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Sunday, December 5, 2010

Complicated Musculoskeletal Problem: Email Advice

Email sent to on 12/3/10

Dear Dr. Blake,

I had just recently been following your website and other works you have done and decided to email you. It is very rare to find a doctor these days who actually communicate and educate people who are not necessarily their patients. For this alone, I already know you are a different doctor - one that we need more of these days. I decided to write to you because of this. As I have problems in the low back, hip, knee, and ankle, I have been given fragmented diagnosis of my condition and none of which I can put into perspective. I chose to write to you because of your experience with biomechanics hoping that I could get a better idea of what os going on with my body. Forgive me, but my medical history is quite long and I will try to make it as simple as possible for you. I am in the hopes that you would be able to give me a better perspective of what is going on.

On Nov 2009, I noticed my right foot did not feel the same. It did not necessarily hurt so I ignored it. On january 2010 I started having right knee pain. My orthopaedic told me I have CMP and sent me to physical therapy. I have been working as a teller for 9 yrs and stand at least 8 hrs a day. My PT told me that my right arch was falling and I needed to get orthotics otherwise I will have hip and back problems. So I started PT in May 2010 and by then I noticed that when I stood up my right knee would always be bending inward and I had to consciously extend it to keep it straight. In August 2010, I started to develop left hip pain and mild left low back pain. I went to a chiropractor who told me that I had LLD in my rt leg and that my left pelvis was anteriorly rotated which was causing a mild low back scoliosis. I got orthotics then and he gave me a heel lift of 5mm. I had mixed feedback with the heel lifts as PT told me I did not need it since my LLD was apparent and not true. I did not wear the heel lifts and I carried on with PT and chiro and I was getting better - knee and hip pain going away with the help of FMLA at work and not having to stand all day.

On October 2010 I made the grave mistake of lifting a sofa. An immediate pain shot right through my left groin to my left back and to the right back. For the next few days I was having back pain and oddly enough right groin pain this time (left groin pain went away) and I could not keep my balance when I walked. A few days after as I was walking I felt a rip in my left buttocks down to the right buttocks that made me lose my balance more. I quickly regained myself but then when I started walking again I couldn't walk straight! As I stride my left leg forward, the right leg would go over towards the left leg. This went on for a day after which was causing me a lot of left knee pain that felt like it was being twisted. A few days of limping around with a locked left knee, I started noticing that both my ankles were hurting. My left ankle actually hurts more than the right. For treatment of such a poor diagnosis (not that anybody gave me a straight one) I went to PT again for the left knee this time, and to my podiatrist for my ankle who said i have the sinus tarsi syndrome and gave me steroids as I refused the shots. I went to 2 hip doctors of which one said I may have torn my cartilage and my gait has probably changed and thus the knee and ankle pain but another hip doctor said MRI came back ok and its just a glute strain.
By now Dr, Blake, I have to say that my hip, back and knee are doing better but not my ankle. It is still very unstable and now I have taken the shot just yesterday to see what happens. My podiatrist and the hip doctor think that when I was walking and lost my balance perhaps I twisted it. I don't think so being that the ankle pain came after the knee pain (then again I'm not a doctor). I have been researching and trying to understand my condition and since no one has given me a clear perspective of what is going on I have been self diagnosing. So far, this is my self diagnosis:

I believe I do not have CMP in my right knee. I think that my right knee pain stemmed from my right foot flatenning/pronating. I believe that my left pelvic anterior tilt was because of my right foot that caused my right knee to keep on bending inwards. I dont know for sure if i have LLD. I believe that because of all that has just been mentioned in this paragraph it has unlocked my SI joint causing the low back pain. For the second injury when I lifted the sofa, I believe that there is nothing wrong with my left knee. I think it was compensating for whatever happened to my hip/glutes/low back. For the low back I am sure it is my SI joints as MRI for lumbar came out ok. So right now I am down to my SI joint/ rt hip/glutes in relation to my ankle. Now my left foot has pronated more and my podiatrist said it s because of the cruciate ligament stretched or tore (Im not sure which one). He said if i dont get better with the shots I may have to have that surgery where they put that screw in my ankle which I dont want. I'm afraid that my ankle pain comes from my hip/glutes/SI joint and that if I dont fix them my ankle will never heal. I am not sure what to make out of everything after this point.

Dr. Blake, I know you are a busy man and I am only one of the many people that you have to attend to. I am from Las Vegas NV and I wanted to tell you my medical history to see If I am one that you would be able to help if I come see you to your clinic in San Francisco. I think that perhaps a gait analysis will give me more info about my condition and of course with your expertise I am hoping to fully understand and get a right diagnosis so i can have the proper treatment and get better. I am sorry this is such a lengthy letter but I have exhausted all other doctors whom I cant get a straight answer from.

Thank you for all your time.



Dear Carina, Thank you for emailing me about your condition. I left it in its entirety on the blog because it is an excellent example of when one thing goes wrong, especially our feet, the whole deck of cards can collapse. When I get a history like this, you look at the first symptoms to tell you what is the root cause of the problem. You felt something was wrong with your right foot, probably a collapsing arch. As the arch collapses inward, the knee twists inward, the hip and pelvis get out of alignment, and the first symptoms probably follow the pronation pain syndrome mentioned in my previous blog.

I know if you are right handed, and you injure your right side, the left side easily wants to compensate. This would lead to left hip pain from favoring the right.  I will assume you are right handed. Even not, enough limping protecting of your right side can lead to a breakdown of the left eventually.

After you had orthotics made, did you feel equally supported right to left? Do you feel that the orthotic devices eliminate all or 95% of your pronation? This I think is crucial to making you well. If you look at the link above and the video on pronation you could email me one of your own with a help from a friend. I would be happy to analyze for you. When symptoms arise like this I believe you have to have great orthotics, not just good orthotics. You may be in good orthotics, which control the pronation of your feet 60-70%. But, I would shoot for 95-100% correction for the next year. It serves like a cast for the pronation. This can only be analyzed with stable shoes and power lacing. Definitely get great a power lacing.

And, only until the orthotics are perfect can you really do the standing eval for leg length difference. Ask your podiatrist if the orthotics completely correct the pronation once you power lace. Ask a good athletic shoe store known for their expertise in running shoes. Watch the videos on pronation with a loved one, and have them watch you walk. Once the orthotics are fine, the standing LLD measurement can be taken.

Carina, I think your summary was excellent. You may have a syndrome called posterior tibial dysfunction and there are many conservative treatments for. This is why I need to see you walk to make sure, but you can ask the podiatrist if you have this also. Make it your goal to get the feet perfect and see what falls into place. You probably should consider an ankle brace temporarily. Look up ASO braces. Ice your ankle 3 times daily for 15-20 minutes (see the post on icing). If you got a shot into the ankle, what was in the shot, and how did it feel over the next 5 hours? Ask the podiatrist exactly what did you get, and into what joint (ankle or subtalar)? Hope this helps until you get the video to me. It is fun making videos. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.