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

Repost - Dr's please respond

Posted by josh s on 12/01/02 at 12:53 (101556)

Hi, I've posted here from time to time over the last two years; I posted this about a month ago and did'nt get a response from any of the Doctors. Thanks to those laypersons who did respond. 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.

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 still 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.

I've hit a big standstill with these problems and am uncertain how to proceed. Doctors please help. Thanks.

Re: Repost - Dr's please respond

J. King on 12/01/02 at 13:57 (101560)

I don't know what these doctors may say but when your feet are 'shot' you know it. It took my feet a little longer to collapse but at 52 I can't work on my feet at all. I can walk but I pay for it. My podiatrist told me to retire from my Postal job and I did. Some things are just not fixable. I see people that hike and jog and run and I am envious but I know that those things would kill me.

Re: Repost - Dr's please respond

Dr. Z on 12/01/02 at 21:30 (101569)

How long have you had the pain. Tell us more about your occupation Beside orthosis what other treatments have you tried

Re: Repost - Dr's please respond

josh s on 12/03/02 at 09:48 (101646)

Thanks Dr. Z,

The pain started when I was 19, became fairly dissabling very quickly and then abated for five years - I believe due to a regimen of bodywork, yoga and walking. During this period I was very physically active- hiking, mountaineering, etc. Then three years ago at age 27 the pain began to return with a vengence while I was working at a job requiring constant standing. I eventually had to quit the job and have'nt been able to stand for any length of time since. It seems that I was employing various of the compensatory strategies available to those with equinus (everted gait, early heel lift, muscular gripping of post. tib., peroneals, instrinsics, etc.), but that eventually my structural limitations caught up with me.

Currently I am a student. I have a part-time job where I have been accomodated by being allowed to sit almost continually. Many of the career directions I am interested in involve physical activity and it is very important that I find out how limited I will be from now on. At present many of the educational directions that I am headed toward will not work for a dissabled person.

Sometimes I can get away with walking a couple miles, but I will usually pay for these ventures with days of aching. I use ice a lot.

Besides orthotics I have tried exercise; for years I stretched my calves to no avail until I realized the equinus was of a bony nature. In 1997 I received a series of sclerotherapy injections in the talonavicular region - administered by a DO orthopedist. Did not really work. Other than this not much has been tried by my physicians. I have been rolfed twice in the last ten years- the first time was very helpful, the second not so. Various modalities- ice, alternate hot/cold, massage, etc. are constantly utilized at home.

The peculiar thing to me is that walking, in general, is easier and less painful than simply standing. Often times while standing I experience sensations of collapse which I imagine to be the talar head collapsing downward. I read in Root's text that pain caused by simply standing is rare and is indicitive of either a vascular problem or biomechanically by a foot that is subluxed.

Thanks again for responding, any advice and suggestions most welcome.

Re: Repost - Dr's please respond

monte on 12/03/02 at 11:31 (101651)

josh

i have the same type of standing pain. Fels a bit better to walk than to stand still....but then the walking catches up to you. I don't have the morning heel pain...it is over the soles of my feet...they almost feel broken. DrZ is able to find the sore spot at the inserion point, but my pain is not typical either. I stretch and ice too and I also tape and wrap my arches. My arches hurt too.

I wonder if it is nerves, but I did have a nerve test that was negative and I have been check out for TTS by Dr Z and others and they say no to that.

I don't know. But I am sorry you are feeling so much pain and are so concerned about your future.

Re: Repost - Dr's please respond

Dr. Z on 12/03/02 at 18:12 (101702)

Any other lower extremity pain or problems .Your back, hips, and knee how are they doing.

Re: Repost - Dr's please respond

josh s on 12/04/02 at 09:04 (101743)

Thanks again Dr. Z, Also thanks to Monte for the kind words - I hope you get better (alot better) as well.

I have had, over the same time period (the last ten years), troubles with both knees. I have alsmost identical buckethandle tears to the posterior medial meniscus horn, bilaterally. These are from a specific injury, have not been treated, and do not (I think) cause me much trouble. I also have had problems with anterior knee pain that has been diagnosed as of the patellar-femoral variety. The patellar-femoral pain began about the same time as the foot pain ten years ago. The period of years when I was without foot pain I also was without knee pain. This pain reemerged prior to the return of the foot pain. However, the rolfing treatments that did not help my feet have helped my knees and the patellar-femoral pain is now only occasionally present.

I do have soreness and occasional pain in the pes anserinus region.

On days that I feel I am pronating more than normal I sometimes get a stabbing pain in the medial knee - like it's being torqued- curiously, this is more common since I received my new orthotics.

Hips are mostly good. I have the common exreme tightness of the illiotibial tract which is occasionally painful. On the right side I notice that my piriformis is in constant spasm. I have received chiropractic adjustments for a rotation in the illiosacral area - but this seems resistant to treatment - the adjustments don't 'hold'. The hip joints proper are good, I think.

I have a history of back pain. One year prior to the initial onset of foot pain (1992) I had a series of accidents that led to a period of severe back pain with sciatica. This pain eventually diminished and returns now only occasionally and with certain over-exertions (extremely lengthy sitting, heavy lifting, repetitive forward bending)- this sometimes results in brief periods of sciatica. At one time it was suspected that I have a spondiolithesis - x-rays examined by a DC were negative however. I have wondered if my foot pain were in part neurological in origin, but this has never been investigated.

I hope this is the type of info you were wanting Dr. Z. Thanks again for taking the time.

Re: Repost - Dr's please respond

josh s on 12/04/02 at 09:11 (101744)

Dr. Z,

Forgot to mention that an MD checked me for peripheral neuropathy and diabetes two years ago - both negative.

Re: Repost - Dr's please respond

Julie on 12/04/02 at 11:23 (101769)

John, excuse my intervention here. This is probably a long shot, but reading your latest posts it's clear that there is a lot going on in your lower extremities and that all these things are probably related.

Are you knock-kneed? That might explain both the damage to your medial menisci and your pronation. And the cause of that could be a muscular imbalance, for example, your adductor muscles may be much stronger than your abductors. Have you ever had this checked out? If this is the case, you might find that strengthening exercises for the abductors might restore the balance. I would guess that such an imbalance would affect things further up: your tight iliotibial tract and your spasmed piriformis (on the other hand, those could be affecting everything lower down).

I'm hesitant to put this little theory forward, because you obviously have knowledge of the body and have probably already looked into your muscle strength/balance. If not, perhaps seeing a sports medicine doctor would be a useful step?

Re: Josh, sorry, I meant Josh, not John

Julie on 12/04/02 at 11:25 (101770)

.

Re: Josh, sorry, I meant Josh, not John

josh s on 12/05/02 at 09:01 (101836)

No problem Julie,

Your comments are welcome and I have thought of these things. For several years I've attempted to come at these problems from higher up in the kinetic chain - perhaps the balanced strength gained from yoga practice allowed my pain free years. But over time I've become convinced that all of my musculoskeletal troubles primarily originate in the feet/ankles. Imagine spending twenty odd years with ankles that essentially don't dorsiflex at all. It seems to me that most of what is happening above is compensatory to what is going on below.

I've researched most available theories on posture and gait - each with their own favorite 'original cause' for postural breakdown and biomechanical dysfunction. Most of these ideas are valid; but since the whole business stands on the feet - the base (feet) is likely the most important. Could be wrong, and it's likely different for every case. In the body it seems that if one looks for cause and effect you will end up chasing symptoms to their causes to another symptom and cause, etc. The kinetic chain is a circle. Since my most serious pain is in the feet, this seems the most natural place to attempt to intervene in the cycle. But then again - so far foot intervention (orthotics, taping) has'nt helped much.

My great fear is that my feet are simply too damaged to succesfully support me in the gravitational field. Hopefully Dr. Z can make something of all this and help me to choose my next move. I ain't givin' up yet.

Re: Josh

Julie on 12/05/02 at 09:51 (101842)

Yes, I thought you would probably have thought of all that. And I agree with you about the base. In your case, ankles that can't dorsiflex do sound like the root of the problems: I overlooked your mention - though I was aware of it from your posts last year - of your equinus. I hope Dr Z, or one of the other doctors, can throw some light on what your next move might be.

Are you still practising yoga? I would guess from what you've said that the standing poses are a problem for you now. But yoga is so much more than physical work: the postures are only a small part of it, as I'm sure you know. I'm thinking that a yoga practice that suits you now, while not the same as your earlier practice, would be a great help to you in dealing with the serious life issues you're facing.

And for the physical side, there is a book by Sam Dworkis, called Recovery Yoga, full of excellent ideas for a gentle yet powerful practice.

I wish you well!

Re: Josh

josh s on 12/06/02 at 15:05 (102001)

Julie,

Thanks for the suggestions. I think you're right about yoga, it would help me now. At the very least just to keep the blood moving. It's tough though, when one is used to a certain level of physicality, to accept serious limitations in one's movement. You'd think three years would bring some acceptance, but it has'nt.

Thanks again for the kind words. It's good of you to still be here, cheering people on.

Re: Josh

Julie on 12/06/02 at 16:42 (102009)

Yes, of course it's tough, especially for a young person. I am sorry! I feel very sure, though, that a return to yoga, with a practice tailored to your present level of physical ability, will be helpful to you. It may even bring you closer to acceptance. And make you even more aware - I know you already are - of what is beyond the physical.

Whatever you do or don't do about yoga, your experience can teach you a great deal that will eventually help you to help others. It already is. My teacher told me, when I was diagnosed with breast cancer nine years ago, 'all that matters is what you do with this experience, how you use it'. That has been my touchstone ever since. Now I teach people with cancer, and train teachers who are interested in this area of work.

With your intelligence and understanding, you'll make something good of what you're going through.

Re: Repost - Dr's please respond

J. King on 12/01/02 at 13:57 (101560)

I don't know what these doctors may say but when your feet are 'shot' you know it. It took my feet a little longer to collapse but at 52 I can't work on my feet at all. I can walk but I pay for it. My podiatrist told me to retire from my Postal job and I did. Some things are just not fixable. I see people that hike and jog and run and I am envious but I know that those things would kill me.

Re: Repost - Dr's please respond

Dr. Z on 12/01/02 at 21:30 (101569)

How long have you had the pain. Tell us more about your occupation Beside orthosis what other treatments have you tried

Re: Repost - Dr's please respond

josh s on 12/03/02 at 09:48 (101646)

Thanks Dr. Z,

The pain started when I was 19, became fairly dissabling very quickly and then abated for five years - I believe due to a regimen of bodywork, yoga and walking. During this period I was very physically active- hiking, mountaineering, etc. Then three years ago at age 27 the pain began to return with a vengence while I was working at a job requiring constant standing. I eventually had to quit the job and have'nt been able to stand for any length of time since. It seems that I was employing various of the compensatory strategies available to those with equinus (everted gait, early heel lift, muscular gripping of post. tib., peroneals, instrinsics, etc.), but that eventually my structural limitations caught up with me.

Currently I am a student. I have a part-time job where I have been accomodated by being allowed to sit almost continually. Many of the career directions I am interested in involve physical activity and it is very important that I find out how limited I will be from now on. At present many of the educational directions that I am headed toward will not work for a dissabled person.

Sometimes I can get away with walking a couple miles, but I will usually pay for these ventures with days of aching. I use ice a lot.

Besides orthotics I have tried exercise; for years I stretched my calves to no avail until I realized the equinus was of a bony nature. In 1997 I received a series of sclerotherapy injections in the talonavicular region - administered by a DO orthopedist. Did not really work. Other than this not much has been tried by my physicians. I have been rolfed twice in the last ten years- the first time was very helpful, the second not so. Various modalities- ice, alternate hot/cold, massage, etc. are constantly utilized at home.

The peculiar thing to me is that walking, in general, is easier and less painful than simply standing. Often times while standing I experience sensations of collapse which I imagine to be the talar head collapsing downward. I read in Root's text that pain caused by simply standing is rare and is indicitive of either a vascular problem or biomechanically by a foot that is subluxed.

Thanks again for responding, any advice and suggestions most welcome.

Re: Repost - Dr's please respond

monte on 12/03/02 at 11:31 (101651)

josh

i have the same type of standing pain. Fels a bit better to walk than to stand still....but then the walking catches up to you. I don't have the morning heel pain...it is over the soles of my feet...they almost feel broken. DrZ is able to find the sore spot at the inserion point, but my pain is not typical either. I stretch and ice too and I also tape and wrap my arches. My arches hurt too.

I wonder if it is nerves, but I did have a nerve test that was negative and I have been check out for TTS by Dr Z and others and they say no to that.

I don't know. But I am sorry you are feeling so much pain and are so concerned about your future.

Re: Repost - Dr's please respond

Dr. Z on 12/03/02 at 18:12 (101702)

Any other lower extremity pain or problems .Your back, hips, and knee how are they doing.

Re: Repost - Dr's please respond

josh s on 12/04/02 at 09:04 (101743)

Thanks again Dr. Z, Also thanks to Monte for the kind words - I hope you get better (alot better) as well.

I have had, over the same time period (the last ten years), troubles with both knees. I have alsmost identical buckethandle tears to the posterior medial meniscus horn, bilaterally. These are from a specific injury, have not been treated, and do not (I think) cause me much trouble. I also have had problems with anterior knee pain that has been diagnosed as of the patellar-femoral variety. The patellar-femoral pain began about the same time as the foot pain ten years ago. The period of years when I was without foot pain I also was without knee pain. This pain reemerged prior to the return of the foot pain. However, the rolfing treatments that did not help my feet have helped my knees and the patellar-femoral pain is now only occasionally present.

I do have soreness and occasional pain in the pes anserinus region.

On days that I feel I am pronating more than normal I sometimes get a stabbing pain in the medial knee - like it's being torqued- curiously, this is more common since I received my new orthotics.

Hips are mostly good. I have the common exreme tightness of the illiotibial tract which is occasionally painful. On the right side I notice that my piriformis is in constant spasm. I have received chiropractic adjustments for a rotation in the illiosacral area - but this seems resistant to treatment - the adjustments don't 'hold'. The hip joints proper are good, I think.

I have a history of back pain. One year prior to the initial onset of foot pain (1992) I had a series of accidents that led to a period of severe back pain with sciatica. This pain eventually diminished and returns now only occasionally and with certain over-exertions (extremely lengthy sitting, heavy lifting, repetitive forward bending)- this sometimes results in brief periods of sciatica. At one time it was suspected that I have a spondiolithesis - x-rays examined by a DC were negative however. I have wondered if my foot pain were in part neurological in origin, but this has never been investigated.

I hope this is the type of info you were wanting Dr. Z. Thanks again for taking the time.

Re: Repost - Dr's please respond

josh s on 12/04/02 at 09:11 (101744)

Dr. Z,

Forgot to mention that an MD checked me for peripheral neuropathy and diabetes two years ago - both negative.

Re: Repost - Dr's please respond

Julie on 12/04/02 at 11:23 (101769)

John, excuse my intervention here. This is probably a long shot, but reading your latest posts it's clear that there is a lot going on in your lower extremities and that all these things are probably related.

Are you knock-kneed? That might explain both the damage to your medial menisci and your pronation. And the cause of that could be a muscular imbalance, for example, your adductor muscles may be much stronger than your abductors. Have you ever had this checked out? If this is the case, you might find that strengthening exercises for the abductors might restore the balance. I would guess that such an imbalance would affect things further up: your tight iliotibial tract and your spasmed piriformis (on the other hand, those could be affecting everything lower down).

I'm hesitant to put this little theory forward, because you obviously have knowledge of the body and have probably already looked into your muscle strength/balance. If not, perhaps seeing a sports medicine doctor would be a useful step?

Re: Josh, sorry, I meant Josh, not John

Julie on 12/04/02 at 11:25 (101770)

.

Re: Josh, sorry, I meant Josh, not John

josh s on 12/05/02 at 09:01 (101836)

No problem Julie,

Your comments are welcome and I have thought of these things. For several years I've attempted to come at these problems from higher up in the kinetic chain - perhaps the balanced strength gained from yoga practice allowed my pain free years. But over time I've become convinced that all of my musculoskeletal troubles primarily originate in the feet/ankles. Imagine spending twenty odd years with ankles that essentially don't dorsiflex at all. It seems to me that most of what is happening above is compensatory to what is going on below.

I've researched most available theories on posture and gait - each with their own favorite 'original cause' for postural breakdown and biomechanical dysfunction. Most of these ideas are valid; but since the whole business stands on the feet - the base (feet) is likely the most important. Could be wrong, and it's likely different for every case. In the body it seems that if one looks for cause and effect you will end up chasing symptoms to their causes to another symptom and cause, etc. The kinetic chain is a circle. Since my most serious pain is in the feet, this seems the most natural place to attempt to intervene in the cycle. But then again - so far foot intervention (orthotics, taping) has'nt helped much.

My great fear is that my feet are simply too damaged to succesfully support me in the gravitational field. Hopefully Dr. Z can make something of all this and help me to choose my next move. I ain't givin' up yet.

Re: Josh

Julie on 12/05/02 at 09:51 (101842)

Yes, I thought you would probably have thought of all that. And I agree with you about the base. In your case, ankles that can't dorsiflex do sound like the root of the problems: I overlooked your mention - though I was aware of it from your posts last year - of your equinus. I hope Dr Z, or one of the other doctors, can throw some light on what your next move might be.

Are you still practising yoga? I would guess from what you've said that the standing poses are a problem for you now. But yoga is so much more than physical work: the postures are only a small part of it, as I'm sure you know. I'm thinking that a yoga practice that suits you now, while not the same as your earlier practice, would be a great help to you in dealing with the serious life issues you're facing.

And for the physical side, there is a book by Sam Dworkis, called Recovery Yoga, full of excellent ideas for a gentle yet powerful practice.

I wish you well!

Re: Josh

josh s on 12/06/02 at 15:05 (102001)

Julie,

Thanks for the suggestions. I think you're right about yoga, it would help me now. At the very least just to keep the blood moving. It's tough though, when one is used to a certain level of physicality, to accept serious limitations in one's movement. You'd think three years would bring some acceptance, but it has'nt.

Thanks again for the kind words. It's good of you to still be here, cheering people on.

Re: Josh

Julie on 12/06/02 at 16:42 (102009)

Yes, of course it's tough, especially for a young person. I am sorry! I feel very sure, though, that a return to yoga, with a practice tailored to your present level of physical ability, will be helpful to you. It may even bring you closer to acceptance. And make you even more aware - I know you already are - of what is beyond the physical.

Whatever you do or don't do about yoga, your experience can teach you a great deal that will eventually help you to help others. It already is. My teacher told me, when I was diagnosed with breast cancer nine years ago, 'all that matters is what you do with this experience, how you use it'. That has been my touchstone ever since. Now I teach people with cancer, and train teachers who are interested in this area of work.

With your intelligence and understanding, you'll make something good of what you're going through.

Re: Repost - Dr's please respond

Carmen A on 4/15/07 at 17:45 (227821)

I have back pain for several years.
Just about 20 years ago,when I had my first pregnancy,doctor discoverder I had a grade 3spondylolisthesis of L5 on S1.
Some doctors in the past recomended operation,some others did not.
Do you know about treatments for this problem?
It is the operation to risky?
The neurologist did not sugested me operation because he said my legs are not in pain or don't get nums.
Thanks for your answer.
Carmen A