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Sunday, August 16, 2020

Stage II PTTD: Email Advice

Dr. Blake --

Thanks so much for your blog, it's great.  I had a few questions I was hoping you might be willing to help me with.  Feel free to share on the blog so long as I am anonymized.

I'm in my mid-40s, am very overpronated in both feet, and have long-term PTTD in my right foot.  I used to be an active runner (many half-marathons, one full) prior to these problems.  Here's the details (all about right foot):

*  Started having ankle and arch pain (in retrospect, classic PTTD pain) in 2009.  Podiatrist believed pain related to accessory navicular.  Kidner procedure performed, hard orthotics prescribed.
Dr. Blake's comment: For the reader's benefit, the posterior tibial tendon is the most powerful tendon to support the arch. 10% of people have that tendon weakened by having an extra bone at its attachment into the navicular. This extra bone is called os navicularis, accessory navicular, or os tibial externum. The posterior tibial tendon is weakened when some of the tendon does not attach where it should to support the arch, it attaches into this extra bone. It would be like 30-40% of the achilles tendon not attaching into the heel bone, but just hanging out up the leg somewhere. 

* Generally pain-free until mid-2016.  Mild flare-ups occasionally.  Podiatrist recommended that I give up running, so I did.  I walk a lot for exercise (and still do), probably 15-20 miles per week.  I wore orthotics religiously, but my footwear was not the greatest (I loved wearing Chuck Taylors with orthotics, podiatrist said that was fine as long as I wore orthotics).

* Got new podiatrist in mid-2016.  Asked if I could try running again.  He said okay.  Started running in neutral New Balances with orthotics.  No issues for a week, then on a run felt sharp pain inside of foot and ankle.  Wore boot for a while and it got a bit better, but pain continued off-and-on for a year.
Dr. Blake's comment: With Neutral shoes, you need a lot of support from the orthotics, with stability shoes, you need less. Hard to know what did it, as it could have just been weak. You are not commenting on strengthening, but post Kidner you should be on life long posterior tibial strengthening. Simple maintenance 3 days a week. I have attached my video of the exercises. 

* MRI in 2017 showed partial PTTD tear.  Podiatrist (who is also foot/ankle surgeon) says surgery may be needed if no improvement.  Got second and third opinions in Dec. 2017/Jan. 2018 from good surgeons (including Clifford Jeng at Mercy Medical in Baltimore).  All had same general take: PTTD stage 2, surgery likely needed, FDL/MDCO.  In this timeframe, I also tried UCBLs and a Richie Brace, which I could not tolerate very well (painful).

* I have small kids, so I told doctors that I'd like to grin and bear it if I could and push off surgery until kids were older if possible.  All said fine, and who knows, it could improve on its own.
Dr. Blake's comment: That is very unlikely, but Stage 2 is not a surgical stage. See if you can get some version of the Inverted Technique for PTTD, or at least varus wedge your current orthotics. Get the Aircast PTTD Airlift Brace and learn to tape like the video below. 

* The very good news: it did improve on its own.  Been basically pain-free for almost 2 years now. 
Dr. Blake's comment: I am humbly happy I was wrong!!LOL
 Dr. Jeng recommended Brooks Beasts to me, which have been great.  I wear them or Brooks Addictions (their similar overpronation product for walking) religiously, with orthotics.  I wear a Bioskin trilok brace on right foot if I can't wear the Brooks (e.g., dress shoes).
Dr. Blake's comment: I am glad you bring this up. The Brooks Beast is an orthotic in a shoe, so when you add another orthotic, you have amazing support. The Brooks Ariel is the women's version of the Beast. 

I had a few questions,if you are willing and have time to respond.

*  As long as things continue okay, can I avoid surgery?  Dr. Jeng implied this when he told me that he doesn't do surgery on feet that don't hurt.  (Interestingly, he said that the overpronation on my left foot is as bad as the right, but it's completely asymptomatic -- this happens all the time, he said.)
Dr. Blake's comment: Usually this condition is bilateral, with one side many years in front of the other. It is a degenerative process so no one can guarantee that you remain asymptomatic. With your history, you stay in good shoes, keep strong, tape and brace when you are in over load (backpacking trip), ice when needed, and stay away from activities that put severe demands on your tendon (like downhill skiing is better then snow boarding, or running flats are better than rocky hill trails). I have many patients in Stage 2 for the last 30 years and doing great, and some progressed over 10-20 years and needed surgery. I think the flareup you had was a good lesson for you. Never treat flareups as anything but another episode that you have to rehab from. That is the mind set you have to have. 

* Any chance I can run again, trying your walk-run program? 
Dr. Blake's comment: I love to have my patients run, and the walk run program is perfect. You run every other or even every third day. You run with the Brooks Beasts, with orthotics, on level ground. I would personally not start this until you are at 2 sets of 25 Level 6 resistance bands (which will take you 6 months to get to and then maintain 3 days a week). Running is so nature to our bodies, and thus innately safe, but we can do anything too much. 

 I very much would like to run again, I miss it.  I'd wear Beasts, orthotics, and the Tri-Lok.  I am willing to risk a small chance of recurrence (10%, say), but don't want to roll the dice with a more substantial chance.  Doctors I have seen have told me not to, though I get sense some of them don't understand runners.  So, I would take your advice to not chance it (if that is your perspective) very seriously.  I'd very much like to run again, but if I am really rolling the dice on a recurrence or worse if I run again, I understand that.  (I have also been told that it's very unlikely I could ever run after FDL/MDCO anyway.)
Dr. Blake's comment: To my above comment, do the posterior tibial taping also to hedge your bet. 

* If it was not too risky to run again, are Beasts/orthotics,Tri-Lok a good strategy? SEE ABOVE

* Are you aware of any business-type shoes that might work for someone like me?  I know they probably don't sell dress shoes with support like Beasts, but something in the ballpark would be nice so I don't have to wear a brace when I have to wear business shoes.
Dr. Blake's Comment: You can take a sturdy pair of Men's dress shoes (Wright, Allen Edmond, etc) and apply a 1/8th inch varus wedge to the out sole by a cobbler. Works like a charm for PTTD
Dr. Blake's comment: Of course, they blend it in. Good luck. Rich 
I very much appreciate any thoughts you may have.  I of course will take them in the spirit offered and not as specific medical advice, because you are not my doctor and haven't seen me in person.

Thanks again for your blog and doing this for folks!


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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.