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Saturday, June 2, 2018

Chronic Foot and Ankle Pain post Illness: Spiraling Out of Control

Hello Dr. Blake,

I came across your blog in search for help for a chronic bilateral foot/ankle/leg problem that I've had for over a year now in which I've had a hard time getting a diagnosis for. I was hoping that I could give you some information and you could possibly offer me your thoughts, as I'm desperate.

First, let me say that I'm 52 years of age and am 5'6 and 120 lbs.

During the Winter of 2016-2017, I experienced a very stubborn bout of diverticulitis in which I have prescribed Augmentin (4 courses) for 4 months. I was mostly bedridden during this time. Once I had recovered in early May 2017, as expected, I had a severe amount of atrophy in my legs. I proceeded to do a lot of stretching, mostly of the calves and began walking (in unsupported shoes, unfortunately) about a quarter a mile a day. On my second day of walking, I came home with discomfort in my feet, ankles, hips and lumbar areas which is unusual for me. The following day the discomfort had dissipated.

Within a week, I developed pain in the left foot/ankle, mostly in the front of the ankle (retinaculum area) as well as pain around the outside of the ankle (peroneal) which traveled a few inches up into my lower calf.  I immediately saw an Orthopedic who did x-rays and suggested that I stay off my foot and ice it. Over the following weeks, the pain began to worsen and I visited the local Urgent Care, ER, and my primary care physician. All thought it was a sprain and I was told to stay off of my feet and to elevate and ice.

A month later, I did go back to see the Orthopedic, as the pain had gotten worse and I was beginning to get the same pain in the right foot/ankle. He suggested visiting a Rheumatologist and offered me ankle sleeves and to use a CAM walker boot when making small trips around the house. He recommended remaining off my feet as much as possible. Oddly enough, during this entire time, I never had pain while walking but several hours later.

I went to see a Rheumatologist and all testing was normal. (RA, and autoimmune disorders)

At this time, I went to see a Podiatrist who did x-rays and said that I had a dropped navicular bone and very mild PTTD. He made me a pair of custom orthotics and I wore them 15 minutes, 3 times a day. On the 3rd day, my feet and ankles were in so much pain, I cried and could no longer wear them. I understand that orthotics have a break-in period but my feet felt like they were shattering while wearing them. He then suggested that I try a pair of PowerSteps to get used to and he'd build them up as needed. (See attachments) I began having more areas of my feet/ankles hurting and was getting terrible tightness in my peroneal muscles in which I began seeing a massotherapist.  

Over the past year, I've seen about 50+ specialists. Neuro's, Neuromuscular's, Rheumatologists, Vascular, certified Foot and Ankle Surgeons, additional Podiatrists, Spinal Surgeons, Neurosurgeons and the list goes on. I was MRI'd from head to toe, blood work, etc. I wouldn't be surprised if the total for all of those appt.'s and tests exceeded $300K. Nothing was ever found. Everything from spinal issues to neuromuscular diseases to RSDS/CRPS, etc. have been ruled out.
Dr. Blake's comment: I am sorry!!

During the past year, my legs have atrophied even more. I've tried PT on 3 occasions which always made my pain worse, so various physicians told me to discontinue therapy. (Land therapy caused mild swelling in the feet and aquatic therapy made my feet hurt worse in general)

What's strange is this all presented as outer ankle pain (peroneal) and went up the side of my calf a few inches. Within a month, the other foot/ankle and leg had begun to hurt in the same places.

I'm only "on" my feet about 30 minutes a day. My pain is still bilateral causing both feet to hurt, my sinus tarsi, achilles, peroneals and calves. Oddly enough, I've never experienced pain in my Post Tib around my inner ankle nor have my arches hurt terribly.

Since August of 2017, I gave up my ability to walk stairs, squat down to pick something off the floor and many other things that involve moving the feet and ankles. I find the best position when sitting is to have my feet flat on the floor, as this causes the least amount of pain. I can do these activities, but hours later, I'm in miserable pain for days.

This problem has also caused my knee to pronate inward and I've also begun to experience extremely tight muscles around my hip, groin and IT band that cause me some grief. I have no leg length discrepancy as confirmed by x-rays.

I see a Chiropractor for my hip which he adjusts, but unfortunately, the relief is short-lived. It tightens back up within an hour. I have had luck with Massotherapy in which she works with my feet, calves, and hips using cross friction techniques. Massotherapy has reduced the minor swelling that I have in my feet/ankles but returns upon use. The relief lasts the evening. I did try acupuncture, it did nothing for me except leave me with bruises on my legs.

I do have a pronation problem, more so on the left foot and the left is generally worse than the right. My ankle also rolls in as I walk. I have flexible flatfeet and my ankle slides inward but in no way goes anywhere near the floor. My arches aren't like a pancake, either. I can slide my fingers under my inner arch while bearing weight. (See attachments) I've had 2 MRI's in which no tears or inflammation were found, as well as an ultrasound of both ankles to look at the integrity of the tendons, ligaments, etc. Both of those tests proved to be normal. I can do a single heel raise on both feet with no problems during the act but increases my pain levels hours later. I've tried multiple shoes for stabilization and have noticed that slipping the shoes on and taking them off causes the symptoms to go through the roof.
Dr. Blake's comment: This is nerve hypersensitivity or allodynia.

I recently saw my original Podiatrist again who said that I've progressed to PTTD Stage 2. I don't know how this could be with next to no activity or walking in a year. Most of my appointments have been in a wheelchair.

My Podiatrist is in the process of making me a new pair of orthotics to help with the pain/stability. He used plaster instead of the foam foot boxes. He said these will stabilize my feet and not allow my ankle to pronate inward which he believes will help me. I truly hope so because the pair that I had last Summer brought me to tears within 15 minutes and I had much less pain back then.

I'm just so perplexed as to why all of my MRI's/ultrasounds have been clear, I can do single heel raises, yet have Stage 2 PTTD according to my podiatrist.
Dr. Blake's comment: You are probably just so much weaker, so your arch is lower now, temporarily until we can improve the strength. This is the key to me. With nerve pain, you have normal MRIs. See comments below. You may have to consider epidurals, sympathetic blocks, or Calmare Pain Therapy. Most start with orals like Lyrica.

Could atrophy be a contributing factor in all of this? (I have a very significant amount in my legs) Would gaining some muscle help my situation? I'd be willing to try just about anything but it's hard trying to find an exercise (or even strengthening) that can be done from a bed or while sitting without much foot/ankle movement.
Dr. Blake's comment: Yes, you were set up for this with the diverticulitis, and sickness in general, that started giving you symptoms from this atrophy. Every day that has passed that you have not had normal activity, you have gotten weaker and weaker and weaker. The question is how to reverse this trend. 

During my research online, it appears that most podiatrists use custom AFO's (like a Richie Brace or similar) along with stretching and physical therapy and have had good outcomes in Stages 2 and 3. I'm perplexed as to why my podiatrist didn't suggest this given my previous experience with his custom orthotics.
Dr. Blake's comment: Unsure also. The Richie Brace or AFOs can undersupport a painful arch at the same time letting the leg take some pressure. 

To reiterate, I can walk stairs and walk pretty normally when I have to. The pain appears several hours later and is quite disabling for days.
Dr. Blake's comment: What happens when your muscles are weak, but functional which yours are, that the joints sag a little bit more than normal, and this stresses the nerve endings. The nerves want to protect you so they hurt telling you that you have a problem. They are your friends in this regards. So, we need strengthening work of all sorts, as long as you can recover. Can you swim with floats at the ankles? Can you ride a stationary bike with the seat lowered so there is less stress on the ankle? Can you do active range of motion like ankle circles twice daily and then ice afterward? Were your original orthotics adjust for 25% of the original arch (if they have a deep heel cup they will still be stable but less irritative)? You really fit into the functional rehabilitation 6-week programs that they put CRPS patients in. The therapists who run these are great at teaching you when to honor the pain and when to push through the pain. We need short walks daily with ice afterward for the weight bearing. You may need oral medications to keep the pain down so you can exercise more. These would be the pain medications like gabapentin, Lyrica, Elavil, Pamelor, Cymbalta, etc. 

I've attached several pictures of my pitiful looking built up Powersteps that I've been wearing when weight bearing. I never go barefoot, even for a trip to the bathroom in the middle of the night. I've also attached pictures of my feet for signs of pronation. I don't know if I truly do have PTTD Stage 2 or perhaps a milder version or something completely different. I often wonder if atrophy could be a significant impact on my pain.
Dr. Blake's comment: I would blame this all on atrophy, forget the advice to rest some more, be on crutches, and move more. It may be an every other day program since you will need time to recover and need time for a pain specialist to get you on the right cocktail of meds. The meds are built up over time until you reach the desired result, then stabilized for 2 solid months, and then the process of slowing weaning off them happens. 

While I understand that you can't diagnose me through my attachments, if you have any thoughts or advice, I'd be grateful hearing them. I certainly don't want bilateral flatfoot reconstruction and feel after meeting with my podiatrist last week, I'm in a race against time due to progression. I'd prefer to try as many conservative measures as possible. If I lived closer, I'd make it see you but unfortunately, I'm in the Cleveland Ohio area.
Dr. Blake's comment: First of all, I looked at the photos you sent and saw a little pronation, worse on the left, but there should be no need for any foot surgery. Secondly, I hope the loss of Game 1 to my Golden State Warriors was not too upsetting to you. It was sad to see little LeBron crying over some of the calls. Look online for the organization of neurophysical therapists, and find a good pain specialist. In California, we would have you lathering up the noneuphoric cannabis!!

I absolutely love your blog! It's so informative and I think it's wonderful how you take the time to help others out. Had I known how to post this there, I would have.
I apologize for the length of this, it's been a tough year.
Dr. Blake's comment: I have added an article on Augmentin and muscle weakness. It could have been the dagger that broke your back. Not sure how long this weakness continues once you stop, but it could have added to the normal weakness of being sick. This is not uncommon. I wish you well my friend. Rich

https://www.ehealthme.com/ds/augmentin/muscle-weakness/

Thank you in advance,

The patient then responded:

Hello Dr. Blake,
I can't thank you enough for taking the time to read over my history and symptoms.
I recently received my 2nd set of custom rigid orthotics. (See above) They have good arch support, a deep heel cup and prevent my ankles from pronating. This is the first pair that I've been able to comfortably wear with reduced pain. The mild swelling that I had in the retinaculum in the front of the ankles, as well as the swelling on either side of the achilles, is now gone. This was within 24 hours of wearing them. I've been told the break-in period for these is an hour a day with a steady increase. I was told that if my pain increased to back off a bit to let my legs/ankles and feet recover.
Dr. Blake's comment: You are always dealing with 3 types of pain: mechanical, inflammatory, and neuropathic. I am glad you finally got some mechanical relief. 
Thank you for the information on nerve hypersensitivity. Not one physician could explain why wearing socks or shoes would increase the pain in my feet/calves. I've noticed that foot baths with jets increased the pain as well as when physicians manipulated my feet. 
Dr. Blake's comment: Yes, the nerve aspect of pain syndromes is not taught, or appreciated, by doctors and therapists in general. 
I have seen several pain management physicians and was refused any types of blocks. The only relief that was offered to me was a spinal cord stimulator in which my insurance company would not cover. As for medications, I have tried the majority that you have mentioned but were not well tolerated. Hopefully, with the use of these orthotics, they'll allow me to build muscle with a tolerable amount of pain. The past few days, I've been able to take short walks (5-10 minutes) with tolerable pain. (No sinus tarsi pain, arch pain, but calf pain which I'm assuming is due to a different foot position)
Dr. Blake's comment: In my mind, with weak muscles, strength, not an invasive procedure like spinal cord stimulator, is what you need. Many rejections to meds like Lyrica is because the doctors start the patient on too high of a dose. If you can research the starting dose of the nerve meds again, I can tell you where to start. 
I will try using the local pool with floats around my ankles, as well as a recumbent bike and ankle circles as my body permits. Thank you for this suggestion. Even though I'm within the Cleveland Clinic healthcare system, many physical therapists don't really know what to do with rehabbing feet/ankles. (My previous 3 visits proved this as I was pushed so hard with the "no pain no gain" attitude that I came home in excruciating pain on each occasion). I did look up the organization of neurophysical therapists and have found several in my area, thank you for the suggestion. 
Is noneuphoric cannabis CBD oil? If so, that is legal in Ohio and they make a lotion that I could try on my legs/ankles and feet. 
Dr. Blake's comment: Yes, CBD. 
When my husband and I brought up atrophy, all of the specialists said that atrophy doesn't cause pain. We were pretty confident there was indeed a connection. Thank you for confirming this. as well as it's connection to Augmentin.
Dr. Blake's comment: Here is an article discussing muscle atrophy to pain. It is so common!!
https://www.epainassist.com/muscles-and-tendons/muscular-atrophy
I do realize that this is going to be a long recovery. You're the first doctor that has instilled hope that there is a way out of this pain without surgical intervention. 
Hopefully, I can find some happiness in Game 2 tomorrow. The first game was a real nail-biter. They're both great teams but the Cavs only bought one superstar! On a side note, no one will ever compare to his Airness. His skill on the court was phenomenal, he had such grace, charisma, and class. That's something that seems to be lost in this day and age. 
Dr. Blake's comment: Too bad you have not had the pleasure of watching Stephen Curry through season after season as I have had. Unbelievable!! But Michael was also unbelievable. LeBron is a physical specimen and talent that may never come around again. But something is missing from his game, maybe a humanness that you see more than me. 
Thank you again for all of your help/advice and thoughts. You've provided me with hope which I haven't had in a very long time. 
I sent you a small Paypal donation this evening to help with your blog. You're a true gem of a doctor to help others as you do. I really admire you. 
Thanks again and Take Care,

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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.