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Dr. Ed or Dr. Z

Posted by Josh S on 1/17/02 at 14:05 (070284)

Hi,
I recently posted describing a situation of bony equinus allowing only about eight degrees of dorsiflexion. My new podiatrist told me to use 1/2' heel lifts until he investigates possible options. In the two weeks since then my pain has gotten worse and my posterior tibial tendon and muscles all along the medial shin have begun hurting more frequently and worse. The new doc as well as the old one both said that much of my pain was coming from the posterior tibial tendon insertions on midfoot. I've done a fair amount of reading about posterior tibial dysfunction and the progressive, nasty course of this condition. To my knowledge I have not not been diagnosed with TPD, but it seems like a distinct possibility. I can still do single leg heel raises, but the right heel does not invert as much as the left while doing so. I also have a history of vague, undiagnosed tearing, ripping and popping sensations/events over the last two years.

My feeling is that I probably need an MRI and some pretty great care to turn my situation around. At present am only able to walk short distances and stand about five minutes. My current pod seems able, interested and friendly, but I have to travel three hours to see him. I want to make sure my next visit really counts.

Any suggestions, comments?

How does one properly encourage a doctor to order an MRI?

Also, it seems MR images from the knee down would be helpful, is this how they are customarily taken?

Thanks

Re: Dr. Ed or Dr. Z

Ed Davis, DPM on 1/17/02 at 18:29 (070320)

An MRI is a good idea.
Ed

Re: Dr. Ed or Dr. Z

Dr. Zuckerman on 1/17/02 at 20:10 (070336)

Hi,

It there is a boney block this is going to be tough. What I can't understand is how you are able to get the 8 degree's. Phyicial examination should help to determine PT dysfunction. Getting an mri could be done before you travel the three hours. Call and ask to get it done before the visit.

The boney block has to be evaluated in order to treat this painful problem

Re: bony block

Josh s on 1/18/02 at 16:37 (070433)

Thanks for the advice doctors!

Dr. Z, as far as the bony block goes- my pod viewed some lateral weightbearing x-rays and noticed what appeared to be an extension of the tibia which looked as though it would collide with the talus after about two degrees of motion. We took another set of laterals with ankles dosiflexed to maximum. The right ankle showed about eight degrees and the talus and tibia were in contact; what appeared to be an extension of the tibia in the first set was an illusion created by the angle of the picture, apparently. The left ankle showed less dorsiflexion and lack of contact betwixt talas and tibia. Apparently this ankle has some soft tissue restriction, or a bony callus that did not appear distinctly on the film. In any event the end-range feel for both ankles is similar: hard. The doctor decided that even at maximum possible range, given the geometry of my talocrural joints, the requisite 10-12 deg. is not present. He differentiated between this problem and a true bony blockage, although he did say that it is possible that constant collision between tibia and talus could have created a bony callus or lip on the talus.

He said we was going to investigate surgical options and in the meanwhile I am to wear 1/2' heel lifts. At my next visit he will also give Dr. Dananberg's equinus manipulation method another try, although this had no effect on ROM the first time.

Dr. Z, regarding your advice to call and ask to get an MRI before I go: Do I simply call the doctor and request this. My health plan is a bit on the stingy side as well, should I also speak to my primary care/referring physician?

Thanks again.

Re: bony block

Ed Davis, DPM on 1/19/02 at 15:09 (070536)

A boney block caused by impingement of the tibial plateau and neck of the talus can often be confirmed by an x-ray view known as a 'stress dorsiflexion view.' It is possible to live with eight degrees of dorsiflexion, although my inclination would be in the direction of surgery if the block is confirmed. A true block, bone on bone, will only get temporary relief from conservative means. If you are young and/or active or have an occupation which is demanding physically, the surgical option should be seriously considered.
Ed

Re: bony block

Josh s on 1/21/02 at 17:47 (070794)

Dr. Ed, thanks for the response.

It seems that just such a 'stress dorsiflexion view' was taken. It showed that in the right ankle the tib plateau and neck of talus were in contact at max dorsiflexion. The left ankle at max dorsiflexion did not appear to make contact, some soft tissue impingement or restriction may be causal here. The neck of the talus appeared to be shaped normally, though the doctor did suspect possible exostosis on the left. Will find out more next week.
Thanks for your comments regarding possible surgery. My new pod seemed optimistic about options in this regard. I am young and formerly very active. If the equinus is truly the primary cause of my difficulties, surgery to resolve would be welcomed by me.
I am now determined to get an MRI. As I've described previously my ability to engage in weight bearing activities is now at an all-time low. Last night I observed my feet and ankles in relaxed static stance and they appeared to be much more pronated than previously. Root, et. al. in their book on podiatric biomechanics mention the existence of a vertically deviated oblique midtarsal joint axis which is resistant to orthotic treatment. My feet are now beginning to appear like the photos in their book- the ankles medially deviated. The fact that my symptoms have not significantly improved despite using heel lifts to accomodate the equinus has me wondering if other factors are significant here. Any thoughts or suggestions?
Not being able to stand or walk for any significant duration (I often crawl about the house), but still able to do the single leg heel lift (though if I do a bunch of them I have subsequent pain in the pt tendon)I am very worried I'm headed for permanent disability. Thanks Again.

Re: Dr. Ed or Dr. Z

Ed Davis, DPM on 1/17/02 at 18:29 (070320)

An MRI is a good idea.
Ed

Re: Dr. Ed or Dr. Z

Dr. Zuckerman on 1/17/02 at 20:10 (070336)

Hi,

It there is a boney block this is going to be tough. What I can't understand is how you are able to get the 8 degree's. Phyicial examination should help to determine PT dysfunction. Getting an mri could be done before you travel the three hours. Call and ask to get it done before the visit.

The boney block has to be evaluated in order to treat this painful problem

Re: bony block

Josh s on 1/18/02 at 16:37 (070433)

Thanks for the advice doctors!

Dr. Z, as far as the bony block goes- my pod viewed some lateral weightbearing x-rays and noticed what appeared to be an extension of the tibia which looked as though it would collide with the talus after about two degrees of motion. We took another set of laterals with ankles dosiflexed to maximum. The right ankle showed about eight degrees and the talus and tibia were in contact; what appeared to be an extension of the tibia in the first set was an illusion created by the angle of the picture, apparently. The left ankle showed less dorsiflexion and lack of contact betwixt talas and tibia. Apparently this ankle has some soft tissue restriction, or a bony callus that did not appear distinctly on the film. In any event the end-range feel for both ankles is similar: hard. The doctor decided that even at maximum possible range, given the geometry of my talocrural joints, the requisite 10-12 deg. is not present. He differentiated between this problem and a true bony blockage, although he did say that it is possible that constant collision between tibia and talus could have created a bony callus or lip on the talus.

He said we was going to investigate surgical options and in the meanwhile I am to wear 1/2' heel lifts. At my next visit he will also give Dr. Dananberg's equinus manipulation method another try, although this had no effect on ROM the first time.

Dr. Z, regarding your advice to call and ask to get an MRI before I go: Do I simply call the doctor and request this. My health plan is a bit on the stingy side as well, should I also speak to my primary care/referring physician?

Thanks again.

Re: bony block

Ed Davis, DPM on 1/19/02 at 15:09 (070536)

A boney block caused by impingement of the tibial plateau and neck of the talus can often be confirmed by an x-ray view known as a 'stress dorsiflexion view.' It is possible to live with eight degrees of dorsiflexion, although my inclination would be in the direction of surgery if the block is confirmed. A true block, bone on bone, will only get temporary relief from conservative means. If you are young and/or active or have an occupation which is demanding physically, the surgical option should be seriously considered.
Ed

Re: bony block

Josh s on 1/21/02 at 17:47 (070794)

Dr. Ed, thanks for the response.

It seems that just such a 'stress dorsiflexion view' was taken. It showed that in the right ankle the tib plateau and neck of talus were in contact at max dorsiflexion. The left ankle at max dorsiflexion did not appear to make contact, some soft tissue impingement or restriction may be causal here. The neck of the talus appeared to be shaped normally, though the doctor did suspect possible exostosis on the left. Will find out more next week.
Thanks for your comments regarding possible surgery. My new pod seemed optimistic about options in this regard. I am young and formerly very active. If the equinus is truly the primary cause of my difficulties, surgery to resolve would be welcomed by me.
I am now determined to get an MRI. As I've described previously my ability to engage in weight bearing activities is now at an all-time low. Last night I observed my feet and ankles in relaxed static stance and they appeared to be much more pronated than previously. Root, et. al. in their book on podiatric biomechanics mention the existence of a vertically deviated oblique midtarsal joint axis which is resistant to orthotic treatment. My feet are now beginning to appear like the photos in their book- the ankles medially deviated. The fact that my symptoms have not significantly improved despite using heel lifts to accomodate the equinus has me wondering if other factors are significant here. Any thoughts or suggestions?
Not being able to stand or walk for any significant duration (I often crawl about the house), but still able to do the single leg heel lift (though if I do a bunch of them I have subsequent pain in the pt tendon)I am very worried I'm headed for permanent disability. Thanks Again.