drblakeshealingsole.com

Sesamoid Fracture: Need Help in Los Angeles, California

2012-02-22T19:02:00.000-08:00

This is an email sent by a young lady several days ago. I have already sent her to a good friend of mine Dr Daniel Altchuler in Santa Monica. I know Dan personally to have similiar philosophies as I do. When you need help, a good place to start looking is go to the website of the American Academy of Podiatric Sports Medicine at www.aapsm.org and look in their membership. Most of the podiatrists in this academy are serious about treating athletes and that normally means they are pretty conservative in their treatments (normally!!).

Hi Dr. Blake,

First of all thank you so much for having an email address where people can reach out to you. I was diagnosed with a sesamoid fracture in my right foot yesterday. I went to the Podiatrist two weeks ago with severe foot pain and swelling. She was treating me for sesamoditis. Two weeks later, I went back still in pain. She xrayed me again and this time the fracture showed up.

Dr Blake's comment: Fractures in many areas of the body can take 2 weeks to never to show up in an x ray. Sesamoids, little bones under the first metatarsal at the ball of the foot, are particularly difficult to diagnosis by x ray. The patient and treating doctor when the injury seems to be sesamoid related should initially attempt to create a pain free environment. It will almost make the diagnosis because it will be harder to create this pain free environment with a true fracture vs an inflamed sesamoid (called sesamoiditis). You have to treat the worse possible cause of pain, unless you go right to a bone scan or MRI. If you create this pain free environment, sesamoiditis will need less time overall to resolve where a stress fracture of the sesamoid normally 3 months to 2 years. And some do have to be removed, so we want to calm that sucker down quickly.

She put me in a cam walker and within an hour or so I was feeling pain at the fracture sight. She recommended that I go back into UNO boot & surgical boot which is what she had me in when she thought she was treating sesamoiditis. You mentioned in your blog that all podiatrists know to how to make a walking boot pain free, yet she didn't mention this as a solution. She also didn't offer me an MRI. Should I be seeing a "better" doctor? She takes conservative measures so I felt she was capable of treating my fracture. Can you give me a referral to a Podiatrist in Los Angeles?

Dr Blake's Comments: Wow, there is a lot to comment there. It sounds like she is trying to rest the area, but is missing some subtle aspect, like accommodative padding to take pressure off. Normally docs do not recommend MRIs initially if they can get the area calmed down in the first followup visit or two. In general, the first month is reserved for making the proper diagnosis, and creating a pain free environment so you and her are half way there. Does not sound like she is lacking in effort, and this is what you want out of the health care provider who has agreed to help you. Those cam walker, also called removable boots, need to be modified alot, but can be very helpful and can even become your friend the next 3 months. For right now, go with what makes you comfortable in all activities, instead of one item that makes you hurt. Common sense and listening to your body is key. Do you need a second opinion? The jury is still out.

While I am emailing you I have another question. Two weeks ago I upped my speed/time on the treadmill and I also began running for a few minutes at a time. The day after this I started feeling foot pain and within 1 or 2 days I couldn't walk. With this increase in my activity it's pretty obvious what caused my fracture.

Dr Blake's comment: Fracture pain comes on suddenly like this, sort of one day you do not have it, the next day you do, whereas sesamoiditis tends to come on gradually.

SO about one week into the doctor wrapping my foot in an UNO boot/Surgical boot I started feeling dull aches in the sesamoid in my other foot. By the way I had surgery 15 years ago to remove a fractured sesamoid from my left foot so I only have one in there. Fast forward a week or so and the dull ache is still about the same. I feel it here and there usually when I put more pressure on that foot. I can still flex/scrunch/point/push that foot without any pain. I am REALLY praying that I didn't fracture this one as well. Is it possible that it is just irritated from extra pressure?

Dr Blake's comment: What makes sense here? A fracture or just soreness in an old injured area from compensating. Everyone raise your hand who thinks it is a fracture.

From what I have learned, sesamoids are very difficult to heal. I have a 2 year old and 6 month old so this has been a huge burden and I am having a pretty rough time emotionally. Also I am experiencing shooting pains in my lower back in only one day from being in the cam walker.

Dr Blake's comment: You definitely need to get an EvenUp for the other shoe and may need some time with crutches (but of course that would depend on how successful you and your health care provider were at achieving this pain free environment). Sure hope this helps you.

Any advice, insight, info along with a referral would SO appreciated.

Best

To All Runners: Barefoot Running Survey---Please Respond!! Research is Needed

2012-02-22T18:04:00.000-08:00

From Dr Blake: Barefoot or Minimalistic Running Shoes are a hot topic. Please take time to help these 2 great podiatrists do research which may help to prevent many injuries.

February 21, 2012

RE: Barefoot & Minimalist Running Survey

To Members of the American Academy of Podiatric Sports Medicine:

I would like to request your assistance in a research project on barefoot and minimalist running. The linked document below is the preamble to a survey we have constructed that attempts to ascertain the scope of barefoot and minimalist running both in practice and runners' attitudes.
David Cauthon and I wrote one of the most comprehensive reviews of barefoot running to date that was published last year in the Journal of the American Podiatric Medical Association. The survey we created is a follow-up to that publication.
We ask your help in distributing our survey link as widely as possible to reach as many runners as we can. The survey population need not be barefoot or minimalist runners as one of the parameters we are investigating is the scope of these practices so ALL runners are encouraged to take the survey. If you work with any running shoe stores, clubs or teams please pass on to them. If your practice has a web site, please post there. Practice newsletters or practice email updates could be other venues.

The preamble to the survey is at: http://www.aapsm.org/survey-preamble.pdf

The link to the survey is: https://www.surveymonkey.com/s/RMYTMJJ

We greatly appreciate your assistance in furthering research that has the ultimate goal of answering so many questions we have about barefoot and minimalist running.
Please distribute this link as you see fit and if you have any additional questions, please do not hesitate to contact me at the e-mail below. Thank you in advance for your assistance.
Most sincerely,

David W. Jenkins, D.P.M., F.A.C.F.A.S., F.A.A.P.S.M.
Professor, Arizona School of Podiatric Medicine /Midwestern University
Board Member of the American Academy of Podiatric Sports Medicine
Clinical Director of Special Olympics Arizona Fit Feet Program
djenki@midwestern.edu

Posterior Tibial Tendon Tear: MRI images

2012-02-13T20:37:00.000-08:00

One of my patients recently tore his posterior tibial tendon, the most important ankle tendon for arch support. He is being worked up for surgery and I thought his MRI images may be helpful to some of you suffering from Posterior Tibial Tendon problems.

The 3 medial ankle tendons that go into the foot are: flexor hallucis longus (FHL), flexor digitorum longus (FDL), and the posterior tibial tendon (PT). See the solid dark circles that make up the FHL and FDL. See the white area where the posterior tibial tendon should be.

The FHL and FDL are well visualized. The medial or inside ankle bone shows old bone chips from a fracture 20 years ago by the sensor.

As we get further into the foot with our imaging, the area of the posterior tibial tendon is more blown-out than the FHL or FDL. Good, solid, tendons should look dark, condense, and have sharp borders. The PT has none of this.

Further imaging into the foot shows the PT tendon non-compact and almost stretched.

This side view of the ankle shows a solid FDL tendon as it comes down into the foot, and an almost nonexistent Posterior Tibial Tendon.

This is such an important tendon in the body that I am forced to send to the surgeons for repair. Hopefully, once the surgical part is done, I can begin the often 2 years of gradual rehabilitation for full strength.

Video from Dr Glass on Ankle and Subtalar Joint Motions

2012-02-11T21:14:00.000-08:00

I want to applaud Dr Glass for his outstanding video on ankle and subtalar joint motions. Even though there are a few typos in the text, the great visual is wonderful. Thank you.

Plantar Fasciitis and The Role of Flip Flops

2012-02-11T20:50:00.000-08:00

PM News

CA Podiatrist Discusses Plantar Fasciitis

Plantar fasciitis is an inflammation of the fibrous tissue that connects the heel bone to the metatarsal bones on the bottom of the foot. Symptoms can include a burning sensation and aching on the soles, and dull or sharp heel pain. "If, first thing in the morning, your heel is really painful, and then as you walk around it feels better, that is the classic sign," says Sheryl Strich, DPM, president of the American Association for Women Podiatrists.

Dr. Sheryl Strich

Surprise: "High heels are not the evil-doer," says Dr. Strich. The most likely culprits are pancake-soled shoes with zero arch support, such as flip-flops, ballet flats, and some casual sneakers. And standing for long periods of time in any shoe -- say, if you work on your feet -- can also cause this common injury.

Source: Ladies' Home Journal

Below are several youtube videos on plantar fasciitis stretches and treatments.

Leg Pain in a Runner: Tibial Stress Fracture (Part 2)

2012-02-10T21:14:00.000-08:00

Recently a long distance runner presented with leg pain of 4-5 months. The pain came on suddenly during a long training run. The patient attempted to run through the pain, because it was not too bad, for 2 months. Then, common sense dictated stopping running for the last 2 months. The pain is not only not better (can I throw a few more nots around) but now hurts walking around which it never did before. He tried changing shoes and icing occasionally. These measures did not help.

In a runner with leg pain developed with long distance training, the diagnosis is a stress fracture until proven otherwise. The following 3 X-rays just taken show a healing tibial stress fracture with marked amount of new bone formation. Try to look along the normal border of the bone. As the normal border gets obscure, this is the new bone forming. Unlike this X-ray, you normally do not see a fracture line with a stress fracture only the subtle new bone formation.

On this oblique view, one can really see the fracture line. Fractures look bad for a long time for 2 reasons. The fracture line looks worse then it really is since there is more water content near the fracture itself in the bone. More water makes the fracture look worse. Fractures heal inside out, so total healing may have occurred internally, but the X-ray still shows signs of the fracture still present.

Due to the compression forces and the muscle contractions of the leg muscles, most running stress fractures on the tibia occur on the back surface of the bone. This makes it hard to locate and hard to see any swelling.

Leg Pain in a Runner: Tibial Stress Fracture

2012-02-09T22:10:00.000-08:00

Over the next week, I am going to talk a lot about stress fractures. This is a common one in the lower inside of the shin (tibia) seen in a runner increasing his mileage.

This AP Tib/Fib Xray documented the new bone formation seen next to the marker in a long distance runner. This bone reaction is called periosteal reaction and signifies that the bone is trying to heal. The new bone formation should be the thickest nearest to the fracture.

Lifts for Short Leg

2012-02-07T22:48:00.000-08:00

Dr. Blake-

I saw your posting regarding athletes and how if they have a leg length discrepency they should consider a full length foot lift as opposed to a heel lift. I would like to know where I can buy a full length foot lift that is as flexible as the one you show in your pictures. I have recently purchased one of the Clearly Adjustable full length lifts, but find it to be extremely ridgid. I think a more fleixble lift would be more practical for being on my feet a lot. I used to enjoy working several times a week until a recent possible hip injury. I was diagnosed with a leg length difference of at least 6mm and have used a heel lift for several years. I am hoping that trying a full length lift will possibly even out an imbalances in my hips and weight bearing on my feet. Any help from you on sources to purchase these items would be great! Thanks!

Jeanne (name changed to protect)

Dear Jeanne, Thanks for your email and sorry for my delay. The material I use is call grinding rubber and you can purchase several 1/8th inch sheets from www.jmsplastics.com. The trickiest part is to skive the leading edge, but try angling the scissors. You can also use 1/8th inch spenco flat insoles and cut out the toes to give more room. Use one pair and you can make a 1/4th inch lift for one side (almost 6 mm). These can be purchased all over. Sure hope this helps you.

Here the black side of a Spenco insole with the toe part cut out is being compared to a typical heel lift.

Here Grinding Rubber from JMS Plastics is being formed into a full length lift and a heel lift.

Here a Spenco insole is being used as a lift of the short left side and an accommodation for a painful big toe joint.

Plantar Fasciitis and Sesamoid Injury

2012-02-06T21:54:00.000-08:00

Hi, Dr. Blake,

I hope 2012 is treating you well! You were so helpful to me last year when I was struggling with my sesamoiditis diagnosis. I am still spreading the gospel of the Even-Up.

I have another question now. I have had a pain in my right inner arch over the past few days, worse upon waking. From my reading I suspect it is the beginning of plantar fasciitis. I read your post about arch height-- for the record I have very high arches and VERY tight calves (one surgeon I saw for the sesamoiditis said I'd never be able to stretch them enough and recommended I get both gastrocnemiuses cut). I stretch them on a foam wedge every morning but maybe it's not enough.

With sesamoiditis on both feet (I have bipartitite sesamoids) I want to be very careful about how to do stretches for the plantar fasciitis! I've already refused to "walk the dog" from the downward facing dog in my yoga class, because I feared for my sesamoids... Do you have any specific instructions?

Also, I guess it's time to face up to the fact that it might be good to wear plantar fasciitis splints at night. But again, some of them look like they pull against the sesamoids in a bad way! And I guess I should wear them on both legs, and so the big bulky ones would be hard to manage. Do you have any splint suggestions?

Thank you for your ideas-- it is such a blessing to feel I can ask you and get a trustworthy answer.

Toni (name changed to protect the identity)

Hey Toni, Thanks for the email. That is not a typical place for plantar fasciitis, but it may be. I have attached a video on plantar fascial stretches that do not pick on the sesamoid, another video on kinesiotaping for arch support, and ways to accommodate the sesamoid if you do go to the removable boot. Rich Also consider the rolling ice stretch twice daily described in the basic plantar fasciitis treatment posts. Thanks for you confidence in me.

http://www.drblakeshealingsole.com/search/label/Plantar%20Fascial%20Night%20Splint

Peripheral Arterial Disease: Feet Give Good Clues

2012-02-06T21:13:00.000-08:00

Feet Can Hold Clues to Heart Health: MI Podiatrist

If you’re wondering about the health of your heart, try looking at your feet. The lowly, stepped-on, shoe-squished foot could very well hold clues about the state of your coronary arteries. If your feet show signs of poor circulation – or peripheral arterial disease – your heart could be suffering as well. Dr. Marisha Stawiski, a Grand Rapids podiatrist, says she regularly checks patients for the subtle signs that could indicate PAD. A loss of hair on the feet is one possible sign of poor circulation.

Dr. Marisha Stawiski checks a patient for PVD (Photo T.J. Hamilton)

That doesn’t mean that people who have always had smooth, rather hairless feet have PAD, she said. “But if you have somebody with a lot of body hair and none on their feet and ankles, it could indicate an arterial issue,” she said. Different pulses, very cold feet, or a change in color also could indicate a problem. If she sees any signs of PAD, Stawiski recommends a simple, non-invasive test called an ankle-brachial index. It compares the blood pressure in the ankles to the blood pressure in the arms.

Source: Sue Thoms, The Grand Rapids Press - MLive.com [2/6/12]

Ankle Braces

2012-02-05T21:21:00.001-08:00

This is an email I just received from a great tennis player and dad!!

Dr. Blake,

What ankle braces do you recommend? I have been wearing the lace up type on my left ankle only, but I rolled my right ankle yesterday which proceeded to swell quickly. I have been using ice and compression and the swelling is down. I realize now that if I want to continue playing tennis, I will need to wear one of the right ankle as well.
Thank you for your recommendations.

Regards,

Steve

Hey Steve (not his real name since he is in witness protection),

I love the ASO Ankle Brace and this is the one I use occasionally when my old injured ankles are at risk (like on the basketball courts).

http://www.tennis-warehouse.com/ASO_Ankle_Braces/descpageASO-ASOAB.html

Metatarsal Pain Email Followup

2012-02-05T11:36:00.000-08:00

This nice patient presented one month ago with a 2 month history of very severe pain in her metatarsals (pain levels on 8-9 out of 10). There has to be something broken or nerve involvement to have that high pain level. New orthotic devices were given to her 2 weeks ago since she stands all day at work. We are trying to avoid a removable cast, which will make her job difficult. There is her 2 week email followup and my response.

Hi Dr. Blake. This is the 2 week report. I'm wearing my new orthotics all of the time now and am attempting to be optimistic. When the inflammation occurs after a short shift at work(4 hours), I recover nicely the next day. Yesterday, I had a 7 hour shift and today I'm pretty swollen and need to stay off of my feet. By tomorrow, I'll probably be much better. It seems like I have to be very strategic about how I spend time on my feet. There's a threshold for how much I can handle.
So, do you have any suggestions? Yes, I am alternating hot/cold . I'd love to hear your words of wisdom. Thanks.

Bobbie (not her real name), Thanks for the email.

    Sounds like you are doing every thing right. Definitely do the contrast bathing once a day and add an ice pack for 10 minutes twice per day.

    I could have the physical department experiment with various forms of taping for you to do, and they could do some treatments of anti-inflammatory stuff to cool things down.

    A Budin splint can be purchased at our sports shop to limit motion around the metatarsal joints, and I can try a different type of orthotic to control the foot motion possibly better. So, a lot to do. Come back in 2 weeks and we will advance your treatment, hopefully in the right direction. Rich

I had 3 types of orthotic devices to choose from initially and I chose the Root Balanced Technique to maximize the metatarsal support. I definitely may have to change it to get more stability.

Ankle Sprain Advice

2012-02-05T10:41:00.000-08:00

Hi, Dr. Blake -

It's been almost a year since I last was in contact with you. I sprained my ankle today, and wanted to check in with you. Last year it was the right ankle, today it was the left. I looked at your blog, but I wanted to clarify a few things with you directly.

I am elevating and icing and took some ibuprofen. I still have a few compression socks and horseshoe padding from last time. Should I start that right away? Should I not use the padding while icing?

I remember how to do the contrast baths, but I seem to recall that I'm supposed to wait a day or two before starting those.

I have attached a couple pictures of my ankle. It swelled up right away. It also feels somewhat different than last year's injury. With that one, I was able to walk without limping. This one causes me to limp. I was not in motion when my ankle rolled, but I was standing on an elevated surface, and rolled down from that (if that makes sense :)

Please let me know if I should come in to see you. I'm pretty sure it's just a sprain.

Thanks,

Roberta

Roberta,

Thanks for the email and I am so sorry about the sprain. Until the swelling is gone for 2 straight weeks, you should use compression 24/7. Those compression socks will help you, along with the horseshoe padding. I am going to use your email for my blog tomorrow, but will remove your identity (probably call you Roberta). Ice for 96 hours, then begin the contrasts at 1 min hot, 1 min cold for 20 minutes. When you ice you can remove the compression. Schedule with me for Wednesday on, but cancel if it is getting better and better. I will try to be even more thorough in my blog. Rich

When you sprain your ankle, you need to immediately control the swelling. The more PRICE you do over the first 4 days, the assault and battery days, and the less swelling you have by the end of those 4 days, the faster your ankle will recover. Now, Roberta's (identity removed) ankle looks more like a high ankle sprain (the ligaments above the ankle called the tib-fib ligaments), and it could be a distal fibular bone fracture. So the next few days will tell us if we should xrays. Ankle sprains get better and better, ankle fractures go much slower. So, if Roberta is not feeling a significant improvement with the ability to weight bear on the 5th day post injury, we should definitely be xraying her. I always recommend weight bearing xrays on the foot and ankle since sometimes how the bones line up to the ground and each other can make a difference in diagnosis and/or treatment. To summarize PRICE for you, it is:

Protection: crutches, bracing, removable boots,etc

Rest: Restricting motion of the ankle just enough to not stimulate the pain response

Ice: All the wonderful Anti-Inflammatory measures we have available including avoiding certain foods.

Compression: Remember Compression should be tighter below the injury and looser above the injury

Elevation: Even 1 inch off the floor makes a difference, but get it up as much as you can for the first 4 to 14 days.Control that swelling.

I will leave a Rx for ankle xrays on my asst Kathy's desk. If you feel you should get an xray, call her, schedule an appt, and go to xray 1 hour before. Rich

More on Gout

2012-02-05T10:10:00.000-08:00

From: Peter Vannucchi, DPM

One reason why there are no high quality evidence studies for gout is due to the fact that the complexities of effective management make it difficult to treat. In Dr. Purdy's community of southern Louisiana, I am certain that primary physicians see lots of gout. Their lack of aggressiveness is not from a lack of understanding the disease, but from the difficulty of getting patients to abstain from the obvious, namely beer. Beer has guanine in it which is rapidly metabolized into uric acid. Beer is the major culprit. So when a patient has a six-pack on Saturday night, you can almost predict that the patient will be in your office or in the emergency room on Monday.

Patients also eat shellfish (namely mud-bugs and shrimp) as well as organ meat, and lots of red meat. Forget about high-purine vegetables - it turns out they are not a problem. Dairy products tend to decrease uric acid to some extent. This is all relatively new data that has come out in the literature.

Chronic Metatarsal Pain in a Runner

2012-02-05T09:48:00.000-08:00

Hi Dr. Blake,

I saw you about a month ago. I have chronic ball of foot pain (had been present for 3 months) that although lessening is still stubbornly persisting. The budin splint you suggested I get has helped.

Budin Splint with Metatarsal Pad attached to limit motion and re-distribute weight around the 2nd Metatarsal.

The pain is has "moved" and is now below my second metatarsal. I've been running on it 3 days a week and this definitely aggravates it. Do you think the Neuro-eze cream might help me?

Do you think that cortizone could help (oral or injection)? I would like to keep training.

I will make an appointment to see you again if you think it would be beneficial.

Thanks in advance for any comments/advice. Tom

Tom,

Thanks for the email followup. Neuro-Eze may help if the symptoms are neurological. Probably more inflammatory. I could give you a Rx for Voltaren Gel to massage in 3 times daily. I will leave with my asst Kathy. Call her Monday with the pharmacy number.

If the Budin Splint is working, tighten it alittle each week.

Definitely continue to ice massage for 5 minutes three times daily. Stay away from cortisone since we are probably dealing with a slightly injured ligament and cortisone can weaken it further.Come back after 2 weeks with the Voltaren gel and bring in your running shoes. When you say that the running aggravates it are you back to the same level of soreness when you run again? Very important, and no limping. Read my blog post on Good Pain vs Bad Pain to make sure you are staying in the Good Pain part. Hope this helps.And, it is normally great when the pain begins to move, as the original problem is being isolated by the treatment prescribed. Rich

Hi Rich,

Thanks so much for your prompt response. It means alot to me! I will call Kathy in the morning for the Valtaren gel. I tightened the splint today and felt some more relief so I think that is a good sign. The soreness after I run is managable and does not affect my gait and definitely no limping or anything like that. It's very stubborn though! I'm trying to balance the running with cross training and I'm being as conservative as I can without losing my fitness. I will review your good pain bad pain post.

Thanks again.

Ganglion Cysts

2012-02-04T22:11:00.000-08:00

Many patients present to my office with lumps on their foot that either appeared suddenly or gradually grew. These are normally ganglion cysts, formed by fluid leaking from tendons or joints. They are totally benign, and occasionally have to be surgically removed. But most patients are told to ice massage them in a circular manner 2 times per day to see if they can break them done. Before any thought of surgery, the ganglions should be drained in an office setting, one or two times. If the ganglions are not superficial, then cortisone can be injected after the draining to further increase the chance that they will not return. If you do get them drained, you need to spend one month with a compression wrap and extra padding over the ganglion to help prevent it from refilling up again. Here is an example of a ganglion from a recent patient. Like some patients, this patient also had a ganglion on his wrist that did need surgery. Ganglion patients can get other ganglions.

These benign lumps are not attached to the skin, are soft to pressure, and can only be documented on MRI or ultrasound. X-rays should be negative. Since ganglion cysts can develop from herniations in the ligaments of an arthritic joint, X-rays may show boney changes under the ganglion. If you can use ice massage to shrink them, routine ice massage 2 to 3 times per week may help keep them from coming back.

Insole Wear Patterns: A Biomechanical Treasure Chest

2012-02-01T22:21:00.001-08:00

These inserts tell a wonderful tale about this athlete. See if you can find all these clues, and find Waldo while you are at it. The foot functions more to the lateral heel (inverted) on the left. The left has a more dramatic push off. The pronation is a little more to the right, but both sides are fairly centered. Pushoff is more explosive on the left.

Sports Medicine Quiz: Biomechanics 3 at Samuel Merritt University

2012-01-31T10:14:00.000-08:00

The following questions cover the in-class presentation from Dr Rich Blake at Samuel Merritt University on Jan 24th and Jan 31st 2012. The students are encouraged to review the entire lecture material within the blog post below for more in-depth self study.

http://www.drblakeshealingsole.com/2011/01/biomechanics-3-sports-medicine-summary.html

Questions for 1/24/12

1. How does Sports Medicine differ from the regular approach to injuries in orthopedics?

2. What does the C stand for in RICE?

3. With contrast bathing, what are you trying to accomplish?

4. What is the 80% Rules for function and pain scale?

5. What does KISS stand for and how is it used in medicine?

6. What is the difference in a 2nd degree sprain vs a 3rd degree sprain?

7. What are common modifications to increase level of difficulty in the single leg balance exercise?

8. In the treatment of any tendonitis, what does the initials BRISS stand for?

9. What does Vit D3 do for bone metabolism?

10. What are the 3 phases of Injury Rehabilitation?

11. Name 3 common forms of strengthening exercises?

12. In Turf Toe is the primary injury dorsally or plantarly?

Questions for 1/31/12

1. What are 5 common mechanical problems seen in gait?

2. What is limb dominance in gait?

3. When watching someone walk or run, where should your gait evaluation begin?

4. What are 3 orthotic modifications used for over supination?

5. Bonus Question: What are 3 potential benefits to the much maligned high heel shoe to the patient?

Biomechanics 3: Sports Medicine Summary

2012-01-24T09:12:00.000-08:00

The following information will form the core of my 2 lectures at the California School of Podiatric Medicine at Samuel Merritt Universitty in Oakland California January 2012. Each lecture is 3 hours and divided into 2 hours didactic and 1 hour on gait evaluation. Students should be prepared to walk with and without shoes.

Intro to Blog and AAPSM

During the course of the lectures, we will discuss the below topics, but will not have time to open and explore all the links. We will watch all the videos and answer all the 60 self assessment questions. I will let you know if you should open a link during lecture time. You are responsible to the level of understanding brought out in the Self Assessment Questions. This blog is a four year project of Dr Rich Blake. I am in my 22nd month, so I have a long way to go. Please come back often in your studies to get more information as it becomes available. I am excited to be part of your education and I look forward to having you as my colleagues. Remember to join the AAPSM as soon as possible (http://www.aapsm.org/). It is the heart and soul of podiatric sports medicine.

Objectives (as outlined by the Department of Biomechanics of the California School of Podiatric Medicine):

These include:

General Definitions of Injuries
Specific Discussion of Injuries
Generalization on Gait and Role of Mechanics on Injuries
Podiatrist as Part of a SportsMedicine TEAM
Further General Rehab Thoughts

1) What are some General Definitions of Injuries commonly seen in podiatric practice?

First of all, What is Sports Medicine? And why is it a fun way to practice?

http://www.drblakeshealingsole.com/2010/05/what-is-sports-medicine.html

Self Assessment Question #1: True or False: A Typical Sports Medicine Approach is based on a TEAM approach between health care provider and patient.

http://www.drblakeshealingsole.com/2010/08/injury-recovery-principles-crossing.html

Self Assessment Question #2: True or False: Patients with injuries should decide themselves when it is appropriate to have surgery.

Acute Injuries --- Generalizations: When is an injury acute, subacute, or chronic? What is RICE? What is KISS?

Happened with last 2 weeks (if not, they are subacute up to 2 months, and chronic after 2 months)
Understand Good History Taking (have a consistant system of questions).

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

Self Assessment Question #3: What does the P in the mneumonic stand for?

Understand RICE What are the goals of RICE?

http://www.drblakeshealingsole.com/2010/09/swelling-reduction-video-on-contrast.html

Self Assessment Question #4: While doing contrast baths, do you end with heat or cold?

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

Self Assessment Question #5: In treating an injury, when do you stop doing contrast bathing?

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

Self Assessment Question #6: What is the best way to apply cold therapy for an injury?

Rest is a 4 letter word--Activity Modification is better way. What are common Activity Modifications for an Injured Runner?
Compression should be greater distal, and less as you go proximal
Elevation is always good, even only a few inches off the ground. When should someone elevate the foot of their bed for sleeping?

Chronic Injuries--what most of your patients will be dealing with. Injuries over 2 months old. What is a Plateau in Symptoms?

Understand Magic 80% Rule What does 80% better mean to an athlete?

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

Self Assessment Question #7: At what % of recovery are sport specific drills usually started?

Understand Good Pain vs Bad Pain Principle

http://www.drblakeshealingsole.com/2010/04/good-pain-vs-bad-pain-athletes-dilemma.html

Self Assessment Question#8: What is the range on the pain scale of Good Pain normally?

Understand the KISS Principle

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

Self Assessment Question #9: Why is it important for health care providers to learn simple techniques?

Sprains What is the difference between sprains and strains?

How are they subdivided?

First Degree--ligaments stretched (no obvious ecchymosis on exam)
Second Degree--ligaments partially torn (some ecchymosis) Why do 2nd degree sprains hurt more than 3rd degree sprains at times?
Third Degree--ligaments torn completely (significant ecchymosis on exam)

http://www.drblakeshealingsole.com/2010/10/ankle-sprain-advice-from-afar.html

Self Assessment Question #10: Why can some ankle sprains, without breaks or tears, take 2 to 3 years to heal?

The ligaments do not repair on their own!! Why are most ankle sprains not casted acutely?
Strength must replace loss in ligament integrity What is the Romberg's Test for ankle instability?

http://www.drblakeshealingsole.com/2010/08/video-on-ankle-strengthening-eversion.html

Self Assessment Question #11: How do you isolate the peroneus longus from brevis in Thera Band exercises?

http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Self Assessment Question #12: When balancing on one foot, how long do want to do it for?

Strains

How are they subdivided?

First Degree--muscle/tendon soreness from stressful activities
Second Degree--partial tearing of the muscle/tendon (ecchymosis will occur within 4 days)
Third Degree--complete tear (normally surgery is recommended, some cases will respond to casting)

http://www.drblakeshealingsole.com/2010/08/achilles-tendon-ruptures-surgery-or.html

Self Assessment Question #13: Can Achilles Ruptures be treated conservatively?

Tendonitis is the tendon part of a first degree strain. If the pain is in the muscle, it is called a strain. If the pain is in the tendon, it is called tendonitis.
Understand the BRISS Principle of Tendonitis treatment Why is the understanding of muscle function crucial in treatment of tendonitis?

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

Self Assessment Question #14: What do the initials stand for in tendinitis treatment?

Overuse Injuries What are some possible etiologies?

The general concept is the the tissue injured is stressed higher than its breaking point (tissue threshold) and it either strains, sprains, breaks (like bones), or gets irritated (like nerves).
Always think and investigate 3 causes of any overuse injury What are 3 common causes of plantar fasciitis? What are 3 common causes of achilles tendonitis? What are 3 common causes of metatarsal stress fractures?

How we overuse something, and cause it to hurt, can be varied, but usually predictable (see the Law of Parsimony)

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

Self Assessment Question #15: What is the Law of Parsimony? How does it fit into the KISS Principle?

Fractures/Traumatic Injuries What are some common foot fractures?

Traumatic Injuries are produced by an event (catastrophic to the patient)
It is very important to understand exactly how this event happened (remembering back to that moment)
It is also very important to understand if the injury was merely accidental, or if there are reversible preceding events that can be avoided in the future.
Like overuse injuries, it is important with all injuries to take a good history (we need to know how it happened, why it happened, and can it be prevented in the future) Why is it important to know Vit D25 levels in this regard?
Traumatic Injuries can be bruises (contusions), sprains, strains, fractures, nerve damage, arterial injuries, or most likely a combination of a few of these.

What is a stress fracture?

What is the difference between a stress fracture and a regular fracture? A better definition of a stress fracture is a fatigue fracture (the bone is fatigued from overuse and then breaks). So a stress fracture implies a fracture produced by overuse. A stress fracture also signifies a small crack not seen on xray, only the new bone formation is seen 2 weeks later denoting a healing response from the bone. However, this is partly untrue, but now part of normal lingo. A stress fracture may start as a small crack on one side of the bone, and become a complete fracture as the athlete pushs through the pain. A stress fracture may start as a complete break in the bone easily observed in an xray. So, to me, a stress fracture is any fracture, big or small, that starts by a history of overuse where the bone may be fatigued. What are the 4 stress fractures in the foot that a very slow to heal?

http://www.drblakeshealingsole.com/2010/11/foot-stress-fractures-answers-to-email.html

Self Assessment Question #16: What is the daily recommended dose of Vit D3?

http://www.drblakeshealingsole.com/2010/04/patient-footlight-1-possible-foot.html

Self Assessment Question #17: When do you place a patient with a stress fracture in a removable cast?

What are the 3 Phases of Injury Rehabilitation?
One of the advances in sports medicine has been the merging of the 3 phases of injury rehabilitation of traumatic injuries. The 1st phase is Immobilization/Anti-Inflammatory, the 2nd phase is Re-Strengthening, and the 3rd Phase is Return to Activity. Sports Medicine Principles have tried to blend them as well as possible for a quicker, but safe, return to full function. While the pain is resting in the 1st Phase, they are also doing some strengthening (at least proximal to the site), and some cross training cardio and some sport specific drills. And so on.

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

Self Assessment Question #18: What are the 6 basic types of strengthening exercises? What type is a calf raise on one foot?

2) What are some Specific Injuries seen commonly in a podiatry practice

Here I have been asked to discuss some of the common injuries I see from a podiatrist's standpoint. Due to time restraints, only some key points are highlighted.

Ilio-Tibial Band Syndrome:

Runs from the lateral pelvis, across the lateral side of the hip and knee, and attaches into Gerdy's Tubercle on the proximal lateral aspect of the tibia (in front of the head of the fibula). Can you find Gerdy's Tuberble on your right proximal tibia?
Women tend to get pain at the hip due to their wider pelvis, men at the knee.
Ilio-tibial Band Syndrome is almost exclusively a repetitive stress syndrome caused by running.
Excessive Pronation causes the iliotibial band to rub across the lateral femoral epicondyle at the knee, or greater trochanter at the hip.
Excessive Supination strains the band as it attempts to stabilize the lateral aspect of the hip and knee from the varus stress.
A short leg syndrome can commonly cause iliotibial band syndrome as the band attempts with every step to straighten the legs (to no avail).
Treatment includes correcting the biomechanics, icing several times a day, strengthening the hip abductors (core in general), and stretching alot. What is the lateral wall lean stretch?

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-29.html

Self Assessment Question #19: With limb dominance seen in Short Leg Syndrome, which side tends to get the ilio-tibial band strain?

http://www.drblakeshealingsole.com/2010/11/iliotibial-band-tendinitis-3-common.html

Self Assessment Question #20: What areas do you avoid while stretching the IT Band with an Ethafoam Roller?

Lateral Ankle Sprain:

Probably the most common traumatic injury affecting the foot and ankle (so master this one).
When a patient presents with an ankle sprain, decide if it is a high ankle sprain, low ankle sprain, rearfoot sprain, or midfoot sprain. What is a High Ankle Sprain?
Understand the mechanism of injury, and the force of the injury, to understand the possible problems created by the injury (including fractures).
An inversion sprain without a fall is better, an inversion sprain without rotation is better, an inversion sprain without coming down from a jump is better, an inversion sprain without someone landing on you is better. It is all about forces. Understand the forces generated by any sprain to predict severity.
There is no right or wrong on xrays or MRIs. If it is black and blue, it means something tore or broke, so xray at least. If you think a tendon is torn, MRI immediately. If the patient still can not walk in 2 weeeks after a sprain, even with a removable boot, get an MRI.

Followup on ankle sprains is every 2 weeks. They should get better and better. If the patient plateaus, change something in the rehab, get a test, something.
With the average ankle sprain, receiving average treatment, some symptoms of pain occur for 3 and 1/2 months, and swelling for 4 and 1/2 months. Return to running with an ankle brace can occur as early as two weeks. But, no limping is allowed. How long do you use just ice?
As will be stressed in the links below, it is so important to restrengthen the ankle for around 3 months to avoid reinjury. Usually the next ankle sprain is worse. While restrengthening, you must get a brace to stabilize the ankle in vulnerable activities.

http://www.drblakeshealingsole.com/2010/10/ankle-sprain-advice-from-afar.html

Self Assessment Question #21: What is one example for getting an MRI after a common ankle sprain?

http://www.drblakeshealingsole.com/2010/08/video-on-ankle-strengthening-eversion.html

Self Assessment Question #22: How is the Peroneus Longus strengthened differently than the Peroneus Brevis?

http://www.drblakeshealingsole.com/2010/08/video-flatfooted-balancing-exercises.html

Self Assessment Question #23: What is the reason some exercises should be done with your eyes closed?

Enthesitis:

Inflammation at the attachment into bone of ligaments or tendons by definition
These can be more stubborn than tendonitis since it is harder stretch out.
Plantar Fasciitis (at the heel attachment) and Achilles Tendinitis (at the heel attachment) are good examples.
Sever's Disease or calcaneal apophysitis is a growth plate injury.
PTTD (posterior tibial tendon dysfunction) is a tendonosis (condition of the tendon itself).

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

Self Assessment Question #24: What is the 3 areas of treatment for plantar fasciitis?

http://www.drblakeshealingsole.com/2010/10/achilles-tendon-strengthening-video-on.html

Self Assessment Question #25: How do you strengthen the soleus differently than the gastrocnemius?

Shin Splints vs MTSS vs Tibial Stress Fracture What are Shin Splints exactly?

This is a great example of the Weakest Link in the Chain Concept. Leg pain arises from excessive stress placed on the leg muscles which will be outlined in the links below. The tendon causes the motion, the tendon moves due to the contracture of the muscles (in this case in the shin area), the muscles attach into the bone's covering called periosteum, and the bone resists the force pulling on it. In an overuse situation, the same action can produce tendon pain, muscle pain, periosteal pain (classic shin splints), or bone pain. The bone pain can get inflammed called Medial, Anterior, or Posterior Tibial Stress Syndrome, or can actually break (Medial, Anterior, or Posterior Tibial Stress Fracture). The injury occurs at the weakest link in the chain.

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-3.html

Self Assessment Question #26: What are the 11 common factors that can make an area the weak link in the chain?

http://www.drblakeshealingsole.com/2010/06/shin-splints-part-i.html

Self Assessment Question #27: What are the 10 common treatments for shin splints?

http://www.drblakeshealingsole.com/2010/06/shin-splints-part-ii-anatomy-lesson.html

Self Assessment Question #28: What are the 4 basic types of shin splints?

What is Compartment Syndrome?

The compartments are fascial enclosures which house several muscles. There are 4 compartments in the foot and 4 in the lower leg. The fascia which covers the muscles can be too tight for the amount of muscle hypertrophy or swelling within the compartment. As pressure builds up within the compartment, the fascia does not give enough, and the blood circulation in the compartment is restricted (the walls of the vessels are compressed due to this pressure).
Acute Compartment Syndrome, normally produced by a blow to the outside of a compartment, is caused by the swelling in the compartment, and is a medical emergency. A compartment release is crucial to save the muscles from dying.
Chronic Exertional Compartment Syndrome can be a diagnostic nightmare. Injuries in the foot or leg that seem to have a solid limit of activity (the pain can only run 3 miles before the leg pain gets bad) may be compartment syndrome. Compartment syndrome has always been a surgical treatment, but with deep tissue work, there is a promise in the future of conservative management.
Diagnosis of Compartment Syndrome is needle catheter in the compartment to measure the pressure. Normal resting pressures are between 0-4 mmHg. Pressures that climb above 40 mmHg and stay there after activity is stopped is considered compartment syndrome. What do you think happens to the muscle strength in a compartment that has a release?

Patello-Femoral Pain:

Also called Runner's Knee, Biker's Knee, Dancer's Knee
Also called Chondromalacia Patellae, Patello Femoral Dysfunction, Quadriceps Insufficiency, Patello Femoral Insufficiency, Patellar Subluxation Syndrome, etc, etc, etc...
Associated with Excessive Internal Patellar Rotation or Position produced or aggravated by the internal talar rotation with foot pronation.

All patients with Patello-Femoral Dysfunction should be treated with core strengthening especially external hip rotators, Quadriceps strengthening especially VMO, Vastus Lateralis Quad Stretching, Knee Brace to better patellar tracking, and foot stability with orthotic devices, stability shoes, and power lacing. What is a stronger muscle the vastus medialis or vastus lateralis?

http://www.drblakeshealingsole.com/2010/07/video-quadriceps-stretching.html

Self Assessment Question #29: When stretching the right quadriceps, it is best to use your right or left hand?

http://www.drblakeshealingsole.com/2010/11/gait-evaluation-with-emphasis-on-knee.html

Self Assessment Question #30: What is Malacious Malalignment Syndrome and how does it relate to knee pain?

Heel Pain: When does plantar fasciitis hurt more, am or mid-day?

Myth: All Plantar Heel Pain is Plantar Fasciitis.
Myth: All Posterior Heel Pain is Achilles Tendinitis
You should be an expert on every aspect of these two common injuries, but very crucial to know when it is not plantar fasciitis and achilles tendinitis.
They are so very common injuries that I see very sloppy management of heel pain. Too many generalizations are used that don't apply to that patient. If I can get you a little ahead by understanding plantar fasciitis in the links below, it will be a start. Heel Pain is complicated at times, and very debilitated, and common enough to have clinics dedicated to that body part alone.

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

Self Assessment Question #31: 2 months of treatment for plantar fasciitis and the patient is not getting better, should surgery be considered next?

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

Self Assessment Question #32: True or False. After a plantar fascial tear period of cast immobilization, there is no need for physical therapy?

http://www.drblakeshealingsole.com/2010/12/plantar-fasciitis-sleeping-splints.html

Self Assessment Question #33: What are 3 common adjustments made to sleeping splints?

http://www.drblakeshealingsole.com/2010/10/plantar-fasciitisheel-pain-orthotic.html

Self Assessment Question #34: What are the 2 most important aspects of an orthotic device for heel pain from plantar fasciitis?

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

Self Assessment Question #35: What is the common denominator in all 3 stretches demonstrated?

http://www.drblakeshealingsole.com/2010/08/plantar-fasciitis-all-important-wall.html

Self Assessment Question #36: What is the difference between counting as you stretch, and taking deep breathes?

http://www.drblakeshealingsole.com/2010/05/quick-tip-7-rolling-ice-stretch-for.html

Self Assessment Question #37: If you ice for 5 minutes, how long does it take to have your soft tissues thaw out?

Turf Toe: What is Turf Toe? Does there have to be turf involved?

Turf Toe can occur to any toe, but primarily the first or second toes.
The mechanism of injury is the toe in a cleated shoe gets stuck in the ground, the metatarsal dorsiflexes over the toe too far spraining, straining, and perhaps breaking things.
Primary Injury is to the plantar surface of the joint, or plantar bones or tendons.
Secondary Injury is to dorsal aspect of the joint with compression fractures, etc.
Treatment is normally immobilization/anti-inflammatory, then spica taping, shoe inserts to restrict toe bend, activity modification. Budin splints can be used when the injury is to the 2nd through 4th toes.
Since most of the injury is soft tissue, I would highly recommend an MRI sooner than later so you really have a handle on what was injured.

http://www.drblakeshealingsole.com/2010/09/hallux-rigidus-spica-taping-also-for.html

Self Assessment Question #38: What type of tape is typically used to limit first toe dorsiflexion?

http://www.drblakeshealingsole.com/2010/10/toe-pain-help-with-budin-splints-email.html

Self Assessment Question #39: Can a Budin Splint be used for a first toe injury?

3) Gait Evaluation/Motion Evaluation helps find the Root Cause of many injuries

Sport Specific Knowledge is Important to Properly Treat Patients Injuries:

One of the best recommendations I ever got from a teacher was to go out to the malls, the parks, the streets, and watch people walk or run. Boy do you see the full range of gait patterns. You can begin to appreciate smooth vs choppy gaits, or gaits that may produce problems. We will watch each other walk in class, just to get the basics down. I have built my entire practice on this skill. And in doing gait evaluations, you can learn what is wrong quickly.

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

Self Assessment Question #40: What are the 5 common categories of mechanical problems seen in gait?

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-14.html

Self Assessment Question #41: What are 3 common knee symptoms sometimes related to excessive pronation?

http://www.drblakeshealingsole.com/2010/11/top-100-biomechanical-guidelines-13.html

Self Assessment Question #42: What are 2 foot injuries associated with excessive supination?

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

Self Assessment Question #43: If the right shoulder dropped lower than the left in gait evaluation, what leg is normally longer in an adult?

http://www.drblakeshealingsole.com/2010/11/gait-evaluation-with-emphasis-on-knee.html

Self Assessment Question #44: Is squinting patellae associated with genu varum or genu valgum?

http://www.drblakeshealingsole.com/2010/10/top-100-biomechanical-guidelines-6-err.html

Self Assessment Question #45: When dispensing a new pair of orthotic devices, why is it important to evaluate their gait?

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

Self Assessment Question #46: What are 3 positives of high heel fashion shoes?

http://www.drblakeshealingsole.com/2010/07/general-principles-of-running.html

Self Assessment Question #47: Where should your center of gravity be while running?

http://www.drblakeshealingsole.com/2010/04/toenail-clippings4-dominance-seen-in.html

Self Assessment Question #48: What is limb dominance seen in gait?

http://www.drblakeshealingsole.com/2010/12/top-100-biomechanical-guidelines-29.html

Self Assessment Question #49: How is a decrease in limb dominance achieved?

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

Self Assessment Question #50: What are the 11 common injuries related to excessive supination?

This same principle applies to dance, tennis, soccer, skiing, racewalking, zumba, etc. If you want to learn, experience. Be a student of motion. Motion is one of the secrets of life. Ask anyone whom has had it taken away permanently or temporarily. Ask any 80 year old what is one of the most important aspects of their life. Motion, to be moving, to keep moving. And there are rules along the way to obey to try to keep moving as long as you can. One of the things I am most proud of podiatry as a profession, it is dedicated to keeping people moving. Amen.

As you treat injuries from different sports, gradually learn about that sport. If a ballerina comes in with an injury, learn alittle each time about her sport. What are the main producers of pointe shoes?
http://www.allaboutdance.com/cats/pointe-shoes?range=41%2C80%2C93

4) What is the best way for a podiatrist to be part of a SportMedicine TEAM?
What is probably the most important characteristic of a Great Team?
We have talked about what is sports medicine. And that there are sports medicine doctors that do not practice sports medicine principles, and non sports medicine doctors that do practice sports medicine since it is more of a philosophy than label. So, when you are in a sports medicine team, you must see where you fit in. I love the team approach to medicine, so this is what I do. I get my patients seeing other doctors and therapists as much as possible, and it works real well. If you are part of a team, try to be the podiatric part that understands when to get consults about nerves, etc, and how to treat knee or hip injuries with lifts or orthotic devices. Get the physical therapists as involved, or they may be in charge of you on a professional team. In the dugout or locker room, the therapist/trainors rule!! The buck stops with them. You need to inform them of your skills, but let them decide when you are to get involved. But, as a very valuable part of that team, you need to be the primary care doctor for their foot injury. The buck should stop with you! If you take on a patient, you should be involved in all aspects of their care (conservative or surgical) until they discharge you, or the injury resolves. I find many podiatrists not able to do this team function since they want to be too specialized (normally towards surgery). A good sports medicine team needs a podiatrist who is conservative in their approach, since 99% of all injuries are treated like that. You, as the podiatrist, are more skilled than anyone at the simple approaches to most injuries. My blog is filled with these treatments that I use daily with my patients. Don't give that part of foot care away. If you want to be the podiatrist for the San Francisco Giants, or New Orleans Saints, etc, but your main interest is surgery, please co-captain with a conservative based podiatrist whom you can trust to call you in when the big guns are needed.
I can not emphasize the TRUST part. TRUST is everything in a team. If I trust you, our team works. If I do not trust you, the team will never work. Work hard never to break the trust of those you work with. It is the best advice I could ever give you.

5) What are other General Rehabilitation Thoughts

What are the general concepts in Injury Rehabilitation around return to activity?

Since most athletic activities are based around running, a good understanding of the walk run program is crucial.

http://www.drblakeshealingsole.com/2010/03/walkrun-program-for-injury.html

Self Assessment Question #51: What are the 10 levels of a Walk/Run Program?

What are the general concepts in Injury Rehabilitation around cross training?

Podiatrists, temporarily sidelining their runners in the 1970s, while the running injuries healed invented triathalons (like Al Gore invented the Internet!!). Cross Training is needed while injured and while healthy. Cross Training is an attempt to keep moving, but avoid injuries by working on other aspects of overall conditioning. A basketball player, like myself, may not be able to cross train by running, but yoga, stretching, bike, swimming, etc may all fill gaps in my overall health. If I am a basketball player that plays 4 days a week, my cross training schedule should not fatigue muscle groups that then limit my basketball playing. The cross training should relax, tone, improve my conditioning so that my basketball improves.

Self Assessment Question #52: Would an injured ballet dancer with knee pain get better cross training with running or swimming?

What are the general concepts in Injury Rehabilitation around bracing and taping?

You need primarily to brace and tape if you are permanently injured and the brace/tape allows some activity without pain, or if you are recovering from an injury, and you have not regained your overall strength yet.
This is one of the reasons we want to get patients not of the casts as soon as possible (1 day in cast, 2 days to restrengthen).
This is also one of the reasons we start restrengthening right after an injury.

http://www.drblakeshealingsole.com/2010/04/tips-to-avoid-castimmobilization.html

Self Assessment Question #53: What is Cast Disease?

What are the general concepts around footwear considerations?

Footwear is podiatry. And one person's best shoe ever, hurts another. Analyzing the qualities of shoes can and is as important as analyzing the patient's biomechanics.

http://www.drblakeshealingsole.com/2010/10/great-foot-story-practice-of-excessive.html

Self Assessment Question #54: What is to practice Excessive Happiness?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic.html

Self Assessment Question #55: What are 11 reasons that the treatment plantar fasciitis can be different in all the patients you see?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_18.html

Self Assessment Question #56: Why must the patient be encouraged to follow up with the doctor/therapist so that they are aware of their progress?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_24.html

Self Assessment Question #57: What are the 2 categories of injury based on severity? And how is there overall success of treatment different?

http://www.drblakeshealingsole.com/2010/07/philosophy-of-treating-athletic_25.html

Self Assessment Question #58: If you restart running, but pain returns, how long in general should you wait to try running again?

Self Assessment Question #59: A runner with medial knee pain for 5 days and excessive pronation noted in gait. What would be 5 KISS type treatments that may resolve the situation that you could recommend at the first visit?

Self Assessment Question #60: A patient was running yesterday and got sharp pain in the top of his metatarsals. He had to limp several miles back to his car. That night the foot became swollen. What is your primary diagnosis? What dietary issues should you discuss?

When Do We Begin to Save Our Joints? More Musings from my footstool

2012-01-23T22:22:00.000-08:00

This post is dedicated to Lynne.

Just saw Lynne several days ago. Lynne brought up the age old question at her young age of 59 "do I stop running now to save my knees for the future?" Her knees have some X-ray and MRI findings of wear and tear. Lynne has never had any pain. She did have an episode of knee swelling and sought medical advice. Age old probably sage advice is to stop running since it is the most stressful of her activities on her knees.Lynne is high level triathlete. Yet is it the best advice for Lynne? Does running chew up your knees and hips and ankles silently until you wake up one day and can not walk? What do we know about the Nutritional Theory of cartilage health? What protects joints? What breaks them down? So many questions to be individualized for each of us.

My bias for recommending to Lynne to keep running comes from 5 factors. #1 Joint Cartilage is feed from pressure created in the joint from activity (nutritional theory of cartilage health). #2 Pain is our friend and will normally tell us way before severe damage is created that we must start limiting certain activities. #3 Sports Medicine for podiatrists evolved from being able to get injured knee patients to run pain free when the medical establishment was telling them to stop running forever, and I come from that time period of the mid 1970s.. #4 I personally want to keep exercising until I am 100 and I will continue to find ways to exercise (my last 3 orthopedic injuries found me at odds with surgeons wanting to cut, and I was able to successfully rehab each one, and am back playing full court basketball painfree). #5 When you break away from generalizations like stopping running to avoid knee wear and tear, you must own your knee more directly and do positive things daily for it.

So, Lynne had been running for 40 years, never had knee pain, did get swelling and her images showed classic wear and tear of a 59 year old. She did not have the knee joints of a 90 year old, so all the running she has done has not been bad for her knees. There was a famous study from Sweden or Norway (way up there) in the 1970s. Twelve 90 year olds who had died had there hip joints examined. All 12 never had hip pain. 6 of the 12 were very active their whole lives. 6 of the 12 were very inactive their whole lives. Guess who had the hip joint cartilage of 20 year olds--yes, the active group. The 6 individuals who had been inactive had hip joints of 90 years old (and not a day older). This study helped secure the global recognition that the cartilage in our joints needed pressure to drive the synovial fluid into the cartilage (a form of forced feeding).

Lynne stopped running to save her knees, but may be actually speeding their demise. Lynne can sure be smarter and try not to run down hill frequently where the force that your knee must absorb is up to 10 times body weight. And Lynne can get her knees strong with daily quad sets, straight leg raises, and short arc quad leg presses. Since most of her problem with wear and tear is behind the knee cap, and the load on the knee cap increases dramatically over a 45 degree knee bend, Lynne should do her activities and exercises in a 0 to 45 degree flexion range. Running is perfect for that, some parts of biking may not be. Let pain be your guide. Lynne should ice her knees with swelling or pain after activities, she should wear a knee brace (I love the Bauerfiend GenuTrain for this problem) when she runs to see if it helps. She could also learn the many ways of taping her knee like McConnell Taping. She should take glucosamine daily. And lastly, Lynne should listen to her body and get back out there, and not listen to general rules that may not apply to her. And as Sue Sylvester on Glee says: And that is how I C it!

Bad Sores: Top Podiatrist Recommends this Product

2012-01-22T21:32:00.000-08:00

I recently sent a diabetic patient to a top wound specialist for an opinion. His recommendation to her was to use Winvivo Healing Balm. She definitely looked a lot better in the three wounds I had been trying to help her with. It can be used for superficial or deep wounds. It should not be used in the face of a possible infection. I believe the product has some great potential, but it is always trying to find out who it is beneficial for.

http://www.winvivo.com/healingbalm.html

Wound in a diabetic after I scraped the callus and dead tissue away (called debridement). Careful debridement is always the number one treatment for these injuries/sores.

Application of Winvino to the wound bed.

Closeup of the wound bed after application of the product. I like it because it can penetrate into a wound. I love another product called Acticoat when the wound is superficial.

Electronics for Heel Pain: If this works, the Stock is definitely worth buying.

2012-01-19T12:24:00.000-08:00

http://www.marketwatch.com/story/bioelectronics-study-on-plantar-fasciitis-to-be-published-in-the-journal-of-foot-and-ankle-surgery-2012-01-19

Brown Fat for Anyone?

2012-01-18T21:45:00.000-08:00

My good friend Dr Karen Langone from Long Island, New York, posted this great article on her Facebook page. You should not need any more reasons to exercise. After you study the article from the New York Times, I will give you a quiz on PGC1-alpha, brown fat, and irisin. Does two irisins make one PGC1a or 2 PCG1a s make one irisin molecule?

http://well.blogs.nytimes.com/2012/01/11/exercise-hormone-helps-keep-us-healthy/?ref=health

Dry, Cracked Heels

2012-01-18T21:07:00.000-08:00

http://www.alimed.com/heel-so-smooth-heel-sleeves.html

This is one product available for dry, cracked heels. Works well.

REFLARES OF PAIN: UNFAIR, BUT PART OF THE PROCESS

2012-01-17T22:14:00.000-08:00

This is an email from a typical patient expressing her frustration over a recent reflare of her symptoms. The symptoms are in the front of her foot, and a recent MRI showed no sign of fractures or neuromas.

Hi Dr. Blake,

My foot has been flare up since Sunday after a yoga class, I have been using the contrast bath, but not too much ice though, according to the acupuncturist, she thinks that I need more blood circulation to improve the nerve problem. Icing is not a good option in Chinese medicine.

Last time (Thursday) I visited her, we had a very good acupuncture session, she attached electrodes to needles to provide continued stimulation (like the Stim unit). After the treatment, I felt good, walked without any nerve problem for a while.

Sunday morning I went to a yoga class, I felt OK during the walk from my home to the gym, but there were several standing poses in the yoga class that required strong foot position, then I felt a lot of nerve activities. After the class, I went home to apply a contrast bath, and it seems to quiet down a little.

But yesterday and today, I can feel the nerve problem all the time even when wearing my MBT shoes or sneakers (on a better day, I can almost feel normal in those shoes).

So now I'm applying ice, hoping it will not get any worse.

I forgot to ask you if you have a diagnosis report that I can bring with me when I visit my Physical Therapist and my Acupuncturist. I went to my PT office on Friday, but they were not sure if it's OK to treat me with massage and ultra-sound, so they asked to see the doctor or MRI report and maybe your recommendation for PT.

Also I want to ask you if it's OK that my Acupuncturist massage my foot, in her opinion, she thinks there is scar tissues developed, so she wants to deep massage them to break down the scar tissues.

I forgot to ask you if you have seen any possible fracture in my MRI? These two days, I started to feel "similar feelings" as when I had the stress fracture on my metatarsal two years ago. Am I starting to get paranoid or is it really a fracture?

Can you see it from the MRI if there's any fracture line, since we did not looking for fracture but neuroma, is it possible the MRI might miss a fracture line?

I still have my immobilizer boot from two years ago, should I start to wear it, will that help to improve my condition?

Sorry to ask you tons of questions, I was feeling better last week and felt the condition might be improving, but now I feel the problem again, it really brings my spirit down again and my mind starts to go crazy a little........

Thank you very much in advance.

And here is my response:

Thanks for the email and sorry about your flareup. Flareups are quite common, and you have may a few more until we get this under control. One of the secrets to not going insane is in quickly controlling the symptoms of a flareup. Definitely the boot and icing are wonderful to do right now. Wear your removable boot 24/7 for three days longer than you need. If it puts stress on your back, go to our sports shop and get an EvenUp for the other shoe. Ice for 10 minutes 3 to 4 times per day. 2 Advil 3 times per day for 5 days on, followed by a 2 day rest is appropriate. Since it is nerve pain, absolutely no deep massage at all. Accupuncture is great. PT is rarely helpful at this time. The MRI shows no fractures. When you know it has been irritated by the yoga, only ice for 48 hours. The contrast bathes may have heated it up too much. Hope this helps. Finished your orthotics today!! See you soon. Rich