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Wednesday, December 3, 2014

Nerve Pain and Gait Changes with Drop Foot: Email Advice

Hello Dr. Blake,

I recently discovered your blog and certainly appreciate the expertise you share.  I see that you are aiming for the Camino de Santiago.  I would like to travel part of the camino but am struggling with my current right foot condition.  Having grown up in Madrid, Spain, I believe that you will enjoy the journey.  I am 65 years old and recently retired!  I am 5'4 and weight 120 lbs.  Other than the spine and leg issues, in good health.

In July 2013, I was diagnosed with L5 radiculopathy with right foot drop (significant).  This was very painful and the pain was mainly below the knee.  MRI did not indicate the L5 radiculopathy, only an EMG. (Dr Blake: 1 problem with low back MRIs is that they are done in spine neutral, most stable position), and not when the spine is stressed so problems with bulging discs can be missed).   After 60 PT sessions, including traction and short term use of an off the shelf AFO (which caused medial pain and per the physiatrist plantar fasciitis), and the passage of time, I have recovered much of the foot control without any surgery.  What remains has caused havoc in my life due to medial foot pain.  I have also had an orthotic with a cork base which was adjusted many times by an Orthotics Center but which I believe contributed to subsequent problems due to a tendency to "roll" the foot due to the weak everters.  I have used KT (kinesiotape) in many ways to support the foot.  More recently an MRI showed a split longitudinal tear of the Peroneal Brevis and tendinosis of the Peroneal Longus (Dr Blake: these tendons can look like this in normal ankles, so difficult to take too serious unless surrounded by major inflammation).  This occurred after initiating additional PT.  The PT indicates that I have a very weak Posterior Tibialis and is also making me a new orthotic that is to support the believed weaknesses better than the prior.  I am awaiting the new one shortly.

I recently had a gait analysis  at a Motion Analysis Center in Michigan, and the report indicates:
*** Dr Blake's notes in red
Mild R forefoot inversion in stance and swing (perhaps anterior tibial spasm)
Mildly decreased R ankle dorsiflexion in early swing (some foot drop)
Minimally decreased ankle dorsiflexion in early midstance bilaterally (antalgic stiff gait)
Mild forefoot adduction in stance bilaterally with R slightly worse than L (perhaps anterior tibial spasm)
Mildly decreased ankle plantarflexion moment in stance bilaterally (stiff not propulsive gait)
Moderately decreased ankle and hip power generation in pre-swing bilaterally
Pelvic rotation pattern reversed versus normal with protraction rather than retraction in midstance.

A fine wire EMG indicated that the TP was active 15-30% of the time when it would normally be active and only during the late mid to terminal stance (so would say 50% loss of Post Tib function)

You would not think that something that is mild/minimal would cause so much pain in the medial foot.  Certainly the lateral foot PL and PB issue causes some discomfort but that is not the main cause of pain.

Recently was referred to another physician that uses ultrasound of the tendons and he said that arthritis of the first metatarsal may be the primary issue and gave me a steroid injection which for a couple of hours helped a bit but then the joint pain was significant.  The orthopedic surgeon that referred me to his colleague for the ultrasound wondered if the problem may be the Anterior tibialis insertion in the Medial Cuneiform.  His colleague did not. (I would have to say Anterior Tibial spasm compensating for weak PT tendon and weak extensors--the ones that causes the drop foot---would be my first choice)

Given the time that has elapsed what might be fixable?  I am willing to have a custom AFO too.  Icing does not usually help.  Ibuprofen minimally helps.  I cannot take Neurontin due to side effects. 

So....the physicians are perplexed about what to do to help me.  I am awaiting the new orthotics which may or may not help.  I am interested in your thoughts/questions to help sort this out more. 


Dr Blake's comment: I am assuming that the MRI did not show a tear in the Anterior Tibial Tendon or Arthritis near the Medial Cuneiform. Have them check if the Anterior Tibial is in spasm. Local anesthetic blocks into the muscle can break the spasm, and biotox is also being used. If it is truly the anterior tibial spasm that is dorsiflexing the ankle and holding up the medial arch, then an AFO should be used until you gradually regain full strength of the ankle, and normal heel to toe motion. Let me know if you have other questions. 

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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.