posted on 14 Mar 2014 23:18 by melliott77
Thomas M. Novella, D.P.M. - Podiatrist - New York City, NY
- Businessman with anlke pain
Thomas M. Novella, D.P.M.
~ Podiatric, Sports, and Dance Medicine ~
35 year-old businessman with lifelong ankle pain
This affable young man presented to my practice nineteen weeks ago. He'd had walking pain in the outside front of his ankle for twenty-eight years. That's basically his whole life. He couldn't run. He couldn't walk with his two kids in Disney World. He couldn't walk across town or through Central Park. He couldn't walk more than ten blocks in a row. If he walked more, he'd have intense pain in the outside front of his right ankle, which would last for several days. He always had some pain in the outside front of his ankle. He was visiting me as a last resort, as he was contemplating having an orthopedist fuse his ankle, which would render it rigid for the rest of his life.
He hadn't injured his ankle, sprained, jammed or twisted it. The pain began one day when he was a child and never let up. He'd visited pediatricians, orthopedists, and podiatrists. He'd had many X-rays, none ever showing pathology. He had two MRI's, each of which showed a very slight amount of stress in the bones in the outside front of his ankle, but no torn tendons, no spurs, no arthritis, joint coalitions, or tumors. He had no neurological problems. His consultations with two rheumatologists also yielded the same result: no arthritis or other joint pathology to cause such debility. He'd visited several physical therapists, none of whom could provide lasting help. He had been told to stretch his calves, but never felt any improvement in his flexibility despite years of dedicated stretching. Cortisone shots, anti-inflammatory medications, and acupuncture all produced no definitive help.
He had pronounced flat feet all his life. He came in with a bag full of orthotics. None of these orthotics helped him. Any orthotic he tried that was higher than a pancake not only didn't help his ankle, but poked severely into his arch and gave him additional pain. He could not walk in shoes that had a separate heel, like a standard business shoe. They'd heighten his pain. He could only wear wedgie shoes or sneakers, i.e., shoes that had thick soling under the arch. He had slight relief of his constant pain level with a robust lace-up ankle brace, but it couldn't get him past ten blocks.
This is the kind of case I love, because all problems have a reason. One would think a case like his would present a major challenge to find a reason, but I approach all cases of this nature similarly. I look for deviations from the norm, and try to figure out why they exist. In this case, I figured his pain was due to what's called an "impingement" syndrome (pinch syndrome). My approach to this case again was thanks to my having worked with dancers. This is a site that often pinches in dancers. In this gentleman's case I saw elements of severe bone-on-bone jamming, or impingement, in the outside bones of his ankle, due to severe sagging in his arch. The MRI, the insidious onset, and the position of his foot seemed to bear his out. All I had to do was prove it and figure out why. There wasn't enough pathology on the MRIs to keep me from getting him better?or to justify an ankle fusion, for that matter.
He had severe sagging in both arches, but only pain in one ankle. I looked for the most common cause of pronation, or arch sagging, and he only had it on the involved side. As you may have guessed, his pronation was caused by an extremely tight calf on the involved side. A tight calf will bully the arch into flatness, depending on how lax the patient's ligaments are. His were very lax. Ligaments are the elastic bands holding the bones together; tendons are the strings the muscles pull that are connected to the bones). When I measured the calf tightness on the uninvolved side, it was slightly too loose, not at all tight. Again I looked for the most common cause of this disparity: leg length difference. Guess what, he sure had one. His involved side leg measured one inch shorter than his uninvolved side.
When the leg length difference is as significant as this, the body has to do something to keep the pelvis, and thus the whole spine, from behaving in a dangerously lopsided manner. The calf is just waiting in the wings to become a ready heel-lift for a short leg. What happens, as was displayed in this young man's gait when I watched him walk, is the heel on the short side pops off the ground prematurely early in the walk cycle, thus lengthening the short leg, and helping keep the pelvis and central skeleton and head even. If your calf heels-off earlier on one leg for whole lifetime, you're going to become much stronger (and tighter) on that side.
Now someone with severe flat feet, causing painful compression at the outer bones of the ankle, surely should like an orthotic to crank his foot out of pronation and thus pry the bones at the outer ankle away from each other, no? So why did this patient not respond to any of many orthotics, in fact why did he only get painful blisters under his arch whenever he tried a non-flat orthotic? Because his tight calf did not let his foot respond to the arch-support influence of his orthotics. His tight calf continued to bully his arch down to the floor, and any interposed arch support merely subjected the skin of his arch to the same crushing force his calf imparted at his outer ankle.
OK, how come his tight calf didn't respond to years of properly-executed stretching exercises? Because his leg length demanded his calf stay tight to act as a heel-lift. The exercises he did remained academic, not functional, because he had to function with a tight calf. So what was the missing secret ingredient in this case? Simply, as I've done so many times before in such cases, I gave him a heel lift, a substantial rubber one, not some namby-pamby sponge thing, which was 3/8" thick (you don't usually need the full difference for your lift). I asked him to continue stretching his calves. I then asked him to return to me in six weeks, again with his bag of orthotics.
He e-mailed me three weeks after that visit. His constant pain was gone. He was able to walk a mile, or double the previous amount, before a moderate level of pain would come on. He still needed the ankle brace, but he could now wear business shoes and not experience instant pain. I asked him to appoint for the following week. His calf tightness on the involved side was nearly gone. As expected, when I measured his uninvolved calf, it had become a bit tighter...it had become normally tight. The uninvolved calf had become rather flaccid during his lifetime, as a long-leg wants to be shorter with a significant leg length difference. Thus, as had also been evident on his first-visit gait analysis, he did not heel-off at all on the long side.
I found a pair of orthotics in his bag that matched his foot contours beautifully. They were in great shape, as they hadn't been used. They lent themselves to my affixing a 5/16" heel lift to them in my shop, which I did that day and gave them back to him. I asked him to begin using the orthotics and see if he could get out of the brace and gradually increase his activities. I sent him back to the physical therapists he had gotten along with the best to show him some ankle strengthening exercises so he wouldn't incur a sprained ankle with his newfound liberty to walk. I asked him to call me in a month, or if he had any setbacks, to call me sooner.
He did not call me. But last week, he sent me another e-mail, along with several cyber pictures. He documented what he'd been doing for the past three months. There was a snapshot of him and his two little boys enjoying an afternoon at the Museum of Natural History, and another of them at the Central Park Zoo. There was a picture of him and his wife sitting in a caf? in Paris. He said he'd never before been able to travel or take his boys on an outing due to his ankle, and was deeply grateful.
Am I not a lucky guy to have such a wonderful job? And this is all such easy stuff!
Thomas M. Novella, D.P.M.
343 West 58th Street
New York, NY 10019
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