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Question for Elliott

Posted by D.J on 8/19/02 at 22:21 (092951)

In one of your posts recently, you mentioned that an orthotic can sometimes lead to nerve entrapment. Is there a particular article you got that from? I suspect that is what led to my nerve entrapment, assuming my diagnosis is correct and would like to read more it.

Re: Question for Elliott

BrianJ on 8/20/02 at 08:37 (092975)

DJ --

Could you please tell us more about your symptoms and your diagnosis?

Re: Answer from Elliott

elliott on 8/20/02 at 10:40 (092985)

(Sorry for the delay, I was away on brief vacation.)

It appears twice in the Schon-Baxter article I believe you said is in your possession, in the section on medial plantar nerve entrapment. The first reference is on pg. 499, last paragraph: 'Arch supports, especially those that are built up, may compress the nerve.' The second is on pg. 500, first paragraph: 'Not uncommonly, patients will report the onset of the syndrome associated with the use of a new orthosis.' Yeah, I know, a little short on details for your needs. I can't recall if I've seen any other references. Regardless, when I pondered whether I had this, the first author showed me exactly where on my foot the location is: as I've said before, it is close to, but right before (i.e. proximal to), the first metatarsal ball joint (which ruled it out in my case). In my own layman's terms and which many here hopefully can associate with, it would be where the forwardmost part of the arch of an ill-fitting orthotic would jut awkwardly into the foot.

As an aside, the first two sentences in the MPN entrapment section cited above reads as follows: 'After the medial plantar nerve travels underneath the flexor retinaculum, it courses deep to the abductor hallucis muscle. The nerve runs along the plantar surface of the flexor digitorum longus tendon and passes through the Master Knot of Henry. It continues along the medial boarder [sic] of the foot ramifying into branches that lie on the medial and lateral side of the flexor hallucis Longus [sic] tendon.' The middle sentence seems to be at odds with something Dr. Manoli said in another post, about the MPN not running through the tunnel containing the Master Knot of Henry. Perhaps the wording in the article isn't as exact as it should be. Dr. Manoli, if you'd care to comment; thanks.

D. J., in your previous posts I don't think you described whether any of your pain is nervy. Is it?

---

Re: Injury History and Diagnosis

DJ on 8/20/02 at 12:13 (092992)

Brian and Elliott

I see the reference now. I didn't read the article carefully enough. My pain is in the medial arch, about an inch proximally from the big toe pad (not sure the medical term for this). My symptoms are not the typical nervy pain. I have never experienced tingling or numbness. I would describe my pain as a deep dull sometimes sharp pain. It is very intermittent, and follows no true pattern except sitting at a desk definitely doesn't help, and standing causes the most pain. I seem to find some relief from walking barefoot or with flipflops.

My injury first occurred on a run, I felt a slight twinge in the very center of my foot. I kept running until I couldn't run anymore. I saw a chiropractor that said I had plantar fasciitis and said I needed orthotics for my high arches. The orthotics he gave me were quite crappy looking back on it. I then went to a podiatrist who said this orthotic was still not giving me enough support for my high arch. He then built up the orthotic. He referred me to another podiatrist who make me a higher quality of orthotic and diagnosed me with a torn plantar fascia. The boot and crutches gave me no relief and if anything I was in more pain within a week of beginning to walk again. In addition I had began to experience pain medially and distally from the center of the arch. A physical therapist I saw found that my cuboid and navicular were subluxed. After performing a manipulation though, it failed to give me any relief from the pain.

I was diagnosed by Baxter with Jogger's foot due to the area that I was experiencing pain. He asked my if I had any shooting pain out toward the toes or in the ankle. He also asked me if I had pain going up steps or if I my pain was relieved by wearing work boots. I told him no for all of these questions and he still was very confident in his diagnosis and ready to do surgery that day. He also didn't care that previous nerve blocks had failed to relieve the pain saying that the nerve is difficult to hit and even then its 'iffy'. Dr. Schon told me that he really doubted that I had jogger's foot or any nerve problem leaving me very confused.

If I do have a nerve entrapment I am trying to figure out how it happened in my case. I think its quite likely that the orthotics I received compressed that nerve. I also wonder what the connection was between the subluxed cuboid and navicular and my injury. Have you come across anything in your reading about subluxion of these bones leading to a nerve entrapment? I've scheduled an appointment with Dr. Robert Anderson in Charlotte to get yet another opinion. Dr. Anderson seems to be one of only a few doctors that have diagnosed jogger's foot. I plan on hitting the National Library of Medicine as well and seeing what information I can dig up.

Re: Injury History and Diagnosis

elliott on 8/20/02 at 19:30 (093019)

It's probably futile for us to guess a diagnosis over the net, especially when some big names you've seen in person disagree over it. Where exactly in the center of the foot was the pain that started it all?

I will say that I'd be reluctant to jump into a nerve surgery without feeling something nervy, for fear it's something else. That said, I'd guess the surgery is probably less risky than the standard TTS surgery, since it's not near the ankle and only one nerve is involved.

---

Re: Injury History and Diagnosis

john h on 8/21/02 at 08:30 (093068)

I attended a seminar given by the Bonati Institute in Florida. They are well known for arthoscopic surgery of the spine, shoulders,knee, hand.. They perform no surgery under a general and all surgery is out patient. I did not question them but I did read in their information packet about their arthoscopic surgery for TTS. check out their web site at http://www.bonati.com .

Re: Injury History and Diagnosis

DJ on 8/21/02 at 16:17 (093120)

The pain started right in the middle of the arch in the area of the navicular and cuboid I believe

Re: Injury History and Diagnosis

BGCPed on 8/21/02 at 21:49 (093167)

DJ, I am not a Dr but based on the info and your comments I would look at a few things (maybe the Docs can comment) First if you have a true high arch or cavus foot and they INCREASED the medial arch support that could very well do it. If you have even a subtle cavus foot there is a 99% chance that you have a plantarflexed 1st met head.

If that is the case then you need to have the area under the first met cutout, like a silver dollar sized depression to let it drop below 2,3,4 and 5 met heads. I see WAY TOO MANY devices on cavus feet that have had the medial arch built up, or even with a forefoot varus post, which is like putting near sighted glasses on a far sighted person.

As for the subluxed cuboid I think that mostly occurs in the over pronated or flat foot than in the high arch foot. I am not second guessing or disputing your dx or tx to this point just making a few points.

It may be futile at this point but I would ask the orthotic provider to DECREASE the arch,cut out the first met head and do a build up under 2,3,4,5 met heads so that a cross section of the forefoot of the device would look like this 0---- with the 0 being the 1st and the---- being the 2,3,4 and 5 met heads. Hope this helps and doesnt further confuse you.

Re: arthroscopic for TTS? you first (nm)

elliott on 8/22/02 at 09:47 (093200)

.

Re: I had similar

Sandy H. on 8/23/02 at 18:40 (093361)

I had a similar history of orthotics, more pain, higher arch added, even more pain, ditching orthotics, less pain but I still haven't totally got rid of the problem so I am trying orthotics with no forefoot posting and told the pod to keep the arch nice and low and just have the device adjusting the angle of my heel. Is that going to be a helpful device? Dunno. It arrives soon.

Re: I had similar

DJ on 8/23/02 at 21:04 (093371)

I realized that my foot hurts less without an orthotic and without a shoe. Whenever I am wearing a shoe, I find myself wanting to take my shoe off. I am most comfortable going barefoot or wearing a pair of adidas flip flops. Although I have reason to believe that two of my three pairs of orthotics were trash, one pair was done by a very experienced pod who has worked with many athletes and many runners. Perhaps in some rare cases, orthotics cause more problems than they help.

Re: Is it something to do with neurological probs?

Sandy H. on 8/25/02 at 22:13 (093532)

Maybe when the pain is coming from your spine having something pressing makes the pain worse. My pet theory.
1

Re: Question for Elliott

BrianJ on 8/20/02 at 08:37 (092975)

DJ --

Could you please tell us more about your symptoms and your diagnosis?

Re: Answer from Elliott

elliott on 8/20/02 at 10:40 (092985)

(Sorry for the delay, I was away on brief vacation.)

It appears twice in the Schon-Baxter article I believe you said is in your possession, in the section on medial plantar nerve entrapment. The first reference is on pg. 499, last paragraph: 'Arch supports, especially those that are built up, may compress the nerve.' The second is on pg. 500, first paragraph: 'Not uncommonly, patients will report the onset of the syndrome associated with the use of a new orthosis.' Yeah, I know, a little short on details for your needs. I can't recall if I've seen any other references. Regardless, when I pondered whether I had this, the first author showed me exactly where on my foot the location is: as I've said before, it is close to, but right before (i.e. proximal to), the first metatarsal ball joint (which ruled it out in my case). In my own layman's terms and which many here hopefully can associate with, it would be where the forwardmost part of the arch of an ill-fitting orthotic would jut awkwardly into the foot.

As an aside, the first two sentences in the MPN entrapment section cited above reads as follows: 'After the medial plantar nerve travels underneath the flexor retinaculum, it courses deep to the abductor hallucis muscle. The nerve runs along the plantar surface of the flexor digitorum longus tendon and passes through the Master Knot of Henry. It continues along the medial boarder [sic] of the foot ramifying into branches that lie on the medial and lateral side of the flexor hallucis Longus [sic] tendon.' The middle sentence seems to be at odds with something Dr. Manoli said in another post, about the MPN not running through the tunnel containing the Master Knot of Henry. Perhaps the wording in the article isn't as exact as it should be. Dr. Manoli, if you'd care to comment; thanks.

D. J., in your previous posts I don't think you described whether any of your pain is nervy. Is it?

---

Re: Injury History and Diagnosis

DJ on 8/20/02 at 12:13 (092992)

Brian and Elliott

I see the reference now. I didn't read the article carefully enough. My pain is in the medial arch, about an inch proximally from the big toe pad (not sure the medical term for this). My symptoms are not the typical nervy pain. I have never experienced tingling or numbness. I would describe my pain as a deep dull sometimes sharp pain. It is very intermittent, and follows no true pattern except sitting at a desk definitely doesn't help, and standing causes the most pain. I seem to find some relief from walking barefoot or with flipflops.

My injury first occurred on a run, I felt a slight twinge in the very center of my foot. I kept running until I couldn't run anymore. I saw a chiropractor that said I had plantar fasciitis and said I needed orthotics for my high arches. The orthotics he gave me were quite crappy looking back on it. I then went to a podiatrist who said this orthotic was still not giving me enough support for my high arch. He then built up the orthotic. He referred me to another podiatrist who make me a higher quality of orthotic and diagnosed me with a torn plantar fascia. The boot and crutches gave me no relief and if anything I was in more pain within a week of beginning to walk again. In addition I had began to experience pain medially and distally from the center of the arch. A physical therapist I saw found that my cuboid and navicular were subluxed. After performing a manipulation though, it failed to give me any relief from the pain.

I was diagnosed by Baxter with Jogger's foot due to the area that I was experiencing pain. He asked my if I had any shooting pain out toward the toes or in the ankle. He also asked me if I had pain going up steps or if I my pain was relieved by wearing work boots. I told him no for all of these questions and he still was very confident in his diagnosis and ready to do surgery that day. He also didn't care that previous nerve blocks had failed to relieve the pain saying that the nerve is difficult to hit and even then its 'iffy'. Dr. Schon told me that he really doubted that I had jogger's foot or any nerve problem leaving me very confused.

If I do have a nerve entrapment I am trying to figure out how it happened in my case. I think its quite likely that the orthotics I received compressed that nerve. I also wonder what the connection was between the subluxed cuboid and navicular and my injury. Have you come across anything in your reading about subluxion of these bones leading to a nerve entrapment? I've scheduled an appointment with Dr. Robert Anderson in Charlotte to get yet another opinion. Dr. Anderson seems to be one of only a few doctors that have diagnosed jogger's foot. I plan on hitting the National Library of Medicine as well and seeing what information I can dig up.

Re: Injury History and Diagnosis

elliott on 8/20/02 at 19:30 (093019)

It's probably futile for us to guess a diagnosis over the net, especially when some big names you've seen in person disagree over it. Where exactly in the center of the foot was the pain that started it all?

I will say that I'd be reluctant to jump into a nerve surgery without feeling something nervy, for fear it's something else. That said, I'd guess the surgery is probably less risky than the standard TTS surgery, since it's not near the ankle and only one nerve is involved.

---

Re: Injury History and Diagnosis

john h on 8/21/02 at 08:30 (093068)

I attended a seminar given by the Bonati Institute in Florida. They are well known for arthoscopic surgery of the spine, shoulders,knee, hand.. They perform no surgery under a general and all surgery is out patient. I did not question them but I did read in their information packet about their arthoscopic surgery for TTS. check out their web site at http://www.bonati.com .

Re: Injury History and Diagnosis

DJ on 8/21/02 at 16:17 (093120)

The pain started right in the middle of the arch in the area of the navicular and cuboid I believe

Re: Injury History and Diagnosis

BGCPed on 8/21/02 at 21:49 (093167)

DJ, I am not a Dr but based on the info and your comments I would look at a few things (maybe the Docs can comment) First if you have a true high arch or cavus foot and they INCREASED the medial arch support that could very well do it. If you have even a subtle cavus foot there is a 99% chance that you have a plantarflexed 1st met head.

If that is the case then you need to have the area under the first met cutout, like a silver dollar sized depression to let it drop below 2,3,4 and 5 met heads. I see WAY TOO MANY devices on cavus feet that have had the medial arch built up, or even with a forefoot varus post, which is like putting near sighted glasses on a far sighted person.

As for the subluxed cuboid I think that mostly occurs in the over pronated or flat foot than in the high arch foot. I am not second guessing or disputing your dx or tx to this point just making a few points.

It may be futile at this point but I would ask the orthotic provider to DECREASE the arch,cut out the first met head and do a build up under 2,3,4,5 met heads so that a cross section of the forefoot of the device would look like this 0---- with the 0 being the 1st and the---- being the 2,3,4 and 5 met heads. Hope this helps and doesnt further confuse you.

Re: arthroscopic for TTS? you first (nm)

elliott on 8/22/02 at 09:47 (093200)

.

Re: I had similar

Sandy H. on 8/23/02 at 18:40 (093361)

I had a similar history of orthotics, more pain, higher arch added, even more pain, ditching orthotics, less pain but I still haven't totally got rid of the problem so I am trying orthotics with no forefoot posting and told the pod to keep the arch nice and low and just have the device adjusting the angle of my heel. Is that going to be a helpful device? Dunno. It arrives soon.

Re: I had similar

DJ on 8/23/02 at 21:04 (093371)

I realized that my foot hurts less without an orthotic and without a shoe. Whenever I am wearing a shoe, I find myself wanting to take my shoe off. I am most comfortable going barefoot or wearing a pair of adidas flip flops. Although I have reason to believe that two of my three pairs of orthotics were trash, one pair was done by a very experienced pod who has worked with many athletes and many runners. Perhaps in some rare cases, orthotics cause more problems than they help.

Re: Is it something to do with neurological probs?

Sandy H. on 8/25/02 at 22:13 (093532)

Maybe when the pain is coming from your spine having something pressing makes the pain worse. My pet theory.
1

Re: Answer from Elliott

Patrick K. on 11/01/06 at 14:02 (214714)

You should Contact the laser spine institute or visit their website for orthroscopic procedures

http://www.laserspineinstitute.com