What is 80% better mean?

Hi Dr. Blake,

     I have great news!  I can cross country ski again with the insole you made!!!  My foot needs the hole in the insole and the injured toe taped in a slightly down position. When I go on multiple hour snowshoe and hiking adventures, my injured joint does get sore.  However, it doesn't last more than a few hours afterward.

     I have resumed all activities including the gym and I am walking in slippers and street shoes.  When I am on my feet for very long periods of time, the injured joint still gets sore but I no longer have the throbbing/stinging sensation in the toe/joint.

    I hope you are doing great!  I was thinking of seeing you in the spring and keep you updated if the foot regresses.

Best always,

Dr Blake's response: 

Steve (name changed), 

     Thanks so much for the update. You are in that 80% plus zone where you can do everything, but you still have some symptoms. The last 20% minus of the treatment can last a long time, but each day you get less and less fragile, and any flare, lasts shorter and shorter. Hope this makes sense.  See my link below on the Magical 80% Rule.

     Keep me updated. Rich

http://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html

Do You Want to See Why I Love Basketball?

Research on Treatments can be very difficult: Take Foot Orthotic Devices For Example

     I received this email from a patient who is getting good help of his posterior tibial tendinitis secondary to over pronation from his orthotic devices. Due to the asymmetry of his pronation, his left orthotic device is much higher corrected than his right. This is what he needed to be stable.He is an extremely brilliant young man, and wants to know how things work and what works. Research on most products, like this article on orthotic devices, which have helped billions of people, is very difficult. Our medical directior, famous orthopedist Dr James Garrick, who loves his patients to stretch has always been frustrated at the fact that no research (only public opinion) has ever proved that stretching does anything. I know it does, you probably know it does, but put it under a microscope, exam it, probe and poke at it, and you will find it very hard to document scientifically how it works. Finally, after 50 plus years of the western medical world taking a negative stand on acupuncture for instance, now research is showing some of the reasons why it works so well.
     Foot orthotic devices are another one scrutinized. Most of the one billion people who wear and swear by their foot orthotics, and would not dream about doing at least some part of their daily life without them, would tell you have great they are. So why do famous orthotic researchers say to throw away your orthotic devices. I have reviewed some of the orthotic research and find many flaws in almost everyone of the papers. Orthotic devices are medical devices that must be individualized before they can really work. The research projects tend to miss the boat on this. As I review these papers I try to understand how the orthotic devices were made and the research flaws become apparent. Here are some of the questions I ask that point to the study's flaws. What type of orthotic was made? How individualized the orthotic RX was? What types of shoes and lacing techniques were they wearing? How long were they wearing the study orthotics, and had they been adjusted to the wear individuallly? Had the researcher documented that the orthotic devices completely eliminated the abnormal motion that was being studied? How many hours on the treadmill had the runner/walker done before being videotaped for the study? Were the orthotics coupled with good shoes, power lacing, and other typical day to day things that even the average orthotic prescriber would do? And on, and on, and on!! As you read the research, and you look at the lack of sophisication, it is typically on the guise of standardization. The researcher wants to only study the orthotics, so standardizes the prescription, shoes, surface, etc. But, this truly means that the researcher is really studying a generic device, not a custom made functional foot orthotic.
     When I prescribe orthotic devices, it is important that the left and right feet get different corrections when they need them, that the patient get shoes that stabilize them very well, that they power lace, that they wear lifts for their short side if it affects their gait, that they strengthen or stretch muscles that adversely effect how their bodies move, that they learn better running or walking styles when their gait is affected. All of this aims for stability and less shock to the body. So, when I see a great research paper that addresses this individualization of the process within the study, then I will look with more seriousness at the paper, and then the best research paper on custom made functional foot orthotics will have been written.


http://www.nytimes.com/2011/01/18/health/nutrition/18best.html?pagewanted=all&_r=0

 Dr. Blake, Thank you for my new orthotics. Again, it was good to see you and talk with you. Above is a link to the NY Times article I mentioned. Look at the January '11 date, its surprising its been that long since I read it. I'd be curious to hear what you think the next time I'm in your offices. Happy holidays and happy new year!

CRPS Followup Email with Checklist Update

This is a followup email from a patient struggling with CRPS: Complex Regional Pain Syndrome. It is an over-reaction of the nervous system to a painful stimulus leading to great pain and disability. Reversing that nerve hypersensitivity takes a multi-disciplinary approach that is well balanced. Kim is wonderful at her feedback which I hope will help many patients. This is her program which varies greatly from patient to patient, but the basic principle areas are the same.  Dr Blake

Hi Dr. Blake,

I hope you had a good Christmas with your family.

I'm writing to check in with you. 

I have been doing the Laterality Flashcards, getting three sessions in most days. I will fax you the scoresheet today. I sometimes feel my feet tingling while I look at the pictures, but sometimes I don't feel it. I am trying to sense my own feet while looking at the photos.

I would say that my right leg has improved greatly during this time, and I attribute it to the flashcards. Many days I've had very little pain or sensitivity in the right leg.

However, my left foot and leg are still quite painful. I would say slightly better than when I saw you, but not much. When I haven't walked much it settles down, but when I walk I feel pain just in the foot for the first few steps, but then shortly after the pain shoots up my leg with each step.

I completed a 10-day burst of 400mg Celebrex/day, and am now on the 3rd day of tapering to 300mg/day, with the plan to return to 200mg/day tomorrow. The left foot remains swollen across the area of the metatarsal/phalangeal joints of the second through fifth toes. The swelling is visible on both the plantar and dorsal sides of the foot.

At my last visit, my neurologist suggested a trial of Oxcarbazepine 150mg 2x/day. I am tapering up on that and tomorrow will be at the full dose. He also said it may be time to try a sympathetic block, and I will consult with Dr  S about this. I'm wondering if you think it's time to try this.

I have also been using a compounded cream of Gabapentin/Ketamine/Ketoprofen/Tetracaine 10%/10%/20%/2% 2-3 times daily. 

I am also meditating and relaxing often, several 10-30 min sessions daily.

I have also just started doing a couple sessions of HeartMath, a home biofeedback program, a day.

My sense of what helps: increased Celebrex, Amitriptyline, Noritriptyline, Valium,  flashcards, relaxation

My sense of what doesn't help: the compounded cream

Not sure: HeartMath, Oxcarbazepine, Lyrica

Below is your checklist, sorry it took me a while to fill it out, I'm a bit slower (mentally) taking the meds I'm on.

I am, as you would expect, extremely eager to return to good health and normal productivity, so any advice you have would be welcome.

In particular I wonder if you believe I should try a sympathetic nerve block, or another ultrasound-guided cortisone injection into the neuroma. My body tends to react to invasive procedures by flaring up, so I am reluctant. On the other hand, we are running out of other options.

Dr Blake's comment: Kim was encouraged to try the sympathetic block first to get the nerve hypersensitivity calmed down before addressing the neuroma (the start of the problem in the first place in her foot). The foot pain started and treatment of the foot nerve set off the RSD symptoms. Now she is working to calm her nervous system down. Kim's program is complex, well thought out, and should be successful. 

Regarding another cortisone injection into the neuroma, I do note that the skin over that area is white, and prior to the swelling of the past month, there was a deep depression between the 3rd and 4th tendons, so I thought a third injection was contra-indicated. Now, with the swelling, the sunken area is no longer evident, but there still may be shrinkage of healthy tissue in that area. I do want to be careful not to put too much cortisone.

Thank you so much for looking at my case from this overview perspective. You are the only non-neurologist I've seen who is aware and literate about CRPS, and it's very encouraging to have your support. 

Warmly, Kim (name changed)

Complex Regional Pain Syndrome Checklist

Identifying the Source of pain

• neuroma in 3-4 interspace of left foot
• any walking is very irritating for the left foot and leg pain
• stress or arousal increases pain
• aerobic exercise increases pain in limbs
• scratchy texture on pants causes pain in legs

Mechanical Means of Breaking Pain Cycle

• tennis shoes with wide deep toe box and cushioned soles
• orthotics
• large Hapad to take pressure off metatarsal heads
• minimize walking
• use knee scooter, use crutches, use electric scooter
• temporary handicapped parking permit

     

Oral Medications to Break Pain Cycle

• Celebrex 200mg/day w bursts of 400mg/day 
• Amitriptyline 25mg/day
• Noritriptyline 30mg/day
• Lyrica 150mg/day,
• Oxcarbazepine 300mg/day
• Valium 10mg/day

     

Topical Medications/Applications to Break Pain Cycle

• Dr. B: 2 cortisone injections into neuroma in 3/12, 4/12: first injection reduced pain 15-20%
• Dr. B: 2 epidural injections with no benefit (actually flared the condition)
• compounded cream of Gabapentin/Ketamine/Ketoprofen/Tetracaine 10%/10%/20%/2% 2-3 times daily
• I've tried Neuro Eze but it seems to make the local foot pain worse. Is this a necessary phase to go through to get healing benefit?
• Today I'm trying BenGay on my foot, but it's not helping
• Lidocaine patches (I haven't used these in a while but I'm about ready for one today!)
• Traumeel cream

     

Alternative

• DO for osteopathic treatment weekly
•  DC, for atlas orthogonal adjustments as she recommends
•  Holistic MD: she's done nutritional/gut analysis, beginning heavy metal testing, ruled out porphyria, noted elevated B6 and deficient vit D
• supplements: multivitamin, vitamin C, omega 3 fish oil, various B-vitamins (except B6 which I am too high on), vitamin D, coQ10, probiotic
• we may use other supplements or medications to try to change the balance of the ecology in the gut to favor more beneficial organisms
• Hanna Somatics practice daily and when muscle spasms occur
• diaphramatic breathing and other breath practices
• autogenic training (technique for learning to regulate sympathetic arousal)
• meditation
• relaxation
• restorative yoga and yoga nidra
• HeartMath home biofeedback for heart rate variability
• Laterality flash cards: retraining
• mirror therapy
• Somatic Experiencing (technique for learning to regulate sympathetic arousal)
• jin shin jyutsu sessions
• lymph drainage
• mirror massage (watching someone else get a massage on their foot and leg)

     

Nutritional

• diet emphasizing fresh whole foods, avoiding highly processed foods
• starting gluten-free diet (1 week so far)
• avoiding green beans, rice, beef, beans (the foods on which tests showed some reactivity)
• rotation diet, not eating any food two days in a row

     

Rehabilitation of Limb Function

• foot ROM daily: flex toes, flex ankle, extend toes, extend ankle, inversion, eversion, adduct toes, abduct toes, draw alphabet with foot
• use foot to crumple up a towel to maintain tone of intrinsic muscles of foot
• some side-lying exercises to strengthen L gluteus medius  

     

Being Productive as possible

• continuing to teach my Hanna Somatics class weekly
• maintaining social contact
• reading and continuing spiritual practice
• spiritual book study group
• researching CRPS and treatments/doctors
• doing housework like laundry and cooking as I am able
• corresponding with others with chronic pain conditions to offer mutual support 

Co morbidities

• hypothyroid: now taking 75mg/day levoxyl, retest TSH and thyroid soon
• hyperprolactinemia: pituitary adenoma, watching and checking prolactin and checking optic nerves, optic chiasm, and visual field

     

List of things I know of but haven’t tried yet

• sympathetic regional block
• seeing a professional practitioner for biofeedback training
• hyperbaric oxygen therapy
• other meds

Simple Explanation of Laterality Flashcards and Mirrow Box for Nerve Pain

Funny you should write, I had my first filled out laterality sheet to fax you today and left it at home, duh.  I will scan and email it later.  Doing so so, esp with the hip.  Dr. M had me get a full body bone scan this week and I get results Monday.  I asked them to please look at my foot/heel too, which they did.  I will let you know of results and/or send you copy of the report.  I am taking Dr. H's meds like a good girl and am starting to work with my mirror.  It's all a little confusing still...can you recommend some simple to understand reading about the laterality and mirror work?  Like what is it supposed to do exactly?  Thanks so much.
Kris (name changed)

http://www.drblakeshealingsole.com/2012/12/crps-initiation-of-flashcards-for.html

Kris, If I find something, I will try to send it to you. It is simple to my simple brain. All about rewiring the nervous system. Something about how nerve pain leads to nerve avoidance of the area and at the same time nerve hypersensitivity. The body both tries to protect the area by making the nerves more sensitive, even to normal non-painful stimuli, and tries to avoid the moving the area by shutting down parts of your brain that use that area (this leads to muscle weakness and joint stiffness, and basic disuse stuff. The laterality cards and mirror try to wake up the brain to feel and move that area again.And it definitely does. See how simple it is!!???!!!!! Rich

Thank you I LIKE SIMPLE!  I sit in front of my mirror and move the foot....reinforcing that it doesn't hurt, even when massaging the heel and arch...so it is pretty simple.  The cards I am so much better at...but I miss the same ones each time.  Even tho I study them....my brain still gets confused.  LOL.  Thank you and I will send my filled out sheet this weekend.  Be well!

Ultrasound Exam for the Feet and Ankles: Definitely will Replace MRI in some instances

Simple Ultrasound Examination of the Ankle

Hedy McAdams: Dance Instructor---Keep Moving!!!

This is not just a plug for one of my favorite patients, but I hope educational. One of my life's mantras is "Keeping Moving". Once you stop moving, you may never restart. Hedy is a wonderful teacher for all ages. So, even if you are not in the San Francisco Bay Area, perhaps her videos will motivate you to get out there and "shake it!!"

http://www.danceadventures.com/Dance_Site/home__class_resources_100806.html

CRPS: Follow Up Sympathetic Block and Laterality Flash Cards

Hi Dr. Blake,

Still doing okay. 

The big flare has stayed settled down, and my foot is definitely improved since the block--I can walk more easily than before (though still can't tolerate my tennis shoes on for long, so I mostly wear my Montrail flip-flops which seem to have the perfect soft cushioning for me. (I would encourage anyone with a neuroma that is improved when standing on a soft surface to try them.)

And my forefoot may be slightly less hypersensitive to heat: I experimented last night with momentary partial immersion in (really just touching the surface of) some hot-ish water yesterday (which previous caused instantaneous excruciating pain and muscle spasm in the foot) and it was more tolerable. I didn't push it on the experiment, but I would say it feels less absurdly hyper- hyper- than before.

So with both these improvements, and with your encouragement (and also my husband's encouragement) I called today to schedule a MWF series! (Hubby said: This is one very few things, of all the zillion things you've tried, that actually helped you: why wouldn't you do this again ASAP? :-)

However Dr. S is out of town this week and his assistant (with whom I schedule) says this recommendation is not in my chart so she cannot schedule me till she talks with him this afternoon. She seemed very unfamiliar with this protocol and thought I couldn't possibly be correct, so he must not do it this way with very many people. Anyway it makes some sense to me (in theory) so I am going to go ahead and schedule it after she gets the okay, hopefully for as soon as next week!

I assume if something along the way feels wrong to me after the Monday block or after the Wed block I could cancel the remaining one or ones in the series.

I am excited and hopeful about this! And Dr. S made me very comfortable when he did the first procedure so I have less anxiety than before. I'm more worried about getting the IV in (which caused me to almost pass out last time!) than the block.

Your story with RSD and also your knowledge of RSD has aided my understanding of the role of these blocks and importance of doing them sooner rather than later, so again I thank you from the bottom of my heart.

Also I continue to do the laterality work (I now use the NOI app on my phone) many times daily, as it is on the short list of things that definitively have helped. It also helped me recover from the post-block  flare, when all four extremities hurt: I did both the feet and hands apps, and I believe that helped settle down the other limbs. Thank you so much for that lead on such a valuable, simple, inexpensive, non-invasive tool-- more docs should know about this.

With gratitude,

Kim (name changed)

Dr Blake's comment: I am encouraging Kim to have a series of sympathetic blocks to help her CRPS and also her constant positive feedback on the NOI group laterality flashcards. Please see my other posts on CRPS. 

Short Legs and Knee Pain: Email Correspondance

Rich,

I thought you might be interested in this article I uncovered in regards to leg length discrepancies and knee pain. having run for several years with an insert in my left shoe, I strongly suspected that my left leg was the shorter one. The article confirms this, in stating that knee pain usually occurs in the longer leg, but advises caution, as apparent leg length discrepancies can occur for lots of reasons. 

Based on the above, but still wanting to be cautious, I've been running with a very thin moleskin in the left shoe, and my knee pain seems to be abating. I ran a 1:02:53 in the Kaiser Half, and feeling better every day. If I notice any signs of the knee pain returning I'll follow up and get those Xrays.

Dr Blake's comment: I had recommended a Standing AP Pelvic Xray in normal stance to check on leg length difference as a possible cause of his knee pain. 

Thanks for all your help! It's made a huge difference. I complimented you in a recent blog about my return to competitive running. I'll send you the link when it goes live.

Mike

Article link:

http://www.runnersworld.co.uk/beating-injury/qa-leg-length-discrepancy-causes-me-knee-pain/683.html

Toe Nail Fungus: Email Advice

Hi Richard,

Thanks a lot for today, specially for noticing me standing out there and taking a few minutes to sort out my other concern.  I was just about to leave when I saw you in the main office.  Quite fortuitous.  ONe of the secretaries had just told me that you had just begun an hour appointment. 

So I took Lamisil orally for four months and got rid of a fair amount of fungus on two big toes and three or four smaller ones. Since the treatment I have been applying Desenex powder on my toes almost daily. Nevertheless, a sliver of fungus showed up n my right toe just as the last part of it was growing out on the top.  So now the sliver is about i/8 of an inch by 3/8 lying perpendicular to my left big toe. 

I have a metal file that is about 1/8 wide which was perfect for filing a 1/16 by 3/8 inch section across the toe and about 1/16 inch deep.  I have filed rather  easily, and applied the vinegar patch with your little cover.

http://www.drblakeshealingsole.com/2011/11/onychomyosis-toe-nail-fungus.html

Here are my questions:

1. The vinegar seems to burn a little.  Any concern about overdoing this treatment?
Dr Blake's comment: Vinegar is 5% acid so you do have to watch how your skin reacts.

2. Is there any danger in filing deeper and even getting down trying to make a little hole in the nail just above the skin.  Possibility of infection? or pain?  The reason I ask is that I want the vinegar, if that is the best treatment, to be able to soak in as best I can.
Dr Blake's comment: The nail bed is under the cuticle, and under the nail, firmly attaching itself. You do not want go through the nail since you risk damaging the bed. 

3. How often should I apply the vinegar and for how long.  For the soaks in vinegar, you recommend 2-3 times a week for 30 minutes each time.  Is that the same for the vinegar patch? Dr Blake's comment: The vinegar patches I recommend 3 hours max. If your skin does well, you can try longer. You can do the vinegar patch daily, but probably go to rest the skin every 4th day. Continue to monitor the skin for excess dryness with cracking.

4.  Since Lamisil is clearly a very effective killer of the fungus.  Why would I not use Lamisil ointment to penetrate and kill the new fungus rather than vinegar?  Perhaps because the ointment does not permeate the nail.  All the more reason for trying t create a hole in the nail.  Perhaps cutting through the nail is something that would be better to leave to you.  Do you do such things in a case like mine? Dr Blake's comment: Answered above, but Vinegar is 100% anti-fungal and Lamisil is not 100% active ingridient. Fungus loves moisture, so when medications do not kill fungus well, they can actually make the situation worse by keeping the area too moist. 

5.  I understand that fungi do not do well when exposed to oxygen.  Again, a hole would bring more exposure. Dr Blake's comment: Toenails breathe, they are alive not dead, polished toenails stop oxygen from penetrating the nail bed allowing toenail fungus to thrive after a pedicure. 

6.  What about supplementing the vinegar with Vick's vapor rub and/or tea tree oil?  Is a combination more effective than just the vinegar?Dr Blake's comment: See my blog post below. 

http://www.drblakeshealingsole.com/2010/10/toenail-fungus-summary-of-various.html

7. Is it better to apply powder directly on my toes or better in my shoes and between my orthotic and shoe, or both? Dr Blake's comment: Powder it all. 

8. Finally a question about balancing on one toe.  What do you think about shifting my arms and one leg in different directions to challenge my balance and to increase my ability to balance on one foot? Dr Blake's comment: That is a great idea as you do the Single Leg Balancing Exercise. It is important to continue to make it harder over the next year as you get stronger and stronger. 

Thank you for your excellent in office treatment and for your willing (so far) electronic bedside care!!!!!

Foot and Ankle Strengthening: Email Advice

This is a fun email. You just have to love this gentleman's attitude. It is great!!!



Hi Dr. Blake,

     First, I'm so thrilled to have discovered your blog! It's hands-down the most extensive source of information that I have found on the interwebs.

     I recently started doing crossfit training and I love it, but it's hard on the feet and ankles and that's always been a weak point for me. I've been reading your blog today and I wanted to ask some follow up questions.

     Roughly 15 years ago I had reconstructive ankle surgery on both ankles. The correction in the right ankle was much better than in the left, but I have significantly less pain in both post-surgery. I suffered a hairline fracture in my ankle as well, maybe 12 years ago now.
     After the surgery, I did physical therapy and the therapist focused on strength and range of motion of my ankle. She had one piece of equipment which I didn't think to get the name of but I thought it was really effective and would like to try to buy. This tool consisted of a flat circular plane and a semi-sphere ball that attached to the bottom of the plane. The semi-sphere ball attached with a screw and there were progressively larger balls that could be attached as the ankle grew stronger and more flexible. Does this sound familiar to you, and if so, can you share the name so I can buy one?

Dr Blake's Comment: This is a BAPS board which stands for Biomechanical Ankle Platform System. Our physical therapy staff uses it on all ankle and foot rehabilitation programs.

http://www.activeforever.com/p-1663-baps-board-biomechanical-ankle-platform-system.aspx

    Next question: I can't do metatarsal doming at all, so what can I do to work my way up to that?
Dr Blake's comment: Try do the metatarsal doming with Yoga Toes on. Focus on working on part one of the met doming which is straightening your toes as rigid as possible. 



  I was watching your videos about the four best exercises to do to strengthen the foot muscles and I could not do the metatarsal doming exercise without curling my toes. I suspect this relates to the inflexibility of my foot, hence why I'm trying to find that flexibility tool the therapist had. Thanks so much again for the blog, I feel empowered!

Toenail Fungus

Hello Dr. Blake,

I found your website and have read the toenail fungus section carefully. I have a toenail fungus problem and I am interested in using more simple (non-pharmaceutical) methods in fighting it. Unfortunately I also have a fingernail that got infected by a contaminated nail clipper over a year ago.

I live in a rural area and a few months ago I went to a local dermatologist.  He prescribed Lamisil for my nail fungus. I had already researched the matter and tried to discuss the urea nail removal option but he was not at all interested and was even rude and just cut me off, so to say.  He said, rather sarcastically, "What's the dosage for Urea?!"  I considered the Lamisil option but after looking at a website that had hundreds of people telling about their experiences with side effects in using that, I decided not to go that route.
Dr Blake's comment: If you use Lamisil tablets, I recommend 1 week per month for 6 months. This is called pulsing, and definitely safer than daily dosing for 6 months, and very effective for my patients when I use it this way. Also, if the nails are very thick, the Urea Occlusion technique is more effective than removing the nails, or Laser, in getting the nails to a more normal starting point. See the separate post on Urea Occlusion. Please remember that Lamisil is not benign, and can cause serious side effects. So, have a long conversation with your prescribing doctor. I am definitely recommending now that patients consider laser treatments (even though expensive) first before considering Lamisil. 

http://www.drblakeshealingsole.com/2010/10/toe-nail-fungus-carmol-40-urea.html

I am a "do-it-yourself" type of person and I have been doing soaks of the affected nails for several months now; also, after I do the soaks, I trim the nails (they were a bit softened up by the soak) and cut them way back (up to the cuticle and even beneath it) with some nail trimmers that I have. The nails don't look as ugly that way, but they are still quite unsightly. So, my question for you is this: Is there any way I can get some Carmol 40 Urea and try this myself?
Dr Blake's comment: have your primary care doc order it, and see all the photos on my post. You should be able to do it yourself within reason. 

 I know that I could follow the examples given in your photos. I would go through a podiatrist but I am not a wealthy man and I am afraid that visits to one of those (if I could even find one out here who was open-minded enough to consider this regimen) would wipe me out financially. I don't have health insurance with my job.

Can you tell me how far above the cuticle the nail bed is? The fingertip with the affected nail looks a bit swollen and is a shade or two darker in color than the other fingers.
Dr Blake's comment: The nail bed goes 6-7 mm further towards the arch from the cuticle.

I don't expect free advice from you, and I would be happy to pay you for your counsel and/or any suggestions that you can give me.

Thank you for putting all of this information on your website—it's all very interesting. Your efforts to enlighten others are appreciated!
Dr Blake's comment: Hope this helps.

Sincerely,

Even Dr Blake's Orthotics Can Not Survive This!!!!

hi dr. blake,

good news is i do think the orthotics help – it hurts today, but def not as bad as without. bad news, i think i need to take you up on that extra pair – the attached photo should explain why :>) let me know what i need to do on that, and thank you so much for the offer. hope your back is better.

Go Erica!!

Big Toe Joint Fusion: Email Advice

Hello Dr. Blake,

     I am in my 8th week of recovery from a fusion of my great toe and struggling with pain that I am not sure is related to the original injury or surgery.

2 Slightly Different Views of the Same Right Big Toe 

     Pain occurs mostly on the bottom ball and feels like fire when walking.When my foot is extended (especially when laying in bed) the pain runs along the arch and then to the outside of my calf causing it to fall asleep.   Dr Blake's comment: definitely nerve pain with nerve tension.

     Doctor hit it with cortisone and it is not helping. Dr Blake's comment: nerve pain may and may not respond to cortisone, since it only helps the inflammation involved. 

 My doctor is great...it is just that I will not be able to see him until end of week and I wanted another eye on the x-ray. I have attached photo of x-ray from the 2nd week after surgery as that is all I have with me. Does this sound like sesamoid trauma and is that something I should have my doctor explore? Do you see any indication in the x-ray? Thanks for the blog and for responding with any advice.

Dr Blake's comment: most likely the nerves that run under the fusion area that extend under the ball of the foot and into the arch and then up the leg are irritated. Why they are irritated is what needs to be investigated. The fibular sesamoid looks irregular, but that may or may not be something. The Hallux (Big Toe) looks like it was broken as part of the procedure, so is it stable yet? If not, the healing fracture or healing fusion may be producing enough swelling that the nerves in the area are being stressed. A CT scan may be necessary to analyze the bone healing. Delayed healing of fusions is very common and just needs more time to immobilize. 
     Treat the nerve pain with your own relative rest, icing of the area, crutches if needed, etc. Since you do not want the nerve pain to get out of control, and before you know what is going on, create the pain free environment as best as possible. Sure hope this helps you. Rich Blake

Ice Pack for Easy Molding around the Foot

This is a small ice pack that one of my patients highly recommended for the feet since it molds around the corners/contours well. 

Secure it by wrapping an ace bandage around the ice pack & foot

Works great! Susie (no name change)

Chattanooga Group
www.chattgroup.com
800-592-7329
423-870-2281

Hi Dr. Blake

I was thrilled to see that you posted the “eye/foot” ice pack on your blog today – I hope that it will help some of your other patients as well!

I did some extended research and found a better route of ordering (after I  checked out the Chattanooga Group website which is extensive and confusing)

Offered at Amazon

Chattanooga Blue Vinyl ColPac

“eye pack”

$9.60 each (one in a box)

Eligible for Amazon Prime shipping

Also, would you please give me the name of your gait evaluation  PT that you like the most?

At some point I think it would be a good idea to make an appointment with them and would like the name from you for my files.

Hope you are having a good weekend!

Many thanks!

Susie

1/22/13 Sports Medicine Lecture at Samuel Merritt University

Sports Medicine is great fun and great challenge. With 99% of all sports injuries non-surgical, it is primarily a discipline in rehabilitation. Getting the athletes back to full activity as soon as possible, and with a minimum of re-occurrences of the original symptoms, is the goal of a Sports Medicine practice. It is a world of medicine practiced by many different professions, podiatry being only one. No profession holds more than 50% of the answers to the many challenges facing the provider, so the discipline of sports medicine is humbling at times, and truly team focused.

Who are the members of that team? The discipline of sports medicine is very unique in medicine since it has the PATIENT as the primary member of the team not the health care provider. You and the patient work together as a team to work through the challenges from injury to health. This Patient-focused approach can be intimidating to the health care provider and the patient, so it is not right for every patient and every health care provider to practice. Patients may want to go to a sports medicine clinic, but will not have the mind set to do the hours of stretching, icing, physical therapy, etc required. Doctors/therapists may want to practice sports medicine, but really truly focus on giving shots, doing surgery, doing procedures, with no real understanding of rehabilitation. 

So, how does the student of sports medicine begin to learn the discipline of sports medicine. I will try and put together in these next 2 weeks, the general principles to live by with your own unique spin. Everyone will practice differently thankfully. Yet, there are some basic rules to live by that we will explore together in our limited time.

General Principles for a SPORTS MEDICINE PRACTICE:

1. Listen, Listen, Listen
2. Perfect, Perfect, Perfect
3. Podiatry Owns Biomechanics--listen and watch for the clues
4. KISS Principle when appropriate, full court press when not (How disabled?)
5. The Magical 80%
6. What Phase of Rehabilitation is the Patient In at any visit
7. Do Not Limit Yourself to What You are Taught (Grow!!!)
8. The Foot Bone is Connected to The Ankle Bone....
9. Gait Evaluation is A Key to Diagnosis
10. Learn from Patients First, Books Second
11. Progress From Simple to Complex, as needed, by layering
12. Partner with Your Patient, Not control
13. Learn the complexities of various Treatment Modalities and master the sutleties
14. What are the Common Causes of Injuries?
15. Be a Teacher and Friend, as well as a Doctor
16. Do Not Give Control of Treatments Completely over to Anyone?
17. Understand Foot Inserts and Be An Expert in their Design
18. Listen for your Mentors--they are out there
19. Learn from your followup visits, see patients often (Develop Your Flow Charts)
20. Use email, etc to develop good followup (keep in touch)
21. Find Ways of being Involved, do not be Detached (cry, celebrate, laugh, admit mistakes, work hard for your patients).

Listen, Listen, Listen

This skill is first since it is the basis of our treatments and our human interaction with the patient. But, with the time restraints for modern day medicine, with less time mandated by many factors being spent with patients, it needs to be addressed. How do we hold on to the skill that defines being a good doctor/therapist, as it is eroding from the culture? Doctors/therapists have many chances to hold on to this skill--limited time in the actual visit, email correspondence, patient questionnaires that can be filled out, telephone followups even for more information, the use of medical assistants/physician assistants/nurse practitioners/athletic trainors, can all increase our knowledge base on that particular patient.

http://www.drblakeshealingsole.com/2013/01/listening-is-great-but-sometimes-you.html

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-1.html

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

Perfect, Perfect, Perfect

The 3 Perfects stand for:

1. You as an individual health care provider continue to strive to get better throughout your career
2. While treating a patient, always try to make the treatment as perfect as possible--do not keep settling for less than ideal treatments (the good enough syndrome) especially if the symptoms warrant that the treatment be improved
3. Try to perfect the intangibles: your online education presence, the handouts in your office, the doctors you refer to, etc.

Podiatry Owns Biomechanics--listen and watch for the clues

Almost every lower extremity injury, most back problems, and some upper extremity problems, has a possible solution in Biomechanics. The solution may make a chronic disabling injury disappear, or merely change bad pain into more manageable pain. With 33 common lower extremity injuries produced or aggravated by the foot over pronating, it is easy to see how studying the biomechanics of patients can produce wonderful clues for us. Much of this science is tried into gait evaluation and by muscular, ligamentous, or structural evaluations. The common areas that a biomechanical trained health care provider will look into are:

1. Over Pronation
2. Over Supination (aka Under Pronation)
3. Leg Length Differences
4. Inadequate Shock Absorption
5. Tight or Weak Muscles
6. Tight or Loose Ligaments
7. Neurological Problems
8. Compensatory Problems from perhaps old injuries

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-9.html

KISS Principle when appropriate, full court press when not 
(How Disabled?)

It is a world of modern medicine is a world of procedures. This is what pays the bills, and can be the fun stuff we do. Insurance companies pay more for more elaborate tests and modalities. But, armed with all this great medical training, you must ask at each patient visit what is really needed to get the job done with the least risk to the patient. This is influenced greatly by the patient. Can their needs be addressed simply (KISS--Keep It Simple Stupid), or should there be a full court press (throwing in the kitchen sink if necessary). For most day to day patient visit, KISS is perfect. But, simple problems can be very significant to the patient, or may turn for the worst, needing more complexity. And complex problems can be the other side of the coin. Healthy looking patients can come into the office with negative findings, and an attitude reflective that everything is okay, but in deeper probing and listening, are completely disabled. I am standing here at class (at least while I type this) looking well, but due to my back problem, totally disabled from playing basketball, sitting, driving, putting on my pants, shoes, and socks. My ability to minimize my symptoms, to work as well as possible around them, would make my back doctor mis-interpret the level of my disability. This is done every day in every clinic. Symptoms are either over treated (where KISS was more appropriate) or under treated (see post on Good Looking Syndrome).



http://www.drblakeshealingsole.com/2010/03/kiss-principle-of-medicine.html

http://www.drblakeshealingsole.com/2010/06/musings-from-footstool-5-law-of.html

The Magical 80%

When rehabbing patients, you have 2 scales that you will use consistently to access progress. The pain scale is 0 (no pain) to 10 (most severe pain) is the most common one of the measures used. The functional scale from bedrest (0% functional) to full activities/no symptoms (100% functional) is a lesser used, but vital part of a sports medicine practice. As you treat patients, each visit you will need to assess where the pain and function are at. The goal for most injuries is to attain 80% plus pain relief (pain scale not over level 2 in function) and 80% plus function (full activities with 0-2 pain). For 0-2 pain, can take years to completely go away, and to have an athlete only perform when there is no pain, would be unnecessary. This is considered "Good Pain". It is common for both of these scales to be mis-interpreted. Commonly, the athlete is told to wait on functioning (their sport) while they undergo a treatment to drive the pain down to 0. The treatment is considered successful, until the pain returns with a vengeance as they resume their sport. It is best in most cases to treat while allowing restricted function which you gradually increase while maintaining pain level to 0-2. I always say that I would rather a runner run 1 second per day, then not at all. And if they run 1 second, can they do 2, etc.

http://www.drblakeshealingsole.com/2010/08/injury-rehabilitation-magical-80-rule.html

What Phase of Rehabilitation is the Patient in at Any Visit?

What are the 3 Phases of Athletic Rehabilitation?

1. Immobilization/Anti-Inflammatory Phase
2. Re-Strengthening Phase
3. Return to Activity Phase

With being said, patients (if they had 3 feet it would be perfect) can be solidly in one phase at one time, or be stradeling all 3 phases at once. It is a goal to work patients as quickly as possible through the phases, but at times, they have to be placed (with imaginary handcuffs to the bedpost) in one phase for an finite period of time. I love to start strengthening as early as possible, and even allow some current activities to continue if I can keep the pain level between 0-2. The daily onslaught of patients I see that should be in Phase 1 but are running with pain 4-7 since they went from Phase 1 to Phase 2 and now should be in Phase 3 with other provider is very common. You just have to start over and re-establish what it takes to maintain Phase 1 pain levels (0-2). Or, the patients that were never placed into Phase 1 and have been painful for years, is another common variation of the same scenario.

http://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html

Do Not Limit Yourself, but continue to grow in Knowledge and Experiences

There is such a plethora of resources out there to grow your sports medicine. Be open minded. Learn from everyone. Definitely, become a member of the American Academy of Podiatric Sports Medicine. Learn mainly from your patients. They live with their pain. They have seen others to seek help. What has worked and not worked. What is the new stretching device you never heard of? When a physical therapist sends you a report on the treatment, go over with your patient anything you do not understand. Be a constant learner, it makes this fun!!

The Foot Bone is Connected to the Ankle Bone...

Being in a sports medicine and biomechanics practice, you will begin to understand how the body is so interconnected. What I do affects the rest of the body both positively and negatively. I remember my first patient with runner's knee pain coming in for his first orthotic device check. I asked him how his knee was doing, he said okay (not convincing me that the orthotics were helping him), but then a big smile and he said 20 years of shoulder pain while running was gone completely. If I knew more back then, maybe I could have figured out why. Dr Merton Root, modern day founder of Foot Biomechanics, and inventor of the principles behind modern day foot orthotics, once got a big laugh from his students when he said he could tell after his evaluation which of his patients with neck pain would get relief from his orthotic devices. Yes, the foot bone is connected above, and if you seek to understand how someone should walk or run that is stable for their body, and you can help get them there, you may be surprised at your results.




http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-9.html

Gait Evaluation is Key to Diagnosis

We will spend some time in class reviewing some of the basics of gait evaluation. Of course, it applies to more than one activity. It is truly an evaluation of the technique involved with walking, running, race walking, figure skating, ballet, etc. But, since we all walk, and it can be done right in your office, and it seems to reveal a part of the soul of the human body involved with motion. Being able to continue to move, walk, stay active is one of the secrets to great happiness to the human spirit. And, being good at evaluating walking gait, will key you into problems that the patient may have with their running, backpacking, etc. I remember one of my greatest gait evaluation success stories. Ben was a golfer with back pain, not a good combination. 4 years of treatment from various specialities were not helpful. When he came into my office, I watched him walk to see if that would give me you could tell he had either a functional or structural short leg--correcting that is back pain 101 for me. He did have a short leg on xray and he did great, but the main point I want to make is that after I watched him walk and pointed out some things he said in 4 years no one had ever watched him walk! Gait evaluation may be the key to helping thousands of your patients.



http://www.drblakeshealingsole.com/2010/11/basics-for-gait-evaluation.html

http://www.drblakeshealingsole.com/2011/08/basics-of-gait-evaluation-knees.html

http://www.drblakeshealingsole.com/2011/09/checklist-basic-gait-evaluation.html

Learn from Patients First, Books and Seminars Second

Weekly I learn something new from some patient that affects my medical practice, but you must be on their level. You must be considered a Teammate that shares info, not the All Knowing Doctor/Therapist that only gives it out. Sports Medicine is a team approach between you and the patient. When you give the patient options, ask what they would like to try first. Guide them but not totally dictate. When treatments are not working, it will be easier from them to tell you if they consider you on their side, and more of an equal.

Progress from Simple to Complex, as needed, by Layering

When coming up with a treatment plan, and when your judgment and/or the judgment of the patient does feel that a full court press is needed, the KISS is commonly used. The KISS principle is far from a watered down non-thoughtful approach however. It assumes that the patient will get somewhat to completely better with less than the most sophisticated approaches available. Plus, and not to be under-estimated, it grants you followup visits with the patient to see how motivated they are to do the program, or what findings did they make that may change initial assumptions. If the First Visit was the ground breaker, the followup visits can tell you a lot more about this patient. A common problem with KISS philosophy is that you may know you are following it, but the patient must also know. Many patients leave their doctor's appt with a simple plan, when only partially successful, may feel it is all the doctor/therapist had to offer. So, explain the layering, educate a little from the beginning what the next steps will be. Suggest a routine followup in a short period of time either in person, phone, or email, to make sure both of you are on the same page. Increase the complexity of each treatment modality as you learn what the patient can or can not do.



http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guideline-18.html

Partner with your Patient, not control them

As you can tell this is a big theme of my practice. It works for me, but definitely not with all of my patients. Many patients do just want to be told what to do. Many patients just want to tell you what they expect you to do. One small example is with the barefoot runners. Many times in the last year with this barefoot running craze patients who I think need orthotic devices tell me that they will try anything but orthotics since they want to keep their feet strong, even when I think orthotics used in the short term would speed up their progress. They are being honest with me, and I try to be honest with them.  Try always to work around differing opinions, and you may be surprised you are not always right. Take your patients as they come. Most very different but very much the same as you. Individual needs should replace protocols unless you feel that their safety is in jeopardy. This rarely occurs. For those of you who want to read some fascinating, and eye opening personality categories, read a book on the Enneagram. It means 9 Personality Types. It means that 9 people could sit in a room with a problem and come up with 9 very different solutions. Always consider that your patient will look at the problem different than you and just needs your guidance on good sound options for them.


Learn the Complexities of Various Treatment Modalities, and Master the Subtleties

Every treatment modality you use, can be modified. Every treatment modality, has multiple layers of complexity. Learning and mastering the modalities you use daily will bring you great success as a health care provider. If I ask a patient what they are doing to help their injury, a generic response may be icing, better shoes, strengthening exercises, and physical therapy. Most health care providers would leave it that since it sounded very well thought out---anti-inflammatory, mechanical changes, strengthening and expert help. But, it is fun to probe into each modality, and you definitely have to if they are not improving or getting worse. How are they icing? Can you recommend any changes, or should we switch to contrast bathing for the swelling problem you can see? How did they select their shoes? Do they feel better in the shoes, but only walk 30 minutes per day in them? Are the strengthening exercises hurting them? Are they the right exercises? A blatant example I commonly see is patients with posterior tibial tendinitis strengthening the anterior tibial tendon and not engaging the posterior tibial tendon. What is the physical therapist doing for them? What are the good aspects of the treatment, and what should be modified? Be curious, and keep learning.

http://www.drblakeshealingsole.com/2010/04/foot-orthotic-devices-general.html

http://www.drblakeshealingsole.com/2012/08/general-principles-of-stretching.html

http://www.drblakeshealingsole.com/2010/06/quick-tip-9-begin-strengthening.html

What are the Common Causes of Injuries?

The most common causes of injuries include:

1. Structural Problems---commonly seen in gait evaluation
2. Muscle/Tendon Problems---commonly seen in gait evaluation
3. Ligamentous Issues----sometimes seen in gait evaluation
4. Dietary 
5. Internal Medical
6. Training Errors
7. Equipment Errors---commonly seen in gait evaluation
8. Neurological---sometimes seen in gait evaluation

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-15.html

Be A Teacher and Friend, as well as a Doctor

The emphasis here is on teaching. Some of you will be natural teachers, others not. But, that is what staff is for. Train your staff well in areas you are lacking, we all lack something vital and need help. Delegate, but remain committed to this education. This blog is to educate my patients and others. Our physical therapists helping me can take more time than I to educate. The running shoe stores you refer to must be known to give good advice---teach all your patients at least to Power Lace. Make handouts. Write Lists. Remember the average patient only remembers 30% of what is told in a medical office visit. Give them your email to ask more questions. Be Friend them, if they want, and most do. If you have ever visited Dr Richard Green's office in San Diego, you would know what I mean. His patients were all his friends. Quite impressive role model for me.

Do Not Give Control of Treatments Completely over to Anyone

I make a lot of referrals. Modern medicine is getting away from the concept of primary care giver who knows all--except in the concierge practices now growing. I do only a mediocre job at followup. I am always striving to be better. I want to know what others are saying and doing for my patients. Do not be embarrassed to disagree with another. If the patient is doing better with a referral and trusts that individual, great news. If things are rocky, and improvement slow, analyze what is going on closer for your patient. Help them as much as possible. Be a loyal teammate who has their back.

Understand Foot Inserts and be an Expert in their Design

Podiatrists are foot people. We dedicate our whole lives to make feet happier. Understand all the functions of foot inserts, both custom made and over the counter. I have never found an insert that did not have some value. Some patients need fairly generic inserts to support and cushion, others need very specific support, and others need only cushion. Know what is readily available. Think outside the box and modify inserts for even better symptom improvement.

http://www.drblakeshealingsole.com/2010/04/foot-orthotic-devices-general.html

http://www.drblakeshealingsole.com/2011/04/25-common-shoeinsert-modifications-in.html

Listen for Your Mentors, they are out there

What powerful mentors you have here in Drs Dutra and Choate. Go seek out the local podiatrists in your area, and the current members, fellows, and board members of the American Academy of Podiatric Sports Medicine.

http://www.drblakeshealingsole.com/2012/06/mentors-we-all-need-them.html

Learn from your FollowUp Visits, and Develop Flow Charts

I think we are all pretty smart sounding when we first meet a patient. The first visit, with questionnaires, a lot of action, gait exams, initial prescriptions, etc, is pretty easy for most health care providers. You learn a little about the patient, and you start action. But, it is the followup visits that the true art of medicine is practiced. You learn more about the patient, and them about you. Your listening skills, their response to treatment, your problem solving if there is problems or no improvement, their willingness to do all the treatments you outlined (like ice 3 times per day), and back and forth your team is made.

I love flow charts to organize treatment for patients. One of doctors is a master at it. I have the natural rhythm of an injury rehab flowing in my head so that I can evaluate each patient's progress with it.

http://www.drblakeshealingsole.com/2011/08/heel-pain-flow-sheet-for-treatment.html

Use Email to Develop Good Followup

http://www.drblakeshealingsole.com/2012/12/followup-on-treatment-for-crps-all.html

Find Ways to be Involved, Do Not Be Detached!!




Quiz Questions For 1/29/13

1. What are the five common biomechanical problems normally treated in a sports medicine practice?
2. Explain the 80/20 rule in athletic rehabilitation and how it correlates to the pain cycle.
3. What are the three classic phases of athletic rehabilitation and explain how they can blend together?
4. Explain what tissues at the knee are stressed when a patient excessively supinates.
5. For every treatment modality, there are many layers of treatment going from simple to complex.  Explain how this can be applied in a case of a patient with achilles tendonitis.