnosis of Morton's Neuroma, which can be 1/4 of the battle. Now that you have identified the nerve problem, see a physiatrist or neurologist, to see if the neuroma pain is from a local nerve problem or from your ankle, lower leg, or back. Some podiatrists are good at that, but it is the world of a MD specializing in nerves.
 
    Why do neuromas hurt? They get pinched between two bones and treatment needs to separate those bones. The met pad was great proof of that. Go to http://www.hapad.com/ and order small longitudinal medial arch pads with adhesive backing. See my posts on Hapads. I love them. Have them in all your shoes just behind the sore area.
 
     The irritated nerves hurt more because the body tries to heal them. Your body floods the area with inflammation, and the swelling next to the nerve hurts. Three times a day you should ice or contrast bath over the next month to reduce the inflammation. You will definitely feel better. If you do, keep doing it. Ice 15 minutes on a ice pack, or do the full 20 minutes of contrast bathing. It all depends on your time and what makes you feel the best. Have your primary doc put you on an anti-inflammatory drug 10 days on, 4 days off to rest your system. You may have to go through a few drugs to find the one that makes the nerve feel the best.
 
     So, these are the basic steps right now to get well. You may want to go back to the same podiatrist with this info and just ask 2 questions. Will you help me on this? Or, if not, who can you recommend that will. This is not experimental stuff. So, be confident, kind, and see what she says. The answer may surprise you. Rich
 
  
    

Dangerous Achilles Strengthening Exercise

The video above has two basic parts to it. The first part is the stretching part. As long as the heel is on the ground, the stretch is safe and should produce excellent flexibility. The second part however is the strengthening part. This is very risky since a Negative Heel Effect is created when the heel comes off the ground. Negative heel is when the front of the foot is higher than the heel. This is a very unnatural position and definitely the cause of many injuries. Avoid at all costs. The same exercise starting with the heel and front of the foot at the same level is much safer.

5.6% of What??? could mean Diabetes

http://care.diabetesjournals.org/content/34/4/944.abstract

Hemoglobin A 1c is a great marker for Diabetes. Over 5.6% in laboratory testing means the patient probably has diabetes, so it is one of the best lab screening tests for this terrible disease. For our Diabetic patients, we need them to own their number and we desperately try to keep it below 7.0. Over 7.0 and healing goes way down. Read the short article summary above and get tested if you have a family history of diabetes, have sores that are slow to heal, get chronic infections somewhere in your body, are constantly thirsty, and/or have frequent urges to urinate. The test results just could save your life.

Achilles Tendon Ruptures: Don't Forget about Non-Surgical Options

http://www.htrnews.com/article/20110503/MAN04/105030567/Treatments-Achilles-tendon-tear?odyssey=nav%7Chead

I want to thank Dr Carl DiRaimondo for pointing out that Achilles Tendon Ruptures can be treated non-surgically. I have rehabed about 100 complete achilles tendon ruptures without surgery and another 50 or so surgically repaired. Both have there pros and cons, but both types of repair can be rehabed to 100%+ strength. Both groups seem to start running between 6 and 9 months. Both groups can have failures requiring further surgery. The failures in the surgical group are much more dramatic due to surgical complications. The main complications in the nonsurgical group are re-rupture and inadequate reattachment. Both can be fixed with the surgery in the future.

There is quite a bias in the world  when achilles are ruptured to fix them surgically. They are sent to surgeons from the primary care docs or from the ERs. Only the articles like these can make someone stop and say maybe I could treat this injury without surgery. After one year, whether the tendon was surgically or nonsurgerically fixed, there really is no difference in function. If you are surgically averse like me, and unfortunately you have a problem like this, consider a non-surgical approach. I would be happy to send our protocol to anyone on the non surgical rehab of achilles injuries.