 So last year I wrote this book. I've been practicing for, as Jan said, 37 years, and my practice is all rehab. So I just try to take injuries and make people stronger. So I'm basically trying to present to you the secrets of doing that, secrets to keep moving. So the book title came out of people saying, you know, how do I keep moving? How do I keep moving? How do I just keep going with life, you know? And I just lost my mom, but that was the last five years of her life. It's like, mom, we've got to keep moving. We've got to keep going. And that really, until we can't anymore, that has to be our goal. And some of the things that I'll talk about, they're very common sense. You may say, that is such common sense. I knew that already. But in medicine, you'll leave a doctor's office and there's no common sense of what they say. I just treated a patient the other day who the doctor gave a cortisone shot in an area that didn't even hurt her because an MRI showed that there was a problem there. She didn't come in to get that area treated. And she had a reaction. She got a bad injury from the shot. So she came to me for a second opinion. And it's like, but she says, I don't blame the doctor so much as I blame myself. I was not, I did not listen to myself. I knew that was the wrong decision and I should have known better. I should have said, doctor, no, let's deal with my other problem that I came in here to treat. Let's not deal with it. So if you listen to your, listen to what your body is telling you, sometimes it will, most of the time it will tell you the truth. So I practice up at St. Francis Hospital, which is high between Bush and Pine. I'm on the 11th floor. We're, we're, it was called the Center for Sports Medicine. Treat all insurances except maybe some of the HMOs. But we have, we have four podiatrists, eight MDs, six physical therapists, a whole dance medicine program. It's a huge place that I'm, I'm lucky to be at. I have an email address which you can use. One they'll, tonight if you think about maybe buying the book, but you know, you don't want to make a rash decision. You can always email me and the, the email will give, get you a discount. So, but also if you have a question, we talked to one gentleman and he's going to send me the list of his podiatrists from his, because he's in some HMO that I don't treat. And he's going to, he's going to send me the list and we're going to, I'm going to try to steer him towards somebody who's good. So, so tonight the book, I'll have a book signing after this and it's 49.95. I have my square if you want to pay credit card. But I, I tell my patients, you know, that get the e-book if you, if you like e-book. I mean, I like hard bound books, but if you want to test out a book, buy the e-book for $4.99 and, and see if it's something you want, you want to get. So the library here is kind enough to have one copy that's a reference and two copies that are circulating of the book. And I'm sure you could convince Janet to have more copies. Or have your library, if you're from Oakland or whatever, purchase this, this all, this is my all sales pitch for the night. Okay. All right. So we're here. Thank you. We're here to talk about sort of general rules on, you know, on getting well and on keeping moving. And feet are very important. I've never once regretted being a podiatrist. I was, I was pre-med in college, decided to go to podiatry school because I liked the podiatrists in our running group. And I've never turned back. And it's just been this wonderful profession that, you know, helps people and, and you get instant gratification. You know, my, my internist never gets instant gratification from me. You know, he'll go and I'll say, okay, Rich, you got to, you know, take this pill, you know, but I get instant gratification every day from my patients saying, hey, you know, this pad helped me or this shoe has helped me. And that's always really cool. So one of the secrets of keep moving is to just keep moving. So as simple as that. And I've been amazed coming, you know, watching people as they age. You know, you see people at the bus stop moving their arms. And there's a cultural thing, right? You know, but just keep, keep working your body parts. Keep, if you can't run, you bike. If you can't bike, you're elliptical. If you can't elliptical, you, you, you swim. Whatever you can do, or you, or you take a yoga class and maybe you can't do the whole yoga, but you can do part of the yoga. Maybe you can do polite. Have a lot of things. Take this body seriously. I think we all should exercise a good hour a day. That's something. You know, and we, we may have to break that into four 15 minute segments. But an hour a day is like, there's no excuse for that. And if you're religious, you should also pray an hour a day, but I won't go there. And, and this general advice applies to all ages. It's really, really important to take younger people and get them exercising. The obesity in children now is going skyrocketing. And they're on their video games or they're, they get iPads when they're two. It's amazing the, the distractions they have. And every child should be exercising an hour a day. And that's seven days a week. And so, and that, and you can find something they like. You know, both my one, one of my sons love running. The other son love basketball. And, and it just whatever they like. Another kid will like skateboarding. I don't, you know, a little dangerous sometimes when they almost run into you. But danger for me, not for them. This is really a crucial slide if you have an injury. Because there, there are three phases of injuries that we're always dealing with, with pediatry. There's a time when we want, we have to immobilize something. There's a time then we have to re-strengthen it. And then the, and then we allow people to start their exercise again. So there's three sort of natural phases that people go through. The problem with this is that you, you, you may at this point flare yourself up and not go back here again. So it's not, it's, it's, it's, it's like, if you, any of you walk the labyrinth. You know, you walk and you get close to the center. And then you, and then two seconds later you're, you're off on another. You're, you're like as far away as you were when you started. And, and that can help happen with injuries. Where you, you have to constantly say, am I, am I hurting myself? Because, you know, I was, I was put in a boot and then I was re-strengthened and now I'm, I'm running. But it's hurting again. Maybe I should back it off again. And sometimes you have to go two steps forward, you know, one step back, three steps forward, three steps back. But eventually you get to the Friday. And again, that's common sense. But I have one little story that I want to share with you that just happened a couple of weeks ago. This, and I'm not going to pick too much on UC because, but this man came in to my clinic with level 10 pain on the bottom of his foot from a nerve. I mean it was classic nerve pain. He took a step and, and he said, that's level 10 pain, Rich. So, and for two years he hadn't, he hadn't been able to walk. And for two years UCSF, you know, which I love, I'm a cow guy. I love by UCSF. But they, they biopsied his nerve. They ran nerve conduction tests, low back tests. They gave him shots. And for two years he has not been able to take a step. So it comes into my clinic and he says, what can you do for me? You know, like, I, you know, I don't have any of his records. I say, okay, let's start. Let's, let's, let's, let's go back to a mobilization. So I took some pink felt, which is about an eighth inch thick, and I cut a little well out. And I made it like three eighths of an inch. So I made a pad for under his foot to float the area, to off weight the area that hurt. He walked down the hall and said, this is the first time in two years that I have no pain. Okay. I did, I don't know what he had. I mean, it could be pretty normal. I didn't help the diagnosis, but I, I, I made big progress on, on him walking. But that's the common sense. Like, why weren't they due? I still to this, you know, it's only been two weeks. But like, why, why didn't they treat the foot? Why were they just doing diagnostic things? So I, I don't know. A lot of people, so there are athletes that I treat and there are athletes. And some people run marathons and are not athletes. They have no idea. They're, there's, and probably only a quarter of athletes I treat are true athletes. Athletes take care of your body and that's why we're all here tonight. We want to take care of our body a little bit more and I hope some, some little point comes through. But, so this is a gal who's, who doesn't know the difference between good pain and bad pain, but also doesn't honor her body and, and ignores it. Say, I've got this marathon to run, so I'm going to push through pain so I can, I can do my goal. What kind of athlete is that? I mean, she's not getting paid to do this, right? So, and that shouldn't be, in fact, the professional athletes would never do this. They'd say, huh, I, I'm, I've got a big contract. I'm not going to do that. So, basically, good pain is pain that hurts a little bit, but you can loosen it up. Bad pain is the pain that you've loosened up, but as you've gone for your five mile walk, at four miles it starts to hurt you. And then you've got to say, okay, Uber, where's Uber? Or let me at least sit down on this park bench for a half hour. Don't limp home. Any pain, bad pain is pain that you have to limp home with. You know, and we tell coaches of, of young kids, parents will always say, can my son play basketball now? Can my son play on the soccer team? Can he run across country? And I say, okay, kids don't have a good concept of good and bad pain. But I say, if you, you're in the stands and the coaches on the bench, if they see that child limping, they're in the bad pain realm. And we've got to stop them. So everybody's got to be honest like that. So, so you want to try to figure out, is this pain, pain that I'm feeling, having any residual to, does it hurt the next day? So sometimes people say, I run and I'm fine. The next five days I can't walk. And they go, okay, well, okay, then you weren't given any warning. So we've got to, like, slow you down. We've got to, like, take your five miles and make it two and a half and see if the same thing happens. If two and a half, then we go down, we've got to go down to one mile. We've got to find out how they can do their exercise and not have any residual pain. So I'm always dealing with this zero to two pain. You know, medicine about 15, 20 years ago, I don't know, whatever, started talking about pain level between zero and 10. And you're all forced, you're all forced to learn that. And they'll say, what's your pain today? And you're supposed to give them a number. It's like the most ridiculous thing in the world because, well, when I do this, it's level 10. When I stand here, it's two. You know, it's like, so you have to give them some number. But in general, you know, we want to create an environment, whatever it takes, whether it takes a cast, an orthotic taping, a pair of shoes, that rock, whatever it takes to keep them through their whole cycle of rehab in this zero to two pain level. So zero being no pain and two being mild discomfort. I love these eggs. They're much better than those, you know, those little smiley faces. You know, I don't like this. So what kind of pain gives you, you know, the 10? This is level 10. That's nerve pain. Nerve. If you ever had nerve pain, those are the sufferers of this world. They have level 8 to 10 pain consistently. If somebody comes in and says, I broke my bone and I have level 10 pain, I go, the broken bone, it has maybe a secondary thing, but it's your nerves that hurt and we got to treat your nerves. They're the ones that are giving you that intense pain. So every injury has golden rules that we'll work with. In my book, I go through 52 common foot, ankle, and leg. And please check it out or get the e-book. And I go through like the top 10 things that are like, these are things that should happen with your bunion, with your plantar fasciitis, with your ankle sprain. They're a common thing. There's one injury. Somebody mentioned they have halox limitis. I forget, was it you? So I have, there's like 20 things I do for halox limitis. One of my patients went to Kaiser the other day and she was self-paying to see me and I gave her all these things. So she went back to Kaiser and said, what can you do for me? And they gave her three options. And that was it. That was there. So that's one of the reasons I have these recommendations is like, if your doctor is not giving you them, say why? There's like 10 things I know that can help this injury. I did an article like four years ago on plantar fasciitis, which is a real common heel problem. And I went through the literature extensively and I found 72 treatments that were successful that had a legitimate help for plantar fasciitis. 72 things. So that's why chiropractors can make plantar fasciitis better, podiatrists can make plantar fasciitis better, orthopedists can make plantar fasciitis, because there's so many options, but you have to give the patient at least five options and then have plan B and have plan C, and you have to be able to make it more complicated if you need to. So what are some of these golden rules? I hate slides that have a lot of things on it, so I'll just read through the first couple of ones, but never push through pain that is sharp and causes limping. We already talked about that, bad pain. Never mass pain with pre-exercised drugs, including ibuprofen and aspirin. People tell me all the time and say, yeah, I can run. I run 10 miles and it hardly hurts. I hurt after, so that's probably not too bad. And I go, well, do you take any anti-inflammatories? They go, oh, yeah, I take eight aspirin before I run, or not eight aspirin. Nobody would do that. Eight ibuprofen before they run, which is still really stupid. So you want your body to give you feedback. If you rob that feedback by numbing the body part up, you won't feel it till afterwards and then you could have done yourself some harm. And I have plenty of stories. So everything I tell you is basically the kiss principle. Everything I do, like, I have podiatry students come into my practice at times that are bored, because it's not high-tech. There's nothing I do high-tech. Yes? Could you flash back to the last slide? Yes. Okay. So everything I do is the kiss principle. Keep it simple, stupid. I am stupid if I make it too complex. So find simple things. And I teach podiatry students over at Samuel Merritt Hospital. And I tell them, I say, you're learning all these high-tech things. You're going to know how to do stem cell injections and PRP, which is plate rich plasma. And you're going to learn the greatest surgical techniques. But learn the simple stuff. How to properly stretch. What shoes are good if you have a flat foot? How to wean off ibuprofen. Very simple things. Okay? Cool. But also, I'm stupid if I make it too complex when I don't need to. And the patients are sharing the blame with me if they go along with it. Or they, I have patients, again, not athletes, they come in and they want me to, the first thing out of their mouth, I want a corosone shot. I have a bad nerve. And I say, why do you want a corosone shot? That's just going to mass pain. You can get it. You can get weakness of the tissue. Like, can't we try icing first? Can't we send you to physical therapy first? Oh, no. I know I have a tennis match this weekend. And I said, no, we can't do corosone for that. So, but, you know, that same patient may go to the next doctor who will do that. I won't, but somebody else will. You'll always find somebody else who will. This is always humbling. So if you have an injury, the 80-20 rule is so true, you have an injury, and in one month, the injury is 80% better. Okay? So you're feeling good. You've dropped the pain down to zero to two. You're feeling good with it? Okay, I'm going to start running my 10 miles again. Unfortunately, it takes 20% of the time to get it 80% better, but it takes 80% of the time to get the remaining 20%. And that is, so one month you get 80% better, four more months it takes you to get rid of the rest. And you should be, it's not just time. It's strengthening the tissue. It's continuing to work on the anti-inflammatory regimen. Learning the appropriate stretches, or can I tape it? So there's a lot of other things you can do, but it's a long time rehab. It takes a while. We all have wake links in our chain. Okay, my mom had two knee replacements. My father-in-law had two hip replacements. People come in who've torn both Achilles tendon or have history of shin splints on both sides or plantar fasciitis on both sides. We all have, unless we have a tremendous fall that hurts one side, we tend to get things that affect our weak links. And people come in for it, we treat it, but I'd like to take it a step further and say, how can we make this weak link stronger for you? It could be simply using an orthotic to support their arch. It could be learning how to strengthen their foot because the basic root of the problem is their foot, for them, is weak compared to other people or a tendon, their perineal tendon on the side of their foot. So that saves so many injuries. Being a podiatrist for 37 years, I now have patients who have been there for at least 35 and they come back and say, boy, what you did for me in 1985 is still working in 2017. And that is like music to my ears. But we work with them on not just treating that problem, but trying to take it another layer to help them, trying to get at why they're weak. And it all boils down to you listening to your body. You don't have to be a hypochondriac, even though there's probably a few of you out there, but it is. I tell you my favorite story of a hypochondriac, and this is why it's bad that I have control of this clicker, Janet. So this guy, Richard, who is my namesake, of course, Richard is a hypochondriac, so I get five emails from him before he comes in, like, oh, you know, I have this problem, and I've learned for about 25 years that I've known Richard, have dealt with him. So this one day, he's emailed me five times in the morning while I'm seeing patients. Of course, I haven't emailed him back, and he was okay with that. So he said, well, Richard's been emailing me back, so I'm going to go up to his office because I've got this swelling in my ankle. It doesn't hurt. I'm such a hypochondriac. I know what my ankle looks like, which some of you don't know, and I know that ankle shouldn't be swollen. So he comes up. I just have, on my way to lunch, I pass the front desk, and he's out there seeing, and I'm not going to be coming back for an hour, and he's going to wait there for an x-ray. So I see him out there, and I go, I'm going to have to deal with Richard anyway. So I go out in the waiting room, and I examine him in the waiting room, and I squeeze his calf, and I say, you know, have you been sitting? And he goes, I sit a lot, you know, so maybe it just didn't make sense why his left ankle swelled versus his right. It was like a sixth sense, like, okay, he's a hypochondriac, so I could easily blame him being there. I said, Richard, just to rest our minds, we're going to send you down for a Doppler ultrasound and make sure you don't have a blood clot in your leg. So for the last five years now, when I get an email, sometimes three and four times a day, Dear Dr. Blake, comma, the man who saved my life, comma, because he had a blood clot from his knee to his groin that was fragile, and they were able to take him from radiology, send him to the emergency room, get him on a blood thinner, and that could have saved his life. So every now and then podiatrist saved people's lives. So that was cool. But, you know, I still to this day go, I don't know why I sent him, but something. Okay, in all health classes in high school, if you remember back to your high school or college health classes, you learned rice, rest, ice, compression, and elevation. Okay. We've only added one letter to this thing, and that's price. So we've added a P. So when you get an injury, you have to protect it. So if it's an ankle sprain, you put an ankle brace on it, you rest it, and athletes hate the word rest, so they like activity modification. You got to ice it for four days. Any new injury, you put an ice pack for anywhere from five to 20 minutes based on how deep the injury is. So you got to cool that sucker down for those first four days. And you compress it as best you can with an ace wrap or again a brace, and you do as much elevation as you can. You don't have to get it above your heart, just keep it propped up. And I like also keep your ankle moving. So if it's an ankle for toes and ankles, you keep the ankle moving. So you're actually starting phase one of your strengthening program by moving your ankle, getting the circulation going, and that helps with it. So price is the mnemonic to remember for that. Stretching. People should know how to stretch their Achilles tendon and their quads and their hamstrings. We try to, you know, a lot of kids don't need to stretch, but we try to just get the habit when I coach baseball and basketball for 13 years, and you try to get the kids to do the stretching and they're, you know, they're joking around and behaving a little bit. But when you stretch, you should hold the stretch, like an Achilles stretch. You hold the stretch for 30 seconds. That's, you don't need any more than that, and probably shouldn't be any less than that. There should never be pain, there's another principle. So hold for 30 seconds, never be pain. I like to deep breathe. Good yoga principle. So instead of counting to 30 where we tend to hold our breath, take four or five deep breaths and let that oxygen get down to that tissue we're trying to stretch out. So, and then no bouncing. So you don't want to like, you see people like, oh yeah, okay, I'm going to loosen up and they do whatever they're doing they're bouncing with it. So we call that ballistic stretching and the word ballistic doesn't sound very good, you know, unless you're going to do a bomb or something like that. Strengthening. The golden rule of thumb is that you start to strengthen an area as soon as you hurt it. So day one, as soon as you hurt it, you start to do something to strengthen it. Even though I said there's a clear phase of immobilization and then re-strengthening and then return to activity you still try to blend those phases and as soon as you hurt yourself you can at least do, if I sprain my wrists and I can do this without pain that's active range of motion that's phase one of rehab you know, and then I can start adding resistance and do some isometrics so I can start re-strengthening it as soon as I hurt it. These are the the classic definitions of the types of strengthening we teach people. So from simply, if the only thing you remember is number one, which is again very simple but very effective is just if you hurt your knee you try to keep moving your knee and that activates the quads, it activates the hamstrings but again it shouldn't hurt you can't keep making it hurt but so you try to pain-free range of motion then you can add tightening exercises and weights you can use resistance bands and that's usually when you need to go to a physical therapist and they need to outline a program for you I hurt my back a few years ago and I ended up with like 70 back exercises over a five month period therapists are good at giving you exercises but they never want to take any away so sometimes you have to say well I only have time for 10 you can't do 70 but still you can slowly add almost any body part can be strengthened and should be strengthened this is always controversial, when to ice and when to heat I always tell people air with icing some people if it's a very superficial injury can't ice more than five minutes they start burning the skin nerves I did that once I had to ice my shoulder during the OJ Simpson trial I watched that every night I put my ice pack on my shoulder and my shoulder was numb for like six months it was just a 20 minute ice pack but there's no fat up there so I anesthetized my nerves myself so if you've ever made a mistake I've made it too so you're in some company anyway that's the best length of time ice typically you ice for four straight days with an injury you ice for four straight days but then you ice after you work out to cool things down people sometimes ice almost indefinitely if they have a chronically sore knee they have chronic arthritis in their knee I tell anybody who has arthritis in their big toe or anywhere like you know arthritis 101 is putting an ice pack on the body part once a day for five to ten minutes just to cool the basic inflammation down arthritis causes you'll be so much more comfortable overall right, use it for like at the big toe you're like talking about five minutes of icing to cool it down and probably if it's really bothering you you want to do it like three times a day and then it starts to feel better you cut it down to two times a day and it starts to feel better then you go to your maintenance of just once a day but it's going to be non-painful for a month before you would stop icing for a lot of things that would be the heat so if you wanted I love foot massagers so if you all want to go out and buy I'm sorry I don't have a patented foot massager to sell you okay but I love the massage it really helps the nerve the nerve part you know, you have three reasons you have pain, you have mechanical pain you have inflammatory pain which is the ice is getting at and then you have the neuropathic pain which is nerve pain that settles in and makes the tissue hypersensitive and that the massage can help whether it's a vibration or you're massaging it on a prickly ball or just using a topical cream to massage into the tissue so typically we ice after activity in a chronic stage we use heat before an activity to warm up and some people like when I play basketball I go to the gym I start actually shooting around first for about 10 minutes it's like 8 o'clock in the morning and everything's tight then I'll stretch I'll do my stretches for 15 minutes to help loosen myself up and then I go and practice my play basketball and then afterwards if something hurts I'll go back and I'll put the ice pack on if you want to speed up the warming process you can use a heat pack before you work out some people say ah my hip is always sore I say you know try you know when you try to figure out a stretch for it that's good but also try a heating pack then you go work out if any of you are Golden State Warrior fans there's got to be one or two of you when Steph Curry hurt his ankle last year or hurt his knee I'm sorry and he came back he was like on that exercise bike in between and Kevin Durant in between he didn't go to the bench to sit down when he was not playing he was in the tunnel riding the stationary bike loose and he probably had a heat pack on it too to loosen it up there's wonderful tape out there now that I didn't have for a good 25 years of my practice and now it's stretchy tape it's multi-colored which is really cool good for San Francisco right you could typically tape any body part to some degree some people have to do it chronically some people just through the two months of their injury learn to tape your big toe if you have Halix limitus or tape your ankle this is tape for the Achilles tendon that help the person move them along into the return to activity phase and this is real important there's three types of pain paediatrists are really good at the mechanical so we're always using braces we're using orthotics or wedges to shift body weight around so we're helping the mechanics of something if we think your foot pronates and you need mechanical support and that can help you can help your knees and your hips but there also then can be a very inflammatory reaction so you have to you can't just give somebody an orthotic and say you're fine you should add some anti-inflammatory with that whether it's just straight icing or or doing some sob you can take ibuprofen but as long as you don't do it before you work out so there's always that then there's a neuropathic pain so if somebody comes in and says boy I've had this pain for seven months and it just hurts all the time and you feel their tissue and it's not that swollen I don't know why it hurts any time I say I don't know why it hurts this much there's always a nerve part to it it's always a nerve and you can't see people can have terrible sciatica and you don't see any body parts swollen so it's always and that takes different you can do neuroflossing, neuro-ease there's different things that can help that physical there yes, it just masks the pain just a general principle you don't want to mask the problem so if you have to take ibuprofen to be able to work out there's something going on you should deal with and in the long run it will hurt you so I think if you take it a couple of days it's fine but in general it's a bad general principle yes yes peripheral neuropathy you can use like neuroflossing that's an exercise for the nerves to help that I don't know enough but sometimes sometimes the neuropathy is coming from the ankle the ankle moves too much so we treat the mechanics of the ankle and it takes the pressure off the planter nerves and they feel a lot better and sometimes you have to go through 20 different supplements a different one every month to see I have a list of about 8 supplements in my office that I'll have B12 B6 and I'll have people go through the month of November take a good dose of B12 and if that doesn't seem to cut into your symptoms then in December we're going to do another one and sometimes it takes that I have people swear by one different supplement they found the one that worked for them but if you take them all they have no idea what helped and they probably work against each other a little bit so that's a little difficult most of it is on my website so I have a blog that I can write down after so I don't know I don't know but I have a blog I have a YouTube channel it's Dr. Blake's Healing Soul and like all my exercises on there if you if you get my email and you email me it's actually on my email if I give you a response it will have my blog so a lot of that's on there of course it's all in the book so definitely one of the important things I do is watch people walk and run most people run pretty good sometimes their shoe selection is pretty bad they get into the oh I've got to wear this shoe with five fingers or something like that and there are people that jam their feet against the ground some people it's very appropriate for but a lot of times I'm counseling let's just go up a little bit more and cushion and support and it could be as simple as that that it helps them people run just terrible and they have to go we have a physical therapy staff that will train them to run better I try to give them tips sometimes it's purely they need some exercises to get their muscles working better so it can be a process to change how you run but it is doable but I tell people for the next year oh god what am I gonna maybe they never come back after I tell them that but it takes a while to learn and you have to telephone pole to telephone pole run and sometimes they run too fast sometimes they run too slow which is interesting and then another mnemonic I use all the time is for tendonitis it's called bris it's basically if you have a tendon injury again you're working with the biomechanics of that tendon and why it's why are you getting that you're talking about some form of activity modification some sort of anti-inflammatory and then you're always with a tendon you've got to stretch it out and strengthen it so at least you've got to evaluate for me so this is my mnemonic somebody comes in with Achilles tendonitis I go through this and go what are the mechanics that cause this are they simple to correct or are they going to be difficult to correct and then how can we create that zero to two pain level so how can we get this tissue calmed down and in a better place so we can return you to running that usually requires some form of icing some anti-inflammatory and then learning there are people that are over flexible and there are people that are under flexible are most textbooks talk more about if you're too tight you have Achilles tendonitis because you're too tight and sometimes I have patients who do five days a week a bit from yoga there's no way they're tight they're actually on the other side their Achilles tendon is so loose that I tell them I don't want you stretching for three months because you're too loose so that takes a physical therapist or somebody to like get a handle on what's going on with you and then always strength training so I love dealing with swelling swelling is like a key to so many injuries or so many rehabs all people come in and their ankle is chronically swollen and they're really not addressing it they may have gotten a brace they may have gotten a pair of orthotics they may be on a strengthening program all good things but no one's working on their swelling and swelling floats the joints wherever that swelling is it's bad for the joint the tendons have a hard time stabilizing the joint the swelling floats the joint surface and makes you more unstable I had this one guy in recently who sprained his ankle a year ago and that was the first time and has sprained it like four times since and he's been doing all the right stuff but I looked down at his ankle I said this has been a year and why is your ankle so swollen so I had to do hot and cold baths twice a day and wear compressive sleeve and that really started to change his symptoms and I really wanted him to go to acupuncture I offer people I say for swelling either acupuncture or physical therapy whichever you want at least we want to go like eight times and have them get rid of that swelling and that tissue and those professions are usually really good so usually I had for the warriors last year of Iguodala laying in an ice bath and soaking is the best way of working on swelling or sorry so feet are so easy you don't have to put your whole body in the toilet you can just put your foot right so feet are easy and elbows are okay hands are okay it's hard to get our backs and stuff like that but if you can soak something whether using ice or heat you're going to really help yourself again I talked about nerves and how nerves cause so this is a simple little problem with a nerve this was I think this is the guy I told you about that had this two years of nerve pain I bet he has a fairly simple problem unfortunately the MRI didn't show anything which means it's probably even simpler but because the MRI didn't document anything there was no reason for them to do surgery to remove it so it started this two year process of treatment until all my pink pads came in so but nerve pain if you have nerve pain in your foot you hurt those things really hurt well a third of if you have nerve pain in your foot a third of people are just numb and they think they have peripheral neuropathy they're just numb another third of people have just pain and then the other third get a mixture of pain and numbness so they're the in between people but it's the people who just have pain who've described how can you describe that pain now let's say well if you've ever been to Hawaii it's like somebody pouring a lava onto my foot so you'll get things like that and if you can help somebody with symptoms like that you feel pretty good as a podiatrist if you can't you feel really frustrated so so with nerve pain this is the they come in with this pain nothing else causes pain like this unless you have a bone sticking out of your foot and I think you could all even without this lecture you probably could figure that out so there's a syndrome and I get the most YouTube hits on this I wrote a little blog, a little YouTube video on how foot pain can come from your back and the sciatic nerve comes down the back of your leg through your calf and then goes in both in the bottom and in the top of your foot and you don't have to have back pain for a little bulging disc in your back to cause you to have foot pain that is a level 6, 7, 8, 9, 10 pain but there's no problem at the foot it's just the end of the nerve that's hurting and the problem's coming from your back my very interesting patients is a friend of mine 10 years ago, Tad came in Tad hates doctors so Tad told me he goes, I'm only seeing you because you're my friend I hate doctors and I have level 10 pain from an ingrown toenail that was his chief complaint that the nurse wrote down level 10 pain ingrown toenail so Tad was in the right place so I poke on his foot there's no swelling he doesn't have an ingrown toenail I said, Tad, this has got to be double crush you're irritating the nerve in your back and you're irritating the nerve in your foot by stepping on it and it's the end of that nerve that's hurting you and he looked at me like, you're crazy and then I said you have to go to a back doctor and he goes, I hate doctors but, okay, you're my friend I will go to the back doctor the back doctor initially agreed with me and said, yeah, it's probably coming from his back let's get an MRI Tad had stage 4 prostate cancer there was a metastasis pushing on the nerve pardon me? I guess he doesn't hate doctors now so Tad got 10 years later I actually treated his daughter last year and as of nine years, Tad was doing great but it presented so Tad calls me being my friend and he goes, you're wrong, Blake so guys use their last name right? Blake, you're wrong I go, what was I wrong? It's not my back and I go, what was it? he goes, I have terminal cancer and I'm dying luckily he didn't so so this is the exercise I have on the YouTube for neuroflossing there's a wonderful exercise there are many versions of neuroflossing this is my wife who's back there and she's taking her foot through we're trapping the spine and the pelvis down we're taking the foot through the range of motion to help relax the nerves you do that like three times a day to help a nerve heal if anyone's told they have a bone problem a stress fracture, a bone bruise vitamin D can be the culprit and this is a public announcement because through the public health there's such a vitamin D deficiency in our population and so if you have any knee pain, hip pain, joint pains, your bones ache, get a bone density if you haven't had one in five plus years and get a vitamin D blood test and see where you're at I just had somebody who's 27 years old who has the bones, he's Middle Eastern so there could be a cultural thing but he has the bones of a 95 year old and I told it's going to take us a good 10 years to work through and he's been to now three endocrinologists and we're working them through but he presented with shin pain and I said well he said he had shin pain for two years and worked up at Stanford so I'll pick on Stanford now and I said shin splints don't act like this let's see what your bone is so we got the bone density first and he was so bad so he is so thankful because he's 27 and he can not have a crippling spine that's falling apart when he's 60 because he'll have plenty of time yes, pardon me no bone spur is actually probably have more bone than you want not really but bone spurs would not be a symptom of poor bone density and then yes the AMA wonderful point, the AMA will go as far as this they'll say 15 minutes twice a day between 9 and 9.15 and between 3.30 and 4 to 4 you know having your arms exposed is safe for your skin and it gets enough vitamin D into your body but still with that little bit of exposure we still have a huge epidemic in our country of vitamin D deficiency so do you have vitamin D deficiency pardon me yeah we're not getting enough sun or we're covering our pardon me I'm not a dermatologist I don't know the answer even with fog can't we get the shouldn't we there's a nurse here but I would think we should be able to but that I don't know interesting what yes then you should be able to get vitamin D we don't have too much fog anymore with global warming Donald Trump won't agree with yes pardon me you can get it in a lot of food milk you can get it through supplementation so a lot of people take 400 milligrams 400 units of vitamin D a day and that's all they need if you're low I have people taking 7000 units like my patient Ari he's taking right now 7000 units a day actually 50,000 units a week to now get his vitamin D up our range is like 32 to 80 it's a huge range for normal he was like 6 and then his bone density was so bad if you have a bone problem think about a bone stimulator a lot of insurances don't cover it sometimes they're 500 bucks if you self pay it's out there you can get them for 400 but there's a lot of injuries out there that need a bone stimulator and now they're so sweet this exigen 4000 sounds like a harry potter broom or something the exigen 4000 for some what is it? Quidditch but you apply it to your scan above the fracture 20 minutes twice a day so this is an ultrasound so this came out about 15 years ago and they use ultrasound to hit the cells of the bone to stimulate the bones to have an orgy in there that's the way I look at it they have a wild party they get really stimulated and then they make new bone I don't I know it increases circulation so I don't see why I wouldn't work on it then but it's not designed for that if you have osteoporosis you'd have to use it when you have the fracture because if not you'd be moving it around and it would burn out the battery every two weeks and you'd have to spend a lot and then there's the old traditional way that with casts and crutches so again with any injury you've got to create that 0-2 pain level so however it is so many people go I'm through with the crutches I'm fine I don't need the crutches anymore what's your pain level? 7? 6? like no you've got to go back if the crutches or the casts was the only thing that brought you to 0-2 figure something else out maybe we're missing the diagnosis maybe we're doing something else now I've got a few more slides on injuries here but they're also basically principles in the 1700s the French were revolutionizing the world in two ways one they were revolutionizing the world and two they came out with this off weight bearing pad which was the first described to put the weight on another area so you take the weight off the big toe and you put it on another area I use that principle every day many, many times a day somebody comes in and they hurt one spot and I try to put weight in an area that doesn't hurt and that can bring their pain level way down so this was it's called different names we call it a dancers pad to honor the French because we think they're the first to describe a dancers pad for bunions 101 for bunions podiatrists don't do this I'm like totally shocked at my profession anybody with a bunion should have a toe separated they keep the toe while you're walking, it's for walking in shoes they keep the toe in proper alignment and they should at least three or four times a week for 30 minutes wear their yoga toes yoga toes is an online product I've seen wall greens and bed, bathroom, beyond have knockoffs but you stretch all those toes out and get them in proper form so those are like really crucial things that anybody with a bunion should be using no, a podiatrist a great question I always wish that I wish people could walk around with these things so I actually would recommend people get those five finger shoes and see if they could wear it I say go to the store and walk around because they're very expensive and they're not really padded and everything and that was sort of a hit and miss there's an actress in Oregon who only sells it through his office website designed something called correct toes and it's basically yoga toes for walking but you have to wear wide shoes so he gives you the list of like 10 shoes like Keens or Ultra Olympus type shoes so there's only slippers at home of course but those I love that concept so a lot of times with foot injuries like Morton's Seroma people tell me with Morton's Seroma I have to take my shoe off and have to massage it and it feels so good and you just add that as part of their treatment you try to get them to get in there or have their spouse or partner like and open up those bones not should never hurt hopefully your spouse isn't like Arnold Schwarzenegger but you want to like loosen that tissue up in your foot and again if you just listen to your body don't push if it hurts it tends to help these nerves the nerves that run through the foot can get trapped down the bones and that this is really helpful at getting the nerves to flow through the foot I had a podiatrist call me like 20 years ago and he said Rich are you still taking neuromas out and I was still doing surgery and I said yeah we do them all the time and he goes my office is right next to a chiropractor and I've been sending all my neuromas to him and I'm doing like one neuroma surgery a year you know like it's like going way down like a almost 99% just by getting the chiropractor to get in there and so we start recommending that to the patients or if they go to physical therapy and I've seen like huge results from that too this is another so if you have a broken metatarsal so the metatarsals are things that you walk on you push off from so we're always designing orthotics to support the whole area and then we've got to have an off weight bearing pad so here we're trying to put the weight around where that bone hits the ground and you can do this with your shoes you can take an old insert out of your shoe and mark the sore area with lipstick and then put your foot in the shoe wiggle it around do the twist and find out where that spot comes on and then cut a hole out you'll be amazed it's like my patient with the nerve pain you'll be amazed you can like take apart old shoes that are just not there they're your gardening shoes or whatever so you try to like just off weight it a little bit and give you good results if you have hammer toes the yoga toes works good you want to if your toes are crooked you want to stretch them out it's really simple and that it works pretty good you try to take each toe it's a good 30 seconds on each toe you just try to straighten each one out when you first do it if they've had 60 or 70 years to tighten up it's going to be a little painful so you've got to go easy with them at first but you can start to stretch these toes out and then if it's really painful there's a splint we sell it at our hospital has a sports shop that sells these and you can get them online they're called budin splints and they're designed to limit the motion of the toe the tarsal underneath it hurts and people need to have the budin splint it loops over the toe and then has a pad underneath to keep the toe a little still not too glamorous but athletes get athletes foot the athletes feet which is a fungus or sometimes it's a yeast or Canada a lot of different things they can attack the toenails and they can give you athletes foot it's going to take you a year and the minimum is twice a week they do white vinegar soaks two two parts warm water two parts white vinegar and they do a 30 minute soak and then every night they get some tea tree oil which is cooking oil and they apply that to the top of their foot all around and that prevents recontamination so here you're trying to get rid of it with the vinegar but then it gets recontaminated so the tea tree oil is for the recontamination yes it's 100% anti-fungal but like cooking oil yes cooking oil you can get a whole thing well it's called tea tree oil so it's a certain type so I'm not a cook so I don't know what would you cook with tea tree oil does anybody know okay you've learned one thing I can stop now everybody's learned one thing okay so I was up at Whole Foods on California and Franklin the other day and I saw a model of tea tree oil so I know it's probably rainbow or rainbow is near us so check out the cooking oil look for tea tree oil I learn everything most things from my patients in medical school you learn some things you learn some basic things and then you have to treat patients so the patients come back and say oh what you did didn't work but what I did worked and that's how you after 37 years you develop how you're practicing then so one of my patients who I gave gave them a medicine to apply to their nail twice a day it was 8% tea tree oil was the active ingredient so that patient came to me and I remember the day she goes you gave me something that's 8% why can't I just use 100% so oh that's smart so but that's how you learn so yes yes yes very good point so what I write in the book and basically you want to change the environment so vinegar is 5% acid and it dries sunshine dries feet some of us are really sweaty in our feet and they apologize to me when they take off their shoe and my office go I'm sorry I made a 4 o'clock appointment I should have made a 8 o'clock in the morning appointment because my feet really sweat but anything to change the environment so you want to dry it out foot powder in the shoe a little sun exposure to get your vitamin D we're set but that's great if you have swelling on top of your feet you should get an MRI or CT scan right in the middle of your instep people come in and say boy my foot really swells there and it hurts and typically that's where the weakest link in their chain is they have some weakness in the arch they're supposed to be really solid bones if you don't know what an MRI looks it looks like Swiss cheese in there so they have some arthritis developing it you usually can ice them have them ice have them use an orthotic to support the area get stronger in their foot and a lot of this can go away but anytime you have arthritis you're supposed to be a maintenance program but you can maintain your body in a much happier place people say oh I don't want to do a maintenance problem but you'll be able to walk more you'll be able to do more hiking or whatever so of course podiatrists we make our living on arch pain we make orthotics for people we tape them probably the biggest lesson and Janet wanted me to remind you one of the most important exercises to do and I learned this when I hurt my ankle I learned this when I hurt my knee I learned this when I hurt my back is single leg balancing you get in the door well and you bend your knee a little bit to protect your knee and you try to balance for two minutes on each foot people will give up on that I cannot believe this is so good for your knee you try to stay centered and you try to balance there and when you get really good you can stand in the middle of a soft pillow but people say I can only do 15 seconds and I hold on and I say well you're still doing the two minutes and I stop after 15 seconds and I said no you gotta it's a learn task you can learn there was a study done in 1968 in London who showed that the patients could without falling over they didn't need ankle surgery and these are people it was like 80% of people so they took a group experimentally and they said this whole group on a rehab program the 80% that could do a single leg balance after six months did not need the surgery and the 20% who failed had their ankle reconstructed and that was like early days of sports medicine but literature was coming out like that and now we know so much more about trying to strengthen body parts if you have heel pain or plant fasciitis learning this simple stretch is really important you put your toes up on the wall you should do it with shoes on your toes go up the wall so I'm coming up the wall here and then you pull your knee forward and you you'll feel a stretch all through the arch and on the lower part of the Achilles if you feel the upper part of the Achilles you're really tight this one should feel all like in that plantar fascia under the foot and the lower part of the Achilles tendon that's called a plantar wall stretch yes on something that doesn't move so I put my foot up on the wall and then I drive my knee towards the wall and I hold it again for five deep breaths practice all my good principles of stretching no there shouldn't be any pain I'm not jerking, bouncing around that's a run if you're supposed to do a stretch you want to do that three or four times a day to help limber that up because you want to get to 100 my mantra was stretching we want to get to 100 stretches as fast as possible so if a stretch, somebody says I'll see people a month later so it's 30 days I'll say if you're doing stretching I do it once a day I've done it maybe 15 times so in a month they've done it 15 times and they're a little better five times a day or four times a day for the 30 days they'll get 120 stretches and they should feel a ton better so 30 seconds all stretches about 30 seconds and if it hurts you back off it the clog or a wedge is like vital for for a heel pain because you want to push the weight forward again the biomechanics we're just trying to mechanically off weight the heel and shift the weight forward so women have an easier time and men don't they're all in flat shoes and so with men sometimes I have to design a shimmy for their shoe but I've had guys who are fine with their cowboy boots they'll wear their cowboy boots or at least around the house they'll get a clog that they'll wear and most of the time that helps heal pain I love crocs I don't know if any of you have worn crocs but there are some crocs that are like big jellyfish that you get to stand on they're just so soft it should be like a diagnostic thing if somebody goes to a store and they put on the crocs and they say I have no foot pain then you know shock absorption is part of their problem or if they put on a little heel and it takes care of their pain to me it's all diagnostically it helps me learn what they have going but here's a patient who left his crocs to walk in the soft sand because their heel hurt from a bruise so people have pain under their heel and the heel's just been bruised and they can't walk barefoot around the house that hurts and it's really frustrating to them get a slipper for around the house definitely don't wear your outdoor shoes inside the shoe inside the house but try to soften it up and then I have them get a plastic bottle they fill it halfway full of water and then freeze it so they've got this solid block of ice and then they from a standing position they roll on it so they actually you're trying to push that bruised tissue out of there so that frozen sport bowel routine is really a good way you're icing to cool it down but you're also mechanically massaging it to move the tissue and you can use it to the front of your foot also if you have pain up there if you have pain in the heel and it's not improving you should get an MRI every insurance company covers MRIs that I know of and it's amazing doctors say oh you don't need an MRI well if you've had pain for 2 or 3 or 4 months and like it's not going away why don't you get an MRI it may give us some more information on the tissue here's somebody who after 7 months just had plantar fasciitis we did an MRI and he had torn the plantar fasciitis so now he has another diagnosis he has a plantar fascial tear we have to put him in a removable boot for 3 months and he was fine I had one guy who came in and said Rich I've had 10 years of plantar fasciitis and I go no one has 10 years of plantar fasciitis it's an inflammation it gets better it gets worse but he goes I've had 10 years of plantar fasciitis in my right foot we did an MRI 10 years ago he had completely torn his plantar fascia and it had scarred in you can tell because the plantar fascia should be about 3 millimeters where it attaches and his was about 9 so his had torn and then scarred in but because he kept walking on it it was still fragile so I said then that scarred his let's just try to push you at square one we'll go back to the immobilization phase we'll put you in the cast and sure enough he was he was still a little sore at 3 months but by 5 months he was totally fine so I love MRIs I order MRIs on anything that walks almost you know if I can if I think it'll give me some more information insurance companies of course are hating me more and more I have to like I have to get an x-ray when I don't think an x-ray will touch just as insurance company approve an MRI like do I really MRIs is about $500 if you self pay my St. Francis charge is $2,000 I just had one my insurance I had to pay $1,800 so I was fine I had to pay $200 for my deductible but once when I heard my back when I heard my knee I heard my knee and I called down to St. Francis it was like 4.30 in the afternoon I said can you do an MRI on my knee and he said well we can't do it until tomorrow so I called another place and I hadn't met my deductible so I was going to have to pay the whole thing at St. Francis which is going to be like $1,800 or $2,000 so I called another place and I said can I self pay can you do it today and they said yes and I said can I self pay and they said yeah it's $525 so I just saved $1,300 and I had torn the meniscus I sort of knew I had torn the meniscus in my knee but anyway sometimes you play with the game and when you sprain your ankle some sore again you sprain your ankle we've got to do price we've got to protect it we've got to rest we've got to ice we've got a compression and then I've got to have this young lady do her ankle pumps and her elevation good question so at St. Francis I'm proud to say I've been so anti-meniscal surgery for decades for like since I was here the doctor who founded us Dr. Garrett did not believe in meniscal tears unless they locked on you if you couldn't bend your knee and the meniscus had flapped on itself and then you have to have it removed but he would just basically I strengthened my knee you know first I wore a brace to stop I solely worked through the rehab first I immobilized it then I started to restress what? went to rehab they taught me exercises I did my I did icing for anti-inflammatory I stretched my quads stretched my hamstrings so I stretched those muscles I really worked on developing really good quads best I could and time within three months our son I did this three and a half months before my son was getting married on Hawaii on a beach and so well one that I didn't want to be recovering from surgery and I also had to promise my wife that I wouldn't run before that but I felt pretty good by two and a half months afterwards so it was the back corner of my meniscus so when I bend it really severely like when I kneel in church so sometimes I'll stand in the back you know or sometimes when I'm gardening and pulling those dreadful weeds you know out it'll hurt but I can avoid that mechanical pain and again I could do my basketball so I'm fine if I could do my basketball life is good and then you really want to you really want to again ankle sprains you've got to strengthen them do your balancing and almost done here there is one really severe problem it's the number one surgical problem I treat and I don't do surgery but I'm referring to the surgeon and that's people who come in the office and say you know Rich three weeks ago or a month ago my left arch collapsed or my right arch collapsed and they've lost the tendon so we get an MRI we document they've torn the tendon if it's still attached we can try to rehab them but it's a good year it's a race and it's a lot of things so I always have the surgeon because it could go to surgery and I'd say 50% of them at least have surgery they go in and they have to sew back the tendon and immediately get it back into position you would know if that happened to you where your arch just collapsed in that's not a simple thing when you start to see toes going your toe all of a sudden sticks up in the air or something weird or your arch is collapsed and you know it's surgery when we're dealing with Achilles pain since the sciatic nerve again our double crush runs right down through the Achilles we have to make sure it's not a nerve problem I have patients all the time who come and say I've hurt my Achilles it feels like it's going to tear on me which is what we call neural tension the nerves can feel like that where they feel like they're going to just tear on you so if they can go through a regular Achilles stretch heal on the ground five deep breaths and they feel better it's not a nerve but if they start doing it and say every time I stretch it kills me then they don't have an Achilles problem they probably have a sciatic nerve issue another thing when I got into practice everybody who tore their Achilles tendon probably you all know somebody in your group of friends who's done this everybody had surgery and then there was a an organization which you may have heard of is called Kaiser Northern California okay so Kaiser was so popular that they they don't want to do surgery if they don't have to and I mean they'll do they do a lot of surgery but if they don't have to oh Kaiser Northern California who was training the majority of podiatry residents they said you know let's see if these things heal without surgery we put them in a boot we still rehab them it takes 6 months or so to go through the whole process and sure enough 99% of them healed and you knew after 2 months if they should have surgery or not and so anyway that's been the protocol probably over the last 25 years if the patient can have the patients to undergo really up to a year I tell them it's probably going to take you a year to totally rehab this but we can do this without surgery the reason with Achilles you want to try to go without surgery is because the complications are terrible you get a nerve entrapment you get chronic healing it's really poor blood supply in the Achilles tendon very well so if you can avoid it after a year you're equal to the people who've had surgery without complications so that's been about 25 years coming and we owe that to Kaiser oh yeah sorry so here's the heel bone and the foot goes here the toes are wiggling the other way and then the Achilles tendon sorry not a great slide it's all Janet's fault because she made me force go through these slides fast I couldn't fight a really good Achilles slide yeah so the Achilles tendon goes up your leg and then the calf muscle I'm sorry it's a good point because it's not a great slide weak link in your chain so the weak link in your chain most people with Achilles ruptures never heard in their Achilles they go and snap and if you're again a basketball fan Kobe Bryant did it when he played against the Giants Harrison Barnes was following him around a pick and Kobe looked up at him from the ground and said did you just kick me because that's how it felt and he knew exactly what it was when Harrison Barnes said no I didn't he knew he had torn it and that's what I would say I can't remember one person I'm sure I have one person who had some Achilles symptoms before they tore it but most of them I always ask it because it's such a thing did you ever feel your Achilles no I thought my Achilles was fine shin splints his pain in your shins and really there's exercises to do for the shins but the big thing to know is that a lot of times it can be a stress fracture going on and again if you have shin splints you can treat it the way YouTube tells you to treat it but also think deeper and I just don't see that in the literature shin splints you do this but I never see oh get an x-ray get your bone density get your vitamin D level so that's real important shin splints if you run cross country everybody has shin splints in September and only only 10% of the team still has shin splints in October because shin splints are produced by a violent increase in running a change in activity so you start to get so the shin muscles start pulling really hard and really if you want to do things safely you have to increase your exercises 10% a week and what cross country most kids don't run during the summer and they go from not running to 10 miles a day in September is that 10% a week increase no and so they get shin splints but for most injuries if you walk 9,000 steps a day good for you and you want to increase it you want to go to 9,900 you want to do 10% if you're doing 10 minutes on exercise bike you want to do 11 and 12 it's a slow process but if you want to do it safely you bump up 10% some people will say 15 but I'll go with 10 here I use this this is very age discriminatory but I look at that he's grabbing he's grabbing his leg the tennis coach says I'm sending a patient in who has shin splints I say boy let's get a bone density I mean I worry about his bone when you get past 80 you have four bones by definition I'm sorry the muscles protect your bones so you can still help yourself by definition yes osteopenia is a little weakening and osteoporosis would be a more severe right so get your bone density and then I'm just going to end with Richard's story somebody comes in with legs swelling, calf pain and and even a history sometimes it's leg cramps so if you have leg cramps I tell people okay where do you get them and they say oh calf well learn to stretch your calf stretch your hamstrings but if it's not going away get a dopper ultrasound and see if you have a thrombitis in the legs and then there's that definitely will save your life I didn't know you had some sort of blood clot developing it couldn't be just a little one that gets bad overnight so thank you very much for staying awake for an hour and a half you are the best