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Totally confused - first visit to foot and ankle orthopedist

Posted by Louise on 6/08/04 at 21:47 (152478)

My RHEUMATOLOGIST said I had tarsal tunnel and I should rest my feet, check that my orthotics are fitted well, take diuretics and B6 and wait it out. He said physical therapy for pain relief only, would also help.

PODIATRIST said I have extremely flat feet (true) and that my ankes are very loose and I should get very rigid orthotics. He said I have serious structural problems and tarsal tunnel. I've had very rigid orthotics and can't use them. I now have ones made of semi rigid plastic with sorbothane (?) covering and a met pad.

PHYSICAL THERAPIST said he could probably relieve some of the pain but nothing more. He used ultrasound, massage and whirlpool. I had a lot of tingling after I left on both occasions.

ORTHOPEDIST/FOOT AND ANKLE SPECIALIST: He does not 'like' orthotics because he feels they prevent the necessary process of strengthening muscles and tendons and the foot becomes less and less functional while being 'supported by orthotics'.

Orthopedist took xrays. He spoke a mile a minute so I'll do my best to describe what he said. First of all he said I do not have tarsal tunnel because my feet don't hurt in bed and I don't wake up from the pain???

He said the xrays revealed an extra little bone (navicular?) on the inside of both ankles. He said the muscles and tendons are attached to this bone rather than to the correct bone and rather than wrapping under the arch. He said the condition often causes plantar fascia problems as well (which I had once in the past - before orthotics).

He said my ankles are overly flexible, almost double jointed, and the incorrect attachment makes this more pronounced and is often seen in conjunction with flat feet - which I certainly have.

He said this can cause the pains I have in various parts of my foot and that it can also cause the numbness and tingling I feel in the bottom of my feet and toes - not tarsal tunnel.

He didn't think I should wear orthotics all the time and felt that I should wear ankle supports if and when they make me feel better - but had no specific recommendations.

He recommended physical therapy to include ultrasound, and hot/cold. Also calf stretches with feet together against the wall, and 'power Varis-Valgus with foot plantar flexed. Also strengthening posterior tibialis.'

Because this was managed care and time is so very limited, I feel that I have very little understanding of most of this and don't even know which diagnosis to believe, except that I can see they are related.

Can anyone explain this 'extra bone' in my ankle? What does it really mean? I Googled Navicular and it seems to apply to horses mostly :_)

I would greatly appreciate any clarifications and/or suggestions as to how to sort out the diagnoses and where to go from here.....

Please forgive me for the length of this post.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

wendyn on 6/08/04 at 22:29 (152479)

Louise, I think you and I are twins separated at birth. Your doctor's opinions sound as consistent as mine.

The bone is (I believe) an accessory navaculur bone (I may be spelling that wrong). Spelled right - you should find what you're looking for in google.

I have the same thing, and flat feet, and pain, and tingling etc.

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/08/04 at 23:18 (152480)

You're not in NY by any chance, are you?

When I Googled, I got 'navicular' and there were lots of reference to ankles - most of them however, in horses.....

Interesting to hear that someone else has the same wierd diagnosis.

What have you done to ease your condition and what has helped and not helped?

Thanks.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

Julie on 6/09/04 at 01:31 (152482)

Louise, I can't offer any enlightenment regarding your diagnosis but your orthopedist is surely on the job in recommending you wear ankle supports. Loose ligaments (hypermobility) are making your ankles much more vulnerable to injury, and wearing supports would help to stabilise and protect them. They won't 'fix' the problem, but will help to avoid it getting worse.

The function of ligaments is to allow movement of a joint through an acceptabl, safe range, and to stop movement before that range is exceeded. Hypermobility generally affects all the ligaments. Are your other joints - wrists, shoulders, hips, spine etc - also hypermobile? If so you should consider a regime of strengthening exercises. Loose ligaments can't be altered, but muscles can be strengthened.
.

Re: Totally confused - first visit to foot and ankle orthopedist

LARA on 6/09/04 at 07:45 (152495)

LOUISE WROTE: First of all he said I do not have tarsal tunnel because my feet don't hurt in bed and I don't wake up from the pain???

This guy may be a good orthopedist, but he doesn't know TTS (lots of good doctors aren't familiar with TTS). One of the few universal symptoms I've heard is that REST HELPS - i.e. the longer your are in bed, the more the pain/discomfort should lessen. Doesn't matter if its rest from sleeping or rest from resting. I don't remember waking up from the pain - maybe at its most severe on a couple of days, but that rarely lasted that long, my body instinctly knowing to 'not do so much'. Sleep actually helped my feet feel better. And I'd hate for people to have to wait until the TTS is so strong as to interfere with sleep. I've had TTS for several years now and it doesn't interfere with my sleep.

Given the comments of others, perhaps you don't have TTS anyway so it doesn't matter. If you think your rheumatologist is correct, you might try compression socks. They are easy to try, relatively inexpensive, and if they work they work : ) Very non-invasive. Don't work for everyone so if they don't work it doesn't mean you don't (or do) have TTS.

PT can aggravate TTS. I never found it helpful for any relief.

Re: Totally confused - first visit to foot and ankle orthopedist

Ed Davis, DPM on 6/09/04 at 09:27 (152515)

Louise:
I am reading between the lines here but did anyone mention that you may have an 'accessory navicular?' That is an extra bone next to the navicular that causes weakening of the attachment of tibialis posterior, a tendon that runs in the tarsal tunnel and helps to hold up the arch.
That will cause pain in the tarsal tunnel (inside of the ankle), inside of the arch but not numbness, tingling and pain on the bottom of your foot -- please describe the symptoms. Did you have a nerve conduction velocity test done (NCV)?
Ed

Re: Totally confused - first visit to foot and ankle orthopedist

lauriel on 6/09/04 at 12:11 (152532)

'power Varis-Valgus with foot plantar flexed. Also strengthening posterior tibialis.'

Can you please explain what this entails. I am searching for exercises to help strengthen

Laurie

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/09/04 at 14:48 (152551)

YES - THANK YOU- he spoke so quickly that my notes said 'excessive', clearly it was 'accessory'.

So, the orthopedist, via xray, said I have an 'accessory navicular' bone and that it does prevent the muscles and tendons from attaching properly, supporting the arch properly, etc. And I have it on both feet.

The orthopedist was sure I didn't have TTS and said this condition, with the weakened muscles and arch, could cause burning and tingling as well. No nerve conduction test was done and I was told I didn't need one as he was sure I didn't have TTS.

The podiatrist I saw (who I didn't care for), also was sure I didn't have TTS after looking at the weakness of my ankles and saying that my ankle is too flexible. He wanted to sell me an even harder orthotic and I was sure I couldn't tolerate it and I just had a new pair made by the orthotist.

Symptoms now: pain which increases the longer I walk, usually starting on the inside part of the ankle and top of foot slightly to the front of the ankle bone. I also get pain on the outside portion of the arch. After walking a while I feel like the arch is pushing into my foot/ankle - but that's only after the whole area really starts hurting.

Toward the end of the day I get burning on the bottom of the foot and tingling in the toes - it feels swollen but aside from marks from a sock, it doesn't look swollen.

The tingling and burning have reduced in the last week: I've been using lasix, extra B6 and have had two physical therapy sessions with ultrasound, massage and whirlpool. But the pain with walking has not changed.

Perhaps I should note that 2 1/2 years ago I had meniscus surgery on the knee of the foot that is most troublesome. I believe the way I stand changed after the surgery; new orthotics, however, didn't fix the ankle problem at all.

I have custom made orthotics which have been made for years by orthotists at a large store here in NY, called Eneslow. They have a somewhat flexible plastic arch, a met pad and soft cushiony sorbothane layer. They are posted so that I am pushed toward the outside of my foot.

Thank you so much for reading this and for any suggestions you might be able to offer as I really don't know what to make of the situation or how to proceed.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/09/04 at 14:49 (152552)

I don't have any idea yet. When I get physical therapy based upon these recommendations, I'll pass the suggested exercises on.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

Ed Davis, DPM on 6/09/04 at 15:09 (152556)

Louise:
It sounds like a form of tibialis posterior deficiency caused by the extra bone, the accessory navicular. I am not sure if TTS exists too but would obtain a nerve conduction velocity test for that.

This can often be treated with orhtotics but another option is a procedure called a Kidner procedure in which the accessory bone is removed and the attached post. tibial tendon advanced into the navicular.
Ed

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/09/04 at 16:31 (152571)

Thanks a lot for the clarification and for your thoughts.

I'm now 61 years old and would be hesitant to have the surgery, but I suppose I shouldn't rule it out. I guess I'll try the physical therapy and maybe another pair of orthotics - at least before I consider surgery.

For the first time in my life I understand WHY I couldn't hike, couldn't play volleyball, couldn't do a lot of the things I really enjoyed without injury and undue discomfort in my feet and ankles.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

lauriel on 6/09/04 at 17:13 (152576)

Louise, thanks will look for them

Laurie

Re: Totally confused - first visit to foot and ankle orthopedist

Dr. Z on 6/09/04 at 19:29 (152592)

Dear Louise,

I agree 100% that a new and or orthotic adjustment is in order. In the meantime a soft cast bandage and or taking will take a lot of the stress off of the posterier tibial insertion. Sometimes a Futura elastic support that can be purchased in any CVS pharmacy can give you a lot of relief.

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/09/04 at 20:15 (152599)

One last question if you don't mind too much:

I am familiar with the futuras and ones similar to that.

Would you be able to give me an example of what you mean by a 'soft cast' so that I have some idea of what to look into and try out.

I have a Mueller neoprene adjustable ankle brace that goes around the arch and then another piece goes around the ankle. It also has to straps to go across the ankle in a figure 8. It is shown at
http://www.ankleshop.com/muellerneoadj.htm This brace seems to have been helpful and I'm wondering what you think of it for this condition.

Once again, thank you so much and I wish you practiced in New York.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

wendyn on 6/09/04 at 22:00 (152616)

No Louise, Calgary Alberta

I have the accessory bones too (was diagnosed with them when I was 11). Your symptoms sound a lot like mine. At one point though, my situation was much worse than it is now.

What has helped?

-giving up all impact sports
-taking up non impact sports like biking, elliptical, yoga, weights
-acupuncture helped when things were bad
-custom birks
-well made orthotics (made by a very good podiatrist - I had 3 very bad pairs)
-time
-avoiding shopping whenever possible (shopping is terrible, second only to standing in the kitchen)
-b12 supplments (I was deficient)

What has not helped?
-Hmmm, the bad orthotics did not help

Seriously - the yoga and staying active has likely saved me. Physically and emotionally.

I see a rheumatologist next week. I have weird lumps on my toe joints and sometimes my shins - the doctors have no idea what they are either.

Re: Totally confused - first visit to foot and ankle orthopedist

Louise on 6/09/04 at 22:51 (152621)

Hi,

Thanks for your detailed reply.

I have had the problems since I was 5, although not this badly, but was never diagnosed until now (age 61). It's really quite a shock and it explains why there were so many things I was never able to do.

Is there a difference you might describe between the orthotics that helped and all the ones that clearly didn't help at all? Is there something I should look for or reject immediately?

The ones I had made a month ago can be adjusted free of charge if I know what to tell them. The arch is made of a semi flexible plastic with soft sorbothane on top and a met pad. They are posted. Is this anything like the ones you have?

Have you used any kind of support braces such as aircasts, neoprene wraps, etc.? If so, which helped and which didn't.

Interesting that you say acupuncture helped. I've been thinking about it.

I get some relief from magnets (ones imported from Germany although they have them here and probably in Canada as well - called Bioflex). I put them on the places most tender - usually right in front of the ankle bone and a little above the ankle bone.

I don't do any impact sports - never been able to - ankles would always 'sprain' or hurt or even occasionally collapse on me. But I never understood why. I do own a recumbant bike and will try getting back on that.

The Orthpedist told me to stretch my calves ONLY by leaning both hands against the wall, feet straight and leaning forward. In other words, stretch them together, not one at a time. It feels very different and seems to get to different places in the calf.

I hope we can find some 'tricks' and pass them on to one another.

Louise

Re: Totally confused - first visit to foot and ankle orthopedist

wendyn on 6/10/04 at 20:43 (152697)

Louise, I think you will get your best sense of whether or not the orthotics will work out by how they are casted. I went to one pod who scrawled some quick notes on a sheet, then had his office helper cast my feet. Another had me step into blue foam.

The guy I go to now is actually who many doctors sent their 'difficult' orthotic patients to. He took A LOT of time with me. He watched me walk. He watched me stand. He carefully examined my feet and explained what he was finding.

The casts were made (by him) while I was laying face down - and they were made with plaster. I had one orthotic that didn't feel right at all. He recasted my foot, and made me a new one. No problem.

Ask around - especially at physio offices or running stores. They will likely know who is good at making orthotics and who is not.

Many people here have had success with CPeds as well. The prescription is filled out by a doctor, then the Cped makes the orthotic.

Just don't go to the places where you walk across the mat and someone makes orthotics. I did the walk across the mat thing just to see what they came up with as a diagnosis, and it was laughable. I can't remember exactly what they said now, but it wasn't even close to the structural problems I've had confirmed.

There is no way that you should have to tell anyone what needs to be adjusted on your orthotics. How would you know? You can only say what feels right and what does not. I've had the metatarsal pad - I hated it. My current orthotics don't have one, and this pod said I didn't need it. Other than that, the orthotics sound fairly similar.

As an alternative to the wall stretch, you may want to try the yoga 'legs up the wall' stretch. Lay on your back and put your bum up against the wall, and then your legs up the wall (at a 90 degree angle). If your legs aren't too tight, pull your toes back towards you so that eventually your feet are 90 degrees to your legs and the wall. It might be safer (I would suspect) than starting with a wall stretch.

I'm usually around this bulletin board (have been for about 5 years now...yikes). If you put my name in the text of a post (not in the subject) the board will send me an email and I'll be sure to see your note. Without that, it's sort of a hit and miss as to whether or not I see a post.

Re: Totally confused - first visit to foot and ankle orthopedist

B. on 6/21/04 at 20:00 (153655)

I had problems doing the activities that I enjoyed, too, due to many injuries and problems with my feet. I had been going to see foot specialists since I was 7 years old, but nothing could be done to fix the problem. I had tried shoe inserts, but those were always very uncomfortable. I was also sent to see a physical therapist, who in reality didn't help me out at all. Now that I'm 16, and the bones in my feet have stopped growing, I have had the Kidner Procedure done on my right foot on June 11th of this year. I am still wearing a splint on my foot/leg, and will be getting a regular cast tomorrow morning. My surgery went well and my foot is healing up fine (6 more weeks in a cast to go). I was a little hessitant about surgery at first, but now that I've had it done and everything is going fine so far, I know that I have made the right choice. Next summer, I plan on having the Kidner procedure done on my left foot. I decided that it was best to just get the surgeries done now, when I'm still young and healthy, than to wait until I am much older, and have needlessly suffered through many more years of pain in my feet, ankles, and knees. You should definetely consider the surgery, and putting an end to all those years of unnecessary suffering.