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4th year medical student, been dealing with bilateral foot pain for 9 years

Discussion in 'Biomechanics, Sports and Foot orthoses' started by Bjarni, Mar 26, 2017.

  1. Bjarni

    Bjarni Member


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    Hi podiatrists! I know you don't like people coming here to look for a diagnosis, and I know that it's very hard, if not impossible to diagnose through the internet.

    However my case is absolutely extraordinary and I think it would be of great interest to podiatrists. My medical case is closed by my orthopedic surgeon (in Denmark, where I'm from, we do not have podiatrists, all such work is done by orthopedic surgeons) without any conclusion. She was unable to diagnose me and we did not find any relief. This is the 3rd orthopedic surgeon that has to drop my case because it's impossible to even say what's wrong with my feet.

    I'm hoping that together we may figure out some clues that can, at least, give me peace of mind.

    Let's start with the story:

    Pain description: Bilateral ache in both feet, middle of heel and metatarsals. Worse when standing still, gets better if I start walking. Worst when standing still on concrete with no footwear.

    I'm 27 years old, pain ongoing for 9 years. I study medicine and am on my fourth year.
    Pain came gradually and gradually got worse. I did a lot of skateboarding as a kid, and when I was 17 I started weight lifting and gained about 30 lbs (from about 145 lbs to 187 lbs) over the course of about 1-2 years. Here I was working as a security guard and I started noticing the pain at the end of a shift.
    I did this for one year before going to the army where I stayed for 1 year but the pain got so bad here, that I had to quit. I kept weight lifting but I didn't work on my feet anymore because of the pain. I went into academia and haven't worked on my feet since. It hurts too much.

    I've tried cortisone, nothing. I've got pretty stiff calves but I've been stretching them for about 8 months now and they're getting a bit better. No change in pain, though. I now do brazilian jiu jitsu as a sport, no more weight lifting. I've tried shockwave therapy, no change. I've tried taping for plantar fasciitis = just gets worse. I've tried taping for plantar fat pad atrophy and I'm not sure what I think of it. It does not give me relief, though. I've tried most, if not all, non-surgical plantar fasciitis treatment.
    Custom orthoses do help, but I still get pain. The softer the better, it seems. Heel cups are just "uncomfortable", mostly because they keep sliding in my shoes.

    I don't use any medication.

    No significant family history.

    MRI: (Can post link after 10 replies)

    My thoughts: Repeated trauma from skateboarding and/or sudden weight gain has done something to my fat pads, maybe made them too compliant/soft. Is there any way to test for that?
    My ortho doesn't seem too interested in any of my thoughts. She said that the shadow could be anything and it was hard to say anything about it. She also said that it was hard to say if it was fat pad related.

    What are your thoughts?
     
  2. DaVinci

    DaVinci Well-Known Member

    Was there a report on the MRI?
    What are symptoms like when you get out of bed first thing in the morning?
     
  3. Bjarni

    Bjarni Member

    Report didn't find anything unusual. I wish I could share it, but I can't post links until I have posted 10 times. There is no more and no less pain in the morning. Morning's are just like if I sit for a while, they are generally "better rested" and ready for a day of beating.
     
  4. drhunt1

    drhunt1 Well-Known Member

    Bjarni-first...I'm quite impressed with your English...very good. Now...about your question. I would love to have a weight-bearing plain film radiograph of either, or both of your feet...lateral and AP would suffice. An MRI is of little value in assessing chronic pain, IMO. They just don't show the biomechanical relationships that I utilize, and are very good for assessing soft tissue trauma, plus osteochondral lesions, os navicularis syndrome, Steida's Fractures, stress fractures, Lisfranc's injuries, etc.

    That being written, let me ask you a few questions, not based upon trauma issues, as you've indicated there hasn't been any, and you've had the pain ~ 9 years, (although I believe it's probably been longer than that).

    1) Does the pain seem to change from month-to-month, or year-to-year...or has it been consistent in severity and location?

    2) Do you have a history of lateral instability, ie., ankle sprains while engaged in activities like basketball or soccer?

    3) Do you have Restless Leg Syndrome now, and/or did you have Growing Pains as a child? (We can certainly pursue that line of questioning in greater detail later...especially if your reply is affirmative).

    4) Does the pain increase after days being more active on your feet?

    Let's start there...and see where this leads us...
     
  5. admin

    admin Administrator Staff Member

    Post the link with gaps in the URL. I can edit it into a full link
     
  6. HansMassage

    HansMassage Active Member

    A posture analysis can be helpful also. I s your center of gravity anterior or posterior of midfoot?
    As hinted in the previous post the originating distortion can go back to infancy. For example I have a client with pain like yours and she has anterior hypertrophy of T 9,10,11 vertebral bodies originating from growth stimulation of an arched spine in infancy. When her gravity line is posterior of a heel it develops pain from frepeated hard first contact and then being jerked when the calf is out of sequence and doesn't lengthen as the stride continues.
     
  7. efuller

    efuller MVP

    Since you are a medical student....Do you think the injured tissue is bone, ligament, nerve, vascular, or skin and why? If you have pain in both the middle of your heel and your metatarsals, what is the simplest explanation of pain in both of those separate locations? Is the pain in those different locations caused by the same thing? What physical findings would support your suspicions as to the cause of the pain. One of my instructors favorite quotes was "you have to know your damn anatomy" If you know all of the anatomical structures in the location of the pain, life becomes a multiple choice test.

    Eric
     
  8. Bjarni

    Bjarni Member

    Thank you all for your replies, and sorry that I have not replied sooner, but this thread has my full attention now.

    I will answer you all individually, and as the admin has permitted, I will also include all the links.

    First, let's start with the links:

    Here is a link to the full MRIs on my onedrive folder. There are 2 folders (don't mind the random files, it's just some notes): "DICOM" and "eFilmLite". The DICOM folder is the newest (2015) MRI files and the eFilmLite folder contains MRI's from 2011 I think it was (also shoulder MRI, nevermind those) https ://1drv .ms/f/s!AoQR-r2cisv9g3PJBgkRlUb5qxjU

    Here is a figure1 link for those who use that. I share my thoughts on the MRI and get some feedback: https ://app.figure1 .com/profile?image=5862ad7eaeb0a24d7213520d&t=0

    In case you don't use figure1, here is an image link of my suspect findings: http ://imgur .com/a/EdvGP

    Please note that admin may not have fixed the links at the time of reading, so you may need to fix the links yourselves (spaces in links).
    I don't know what to make of that shadow, and neither does my ortho. I do suspect it is highly correlated to my symptoms though.

    Now, I would like to address each and one of your replies:

    drhunt1:

    Thank you for your complement. English is in fact my 3rd language (I'm an Icelandic native who lives in Denmark and speak fluent Danish and Icelandic) so it always warms my heart when I am complemented on my English.

    I would also love to see some weight bearing imaging, but in Iceland and Denmark (where I have had medical care) no one has even mentioned this. I've spoken about having at least a weight bearing doppler done to rule out some sort of vascular issue upon weight bearing and my GP had never heard of it and they did not know how to interpret the findings. I'm sorry to say, but here, if your feet are hurting, you have plantar fasciitis and that's it. They don't even attempt to differentiate it (only one doctor has done a Tinel's on me and nobody has even brought up fat pad issues). We have no such thing as podiatrists here, either, so there are no true professionals in this field.
    I will, however, bring this up and see what they say.

    Answers to your questions:

    1) No. The pain remains quite consistent but it does change a bit from day to day, depending on activity the day before and sleep. What I have noticed, however, is a few years ago, I couldn't really tell if the pain was worse when barefoot or not, but now I can say with 100% certainty that my pain is A LOT worse when barefoot on hard surfaces.

    2) No history of instability. No instability to be found during testing either (we just had sports medicine and we did a ton of tests for this on each other and we found nothing abnormal with my ankles).

    3) I can not say I have RLS and I did not have growing pains that I remember.

    4) Yes. If I was active yesterday, my feet will hurt more today.

    Thank you for your reply!

    HansMassage:

    I'm not sure how I would measure my center of gravity. I would like to place weight on my heel, but it just starts hurting so fast that I have to start shifting the weight around all the time, from front to back, to the sides (supinating my feet and actually standing on the lateral margin) etc. With regard to your comment about the spine, I do have an extra vertebrae (sixth lumbar I think). Found out by chance at a chiropractor. He did some manipulations, but it was getting so expansive and I didn't feel any difference after about 4 times, so I ended up giving up on it (this was years ago and back then I didn't really see how anything in my back could affect my feet, either). Interesting angle.

    Thank you for y our reply!

    efuller:

    Hi Eric. When standing on hard surfaces barefoot I feel like my calcaneus is hurting me. It's like it's pressing down into my flesh and that causes the pain. When standing in good supportive footwear, it's the same thing, but it just happens slower. Then I start shifting my weight around and the pain starts moving to the front foot and then it starts getting very hard to tell where it hurts because EVERYTHING in my sole hurts at this point.

    I may have several things going on. Perhaps I have some sort of fat pad issue and that is causing my initial pain, but I may also have a contributing factor causing more pain in more places. It's very hard for me to tell you what type of structure is hurting me, but with a gun to my head, it's my fat pad, due to pressure from my calcaneus. The rest could be related to this and all the weight shifting that starts happening or it could be something else. If I shift most of my weight onto my front foot, I have the exact same pain, just in my front foot instead...

    Thank you for your reply!

    Thank you all for your replies and I look forward to hearing more from you!

    EDIT: I realized I didn't write this in the original post, but a physiotherapist (and some of the physicians I've seen) commented on my gait. I have a very stiff gait, pointed out by friends and family too. I walk very fast and my ankle doesn't roll like it should, resulting in this goofy stiff-legged gait. I'm trying to work on it by stretching my calves and actively thinking about my gait when walking.
     
    Last edited: Apr 2, 2017
  9. drhunt1

    drhunt1 Well-Known Member

    As I wrote before...MRI's are of little value in the absence of trauma. Weight bearing, plain film radiographs are MUCH better, at the very least, to ascertain static stance alignment. I believe your complaints are biomechanical in origin. Not having RLS and or a Hx. of Growing Pains makes it slightly more difficult...but not as much as not having X-Rays!

    I'm not impressed that sports medicine docs have supposedly ruled out ankle problems, simply because I believe it's not an ankle problem. It could very well be a problem with the joint below the AJ, ie., the STJ. At the end of the day, after you've been on your feet for much of it, just press on the sinus tarsi dell...or laterally directly on the posterior facet of the STJ and let me know how that goes. I have included a jpeg of the dell overlying the sinus tarsi...
     

    Attached Files:

  10. Have you tied walking around in a Hoka One or similar ?
     
  11. Bjarni

    Bjarni Member

    I'll dry that drhunt.

    Mike, no I have not, but I did buy some Dansko's for my clinical rotations. I have my first rotation next Monday. I've worn them a bit and they are comfortable, but they, like most shoes, just dull the pain instead of eliminating it/giving me enough relief to be satisfied.

    Do you think I could find relief with Hoka One's?
     
  12. Bjarni

    Bjarni Member

    I've also considered these: http :// www. kurufootwear.c om/experts-corner/foot-care/heel-fat-pad. html

    Any thoughts? (Must correct spaces to open link)
     
  13. HansMassage

    HansMassage Active Member

    "Thank you all for your replies and I look forward to hearing more from you!

    EDIT: I realized I didn't write this in the original post, but a physiotherapist (and some of the physicians I've seen) commented on my gait. I have a very stiff gait, pointed out by friends and family too. I walk very fast and my ankle doesn't roll like it should, resulting in this goofy stiff-legged gait. I'm trying to work on it by stretching my calves and actively thinking about my gait when walking."
    The illustration I use for this is the difference between a sail boat and a speed boat. A sailboat starts slow and cuts through the waves but a speed boat starts fast and pounds on top of the waves. It appears that your nervous system has adopted the speed boat method whatever the etiology of your problem. The podiatrist that I worked with would have me take X-ray views partial weight bearing, nto compressed by full weight or suspended, both of which distorted the working relationship.
    I learned from this that to improve function I needed to work with clients in partial weight bearing to retrain ankle function. I have a table with a lift so I can easily have them bear weight on the ischium and adjust the height while working on gait position. Additionally supine I have them place the plantar surface on an exercise ball which allows controlled movement of the ankles in multiple directions using the majority of the posture muscles from the thoracic/lumbar junction down.
    Your gait may be an adaptation in infancy to the failed union of sacral 1 to sacral 2 and allowed you to control the extra motion. My experience with females with this configuration is that they become hypermobile and males become rigid. In either case the working the feet on the ball tended to build proper ligament elasticity.
    Try circling the ball in one direction and if any discomfort reverse direction until full motion can be attained. the feet should be circling to one side and the knees to the other. full control allows one to make a figure 8 motion in both directions. Work on getting good ankle dorsiflexion during posterior direction.
    I hope that will improve your endurance on your feet. Irecomend doing it before and after being on your feet and possibly on breaks.
     
  14. Working via an internet discussion is like playing pin the tail on the donkey while drunk, but EricĀ“s question re where do you think the pain is from and you answer made me consider calcaneal edema might be something to consider and wearing a very soft shoe should help with this, is may of course not be the answer, mut maybe have a look at the MRI again or get someone to read the images again a see if there is any edema

    might be of help https://podiatryarena.com/index.php...f-plantar-calcaneus-patient-discussion.71099/

    https://podiatryarena.com/index.php?threads/calcaneal-edema-bone-marrow-edema.82271/
     
  15. Bjarni

    Bjarni Member

    Mike, I've considered it before, but I can't see any obvious signs of oedema on the MRI (which you can view, if interested, in the links, the full MRI is also included).

    I also understood that you elicit great pain when performing the calcaneal squeeze test on your patient with calcaneal oedema? I don't feel anything unusual if I perform the squeeze test on my heel.

    Did you consider calcaneal microfractures for your patient, instead of oedema?
     
  16. Bjarni

    Bjarni Member

    Gonna add: I also have spider veins, much like these: http ://2.bp.blogspot. com/-Og-V7bqp-bI/Tu-bEysUszI/AAAAAAAAGIo/NN5rMbPn_6Y/s1600/spider+veins. jpg

    On both feet, medial ankle. I've yet to find any clinical relevance, but maybe it makes sense to you guys.
     
  17. HansMassage

    HansMassage Active Member

    From your previous reply That you stand on the lateral edges of your feet to avoid pain, I would expect the tibialis posterior is hyperactive and reduces the major venous return in that area. Spider veins usually develop during the body's effort to bypass the restricted vein. I have good success with reducing the hyperactive response and postural pattern associated with it. And yes clients often report pain with no clear cause somewhere distal to the venus restriction. Possibly it causes some mild necrosis or failure to repair and therefor warning pain when a load is applied.
    An experienced massage therapist like myself may be able to give you answers that other health professionals can not because of our palpatory experience of thousands of hours is so highly calibrated in comparison.
     
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