Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

Continual difficulty, Need some Advice

Posted by josh s on 11/06/02 at 18:35 (099530)

Hi, I've posted here from time to time over the last two years. I'm still in pain and need some advice about how to proceed from here.

I've got ankle equinus bilaterally which appears on stress xrays to be caused by bony factors. The xray shows bone on bone contact at about 4-6 deg. of dorsiflexion. There does not appear to be a bony blockage of the talar lipping variety. It seems that the articular geometry of my talocrural joint is such that contact occurs at this point. My current podiatrist initially talked of speaking to a surgeon about possible surgery to the bones themselves to improve this. He never mentioned it again and has instead focused on heel lifts.

The picture is also one of rearfoot varus, forefoot varus/supinatus and several minor injuries over the years to various of the plantar ligaments. These injuries have never been evaluated and recur from time to time. (For the last two weeks I have been nursing a mild sprain in the lateral side of sole, I suppose of one of the calcaneal cuboid ligaments - my local podiatrist is as useful as an automechanic for these problems.)

Currently my symptoms are of the atypical plantar foot pain variety. Burning pain throughout sole of both feet in morning. Before getting out of bed. Pain generally is not caused by morning activity as in plantar fasciitis. However, if forced to be on my feet for more than a total of 30 min. in a day, I experience severe to moderate pain in deep midfoot area, posterior tibal tendon and generalized sole surface burning. The deep pain has been conjecturally diagnosed as originating from the post. tibial insertion points, but this has never been established using either palpation or radiological diagnostic tools. My feeling is that the pain is coming from chronically stressed ligaments, i.e. plantar ligaments and spring ligaments. Based on my symptoms and a general pattern of collapse I am concerned that I may be progessing along the posterior tibial dysfuncion scale. This has never been adressed by the various physicians I have visited.

Presently using a pair of forefoot and rearfoot varus posted rigid orthoses with 3/8' heel lifts bilaterally and first ray cutouts to encourage 1st ray plantarflexion in the style of Dr. Dananberg's functional halux limitus model. Also use shoes that bring the total of heel elevation to approx. 7/8 inch. These devices offer some relief on walking but standing for any period brings pain. They work only so well that on some days I augment their effects with either low-dye or cross x taping. Some days are quite bad no matter the measures I take.

I am not yet 30, until 4 years ago very active physically, and very concerned that my feet are 'shot'. Still, I would like to aggressively proceed with either a new physician or course of treatment, or both.

I am also concerned about the general lack of diagnosis in my case; the fact that no doctor has yet to identify the source of my pain is worrisome. I have a good general practitioner who I feel would be cooperative in providing a referal for a new course of action.

Any thoughts or advice welcome, Thanks.

Re: Continual difficulty, Need some Advice

D.Thomas on 11/06/02 at 20:01 (099533)

Damn Josh I'm impressed with your knowledge. I wish I knew about my problems as much as you know about yours. Impressive. I hope you find an answer to your problem(s).

Re: Continual difficulty, Need some Advice

D.Thomas on 11/08/02 at 16:05 (099641)

Josh,

After reading your post again I did notice some similarities with myself. I must confess that I don't really understand all that you had posted, but I will just say a couple of things that I think match.

My situation is that I have had constant pain for almost two years now (I have had PF for 8 years). I first started having pain when I was 27 years old. PF is not cool at all but in your 20s and early 30s really sucks!

I have high arches and the main pain is in the medial arch of both feet. I do not have morning pain as you. My pain gets REALLY BAD as the day goes on if I stay on them too long (15 min or more at a time). My feet constantly sweat with burning and throbing all along the bottom if I stay on my feet for any length of time. The best way not to have pain is to completely stay off of them and to limit my time on them in short bursts and get off them before they start to throb and burn.

It also sounds like I have tried the same orthotics with posting the forefoot. I have also tried first ray cutouts to encourage 1st ray plantarflexion with them. When I use these orthotics I tend to get a vibration feeling on the inside of my ankles and along the bottom until I stop wearing them for a week. The vibration drives me crazy and I can't put up with them and go back to my old ones which only support my arch with no posting.

My next step is probably to get a gastroc slide, I have tried everything else. Many Pods and Orthos, in my experience, don't really understand how this helps PF. Dr. Manoli, who posts here sometimes, told me that is probably my next step. I went to visit him in May of this year. I just need to get off my [blank] and do it, but surgery scares the hell out of me.

I have had pain for so long now, I really don't know what it would be like to be without it. I don't know if any of this helps, but I hope things work out.

Re: Continual difficulty, Need some Advice

Sheila on 11/08/02 at 20:06 (099649)

Josh, I have a couple of suggestions for you, if you are willing to think outside the 'box'. I've spent years and years thinking 'medical doctors' and 'medicine'. I've had some recent experiences that have made me begin to change my way of thinking - though I'm slow to do it.

I will try to make a 2 year story short: I am still suffering from some problems (different from yours - but have had 2 surgeries for it and 7 sclerosing injections, all to no avail) and accidentally ran across what I think will be the solution (and what the problem really was) through my Chiropractor when I told him about it. He suggested what he thought the problem was and made a couple suggestions for the podiatrist to try. Knowing I wouldn't remember the medical terms, I said 'here's my foot, you try it'. And it worked. Temporarily, but it worked. So I've gone to a true orthotics specialist (they are FEW and far between!) who also is degreed in the biomechanics of the foot (I think that's the right term).

A little side note and hisory: Medical doctors, for the most part, will go 'stone-faced' when you say the word Chiropractor. For the record, I went to every kind if doctor and orthopedics specialist around about my back before I finally decided to try one of THOSE (Chiropractor) guys. The MD's told me 'there's nothing wrong with your back you just need to exercise.' There are good Chiro's. and bad ones...I went to a quack first...then decided to study up on Chiropractic medicine. I read enough from the library to BE one almost. Then I scheduled several 'interview' appts. and selected a doctor that I thought best fit my idea of the best method. I have a good one now, have had for 10 years, and if it weren't for him I'd probably be in a wheelchair by now. Please note that I don't have anything against MD's and still use them, as well. But I'm learning (showly, and the hard way) that perhaps medicine and surgery should be last resorts instead of Chiropractors and natural methods of healing, etc.

Back to my suggestion - it might be worth seeing a Chiropractor for his thoughts and suggestions. They study several years longer than MD's, specifically their education completely covers bones, joints, tendons, ligaments, more so than the average physician and their training is thinking 'outside the box' vs. surgery and medicine. My studies show, and my chiropractor feels, and my current orthotics experts feel hard orthotics should almost NEVER be used. Just as standing on concrete is bad for you....so would hard orthotics be bad for you.

A very good friend of mine has a daughter who is a doctor and very much a naturalist and 'whacko' so we've thought - she warned me before the 2nd surgery not to have it and to go see this particular orthotics specialist that she thinks is the best she's ever seen...I wish I'd listened to her and asked my Chiropractor about it a long time ago. It would have saved me a small fortune in money and a whole lot of pain and heartache.

I made this really short...there's lots left out, but I hope it gives you something to think about and research.

Best of luck to you!

Re: Continual difficulty, Need some Advice

J. King on 11/11/02 at 10:08 (099788)

What you guys describe sounds much like what I have. I have to ice my feet every days after doing any walking or standing. I have been suffering for many years. Surgery sounds like a poor idea for something that is probably just part of my physical makeup. What would the surgeons cut, my entire arch structure?

Re: Continual difficulty, Need some Advice

D.Thomas on 11/11/02 at 11:12 (099789)

J.King,

There are a couple of things I am doing since none of the conservative methods have worked for me and I have developed chronic PF in my arches.

#1) ESWT I am exploring every option possible here (i.e., insurance will not pay). Even though it has only been shown in studies to help insertional PF (i.e., pain around the heel), there is some evidence to show that it can help with people who have pain in the arches. There is some concern on my part that even if the ESWT helps develop better tissue in my fascia and helps my pain, I still have not fixed the cause of the problem in the first place and I will re-injure the fascia again.

The two competing surgeries I have investigated are as follows:

1) Fascia Release Where approximately 1/3 to 1/2 of the fascia is cut. The problem is there is mounting evidence to show that this will increase stress of the other attached areas anywhere from 60 to 70%. From what I have read, this procedure has a high probability of creating other problems down the road.

2) Gastroc Lengthen - This seems to be gaining acceptance and research as a better method than the Fascia Release.

I am not a doctor and I will not pretend to be one. For example, I don't know what methods there are for Gastroc lengthening and which ones are best, and if it is only applicable for certain PF varieties (i.e., high arches only). I only know my condition where I have high arches and a tight heel cord. From my understanding, my high arches cause me to want more flexibility in my heel cord than normal feet, which I don't have and is a major cause of my problem. So, I am thinking about getting the Gastroc first and then ESWT if need be.

Re: Continual difficulty, Need some Advice

D.Thomas on 11/06/02 at 20:01 (099533)

Damn Josh I'm impressed with your knowledge. I wish I knew about my problems as much as you know about yours. Impressive. I hope you find an answer to your problem(s).

Re: Continual difficulty, Need some Advice

D.Thomas on 11/08/02 at 16:05 (099641)

Josh,

After reading your post again I did notice some similarities with myself. I must confess that I don't really understand all that you had posted, but I will just say a couple of things that I think match.

My situation is that I have had constant pain for almost two years now (I have had PF for 8 years). I first started having pain when I was 27 years old. PF is not cool at all but in your 20s and early 30s really sucks!

I have high arches and the main pain is in the medial arch of both feet. I do not have morning pain as you. My pain gets REALLY BAD as the day goes on if I stay on them too long (15 min or more at a time). My feet constantly sweat with burning and throbing all along the bottom if I stay on my feet for any length of time. The best way not to have pain is to completely stay off of them and to limit my time on them in short bursts and get off them before they start to throb and burn.

It also sounds like I have tried the same orthotics with posting the forefoot. I have also tried first ray cutouts to encourage 1st ray plantarflexion with them. When I use these orthotics I tend to get a vibration feeling on the inside of my ankles and along the bottom until I stop wearing them for a week. The vibration drives me crazy and I can't put up with them and go back to my old ones which only support my arch with no posting.

My next step is probably to get a gastroc slide, I have tried everything else. Many Pods and Orthos, in my experience, don't really understand how this helps PF. Dr. Manoli, who posts here sometimes, told me that is probably my next step. I went to visit him in May of this year. I just need to get off my [blank] and do it, but surgery scares the hell out of me.

I have had pain for so long now, I really don't know what it would be like to be without it. I don't know if any of this helps, but I hope things work out.

Re: Continual difficulty, Need some Advice

Sheila on 11/08/02 at 20:06 (099649)

Josh, I have a couple of suggestions for you, if you are willing to think outside the 'box'. I've spent years and years thinking 'medical doctors' and 'medicine'. I've had some recent experiences that have made me begin to change my way of thinking - though I'm slow to do it.

I will try to make a 2 year story short: I am still suffering from some problems (different from yours - but have had 2 surgeries for it and 7 sclerosing injections, all to no avail) and accidentally ran across what I think will be the solution (and what the problem really was) through my Chiropractor when I told him about it. He suggested what he thought the problem was and made a couple suggestions for the podiatrist to try. Knowing I wouldn't remember the medical terms, I said 'here's my foot, you try it'. And it worked. Temporarily, but it worked. So I've gone to a true orthotics specialist (they are FEW and far between!) who also is degreed in the biomechanics of the foot (I think that's the right term).

A little side note and hisory: Medical doctors, for the most part, will go 'stone-faced' when you say the word Chiropractor. For the record, I went to every kind if doctor and orthopedics specialist around about my back before I finally decided to try one of THOSE (Chiropractor) guys. The MD's told me 'there's nothing wrong with your back you just need to exercise.' There are good Chiro's. and bad ones...I went to a quack first...then decided to study up on Chiropractic medicine. I read enough from the library to BE one almost. Then I scheduled several 'interview' appts. and selected a doctor that I thought best fit my idea of the best method. I have a good one now, have had for 10 years, and if it weren't for him I'd probably be in a wheelchair by now. Please note that I don't have anything against MD's and still use them, as well. But I'm learning (showly, and the hard way) that perhaps medicine and surgery should be last resorts instead of Chiropractors and natural methods of healing, etc.

Back to my suggestion - it might be worth seeing a Chiropractor for his thoughts and suggestions. They study several years longer than MD's, specifically their education completely covers bones, joints, tendons, ligaments, more so than the average physician and their training is thinking 'outside the box' vs. surgery and medicine. My studies show, and my chiropractor feels, and my current orthotics experts feel hard orthotics should almost NEVER be used. Just as standing on concrete is bad for you....so would hard orthotics be bad for you.

A very good friend of mine has a daughter who is a doctor and very much a naturalist and 'whacko' so we've thought - she warned me before the 2nd surgery not to have it and to go see this particular orthotics specialist that she thinks is the best she's ever seen...I wish I'd listened to her and asked my Chiropractor about it a long time ago. It would have saved me a small fortune in money and a whole lot of pain and heartache.

I made this really short...there's lots left out, but I hope it gives you something to think about and research.

Best of luck to you!

Re: Continual difficulty, Need some Advice

J. King on 11/11/02 at 10:08 (099788)

What you guys describe sounds much like what I have. I have to ice my feet every days after doing any walking or standing. I have been suffering for many years. Surgery sounds like a poor idea for something that is probably just part of my physical makeup. What would the surgeons cut, my entire arch structure?

Re: Continual difficulty, Need some Advice

D.Thomas on 11/11/02 at 11:12 (099789)

J.King,

There are a couple of things I am doing since none of the conservative methods have worked for me and I have developed chronic PF in my arches.

#1) ESWT I am exploring every option possible here (i.e., insurance will not pay). Even though it has only been shown in studies to help insertional PF (i.e., pain around the heel), there is some evidence to show that it can help with people who have pain in the arches. There is some concern on my part that even if the ESWT helps develop better tissue in my fascia and helps my pain, I still have not fixed the cause of the problem in the first place and I will re-injure the fascia again.

The two competing surgeries I have investigated are as follows:

1) Fascia Release Where approximately 1/3 to 1/2 of the fascia is cut. The problem is there is mounting evidence to show that this will increase stress of the other attached areas anywhere from 60 to 70%. From what I have read, this procedure has a high probability of creating other problems down the road.

2) Gastroc Lengthen - This seems to be gaining acceptance and research as a better method than the Fascia Release.

I am not a doctor and I will not pretend to be one. For example, I don't know what methods there are for Gastroc lengthening and which ones are best, and if it is only applicable for certain PF varieties (i.e., high arches only). I only know my condition where I have high arches and a tight heel cord. From my understanding, my high arches cause me to want more flexibility in my heel cord than normal feet, which I don't have and is a major cause of my problem. So, I am thinking about getting the Gastroc first and then ESWT if need be.