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Disarray in Foot and Ankle Surgery

[Original response below]

 

Originally posted as a comment on www.orthopaediciq.org.

March 7, 2012
I found your site when googling the internet concerning my foot condition. When I read some of your articles it began to make sense why I was having trouble getting any two doctors to agree. I am picking up my x rays later today and will see if they can put on a JPG.

I am 48 and in good health. Physically active except for the past month (due to foot pain)
In my late 20’s (1991-92) I had bunion surgery done on my right foot. They put in a screw that was removed a few months later and fitted me for some hard soled orthotics . The pain from surgery was intense the first 3 to 4 days but used strong pain meds. Was back to work after 1 week on crutches and in a surgery shoe for several weeks after. This solved my pain in sciatic and foot. However I did not wear the orthotics as often as I probably should have because they could only be worn with flats.
Was good for approx 10 years. as I got older late 30’s and 40’s I could not wear dress shoes as long without achy feet and started being limited to certain shoes but no great pain (I had a closet full of shoes because they would seem comfortable in the store but was unable to wear longer than an hour or so) feet were achy in ball of foot and 2nd toe
Starting around 08/09 I started have a new pain. This was the sharp jabbing (electric pain) when I put on certain closed toe shoes (even flats). So I started getting shoes ½ to 1 size larger and primarily wore sneakers or sandals.
2010 – I went to local podiatrist (got the name from my United Healthcare insurance book) He said my problem was a long 2nd metatarsal that was out of align with the other toes and was bearing all the weight. Said I would be in crutches for 2 weeks and in a boot, unable to drive, for 4 to 5 weeks. I was not able to be off work so decided to live with the pain. I went on diet, lost 15 pounds and this seemed to help. Although at this point I could only wear sneakers (new balance) or sandals.
Jan 2011: I started taking karate and things actually seemed to get better. I was able to jog/walk 3 miles, my overall balance and strength was great (made it to blue belt). I still had some foot pain and intense workouts made it worse. I did research on my pain ordered the book “Why you really hurt” by Burton Schuler and started wearing the homemade Morton’s toe pad (even during karate). Other pains I noticed when doing heavy workout including walking or running included: pain in right inside ankle, some pain on inside of knee, and tended to get out of alignment on hips.
In Jan 2013 I tore my right ACL doing a jump. I Went to Orthopedic Specialists and at the same time also saw their foot and ankle ortho doc (Dr #2, MD, orthopedic surgeon specializing in foot and ankle). said he believed it was a Morton’s neuroma. He said nothing about my 2nd toe needing surgery. If not, there was a procedure where they could remove the nerve. He did warn me of the possible complications and benefits. He also said I should not have too many cortisone shots because it would affect the padding in my foot. And he gave me some hapad metatarsal neuroma pads to put in my shoe. They do help, but takes some time getting used to. I had my ACL surgery, went through 6 months of rehab. He referred me to another orthopedic surgeon specializing in foot and ankle (Dr. #3 MD, orthopedic surgeon). This was approx 4 months after the injection and I was still doing well with much less pain in the foot. Although during this time I was NOT doing heavy exercise or standing for long periods due to the ACL surgery.
The referral (Dr #3) was a much younger guy. He said that neuromas normally occur between the 3rd and 4th toe not the 2nd and 3rd toe, but the fact that the shot helped was a possible indication of a neuroma. I went back to Dr #2 and what Dr #3 told me about shortening the 2nd toe. Dr #2 said “I have a similar problem with my toe and I personally would not have the surgery to shorten my toe” He went on to say… possibly if it got worse later on I might consider. Now when a ortho specialist in ankle and foot tells you he would not have a procedure done (with intensity) this tends to stick in your mind.
It is now 2014. Over six months since my last shot. I even tried walking 3 miles (no running) and this caused pain in foot, calf, inside knee. I cannot walk barefoot. Even showering is a pain. Some days it is better. It is worse when 1st getting out of bed and at end of day after standing or walking a lot. Pain is in ball of foot when I stand and it is achy when at rest. It also is achy when I scrunch my toes to stretch.
I started doing research for alternative treatments to see what is out there (Radiofrequency ablation for neuromas -not many docs do this on the foot), cryosurgery and nerve decompression. In my research I ran across a podiatrist that advertises minimally invasive treatments. I went to him last week. He said the injections are not good and should not have more than one for only diagnostic purposes. He ordered the attached MRI. This doctor #4 (unlike Dr #3) answered all my questions and told me to make a list of any others. I felt comfortable with him, but again he is suggesting the same procedure and I can’t seem to get the statement made by Dr #2 out of my head. But the pain is worse.
Treatment protocol from Dr #4 DPM, FACFAS: Do a transverse ligament release and leave the actual nerve in place. This will prevent possible side effects of stump neuroma, loss of sensation etc. If this does not work we can always go in and remove the nerve. If he has to do the nerve removal, He sews the nerve into the muscle to prevent future stump neuroma. Then while he is there, he will do the osteotomy to shorten the 2nd metatarsal which probably caused the neuroma. He said all my weight is pushing this joint down which also compresses the nerve. Then he wants to do a minor procedure to reposition my big toe over to the left away from the 2nd toe (this would mainly involve soft tissue). But I will have a screw put in both toes to hold in place and they will stay there unless they start to cause me trouble. I will be able to go back to karate after a few months. Won’t have to be on crutches unless I feel unstable. Can walk on my heels, but will be in surgery boots for a while. This is not even the same as what the first pod told me in 2010 (which was I would be on crutches for 2 weeks). Not sure if it was a different procedure to shorten the toe?
So I decide I would go back and see Dr #3 the ortho doc for a 2nd opinion and if I could just get 2 doctors to agree then I would feel comfortable. This Dr #3 had basically told me the same thing, so I just wanted to confirm that as well as the transverse ligament option. This was a disaster. He became extremely annoyed when I asked him about the transverse ligament option…said that was done primarily in Europe and not the US. When asked why or if it was a bad procedure he said he has no failures with the nerve removal and why fix something that is not broken. He went on to say, that if he was seeing repeated failures with the nerve removal he would consider other options. He also said that this was just a “gimmicky” thing used by PODs. Great…just what I need. I told him I did not want to get many more cortisone injections due to possible problems with the foot pad. He said that was not necessarily true (so he disagrees with the POD and Dr #2 MD who referred me to him on the issue of too many steroid shots). He then stated he was not yet sure if the pain was from the neuroma or the long 2nd metatarsal and stated that it was rare to have both conditions causing the pain. He looked at the MRI report and said “well this shows there is a problem in both areas.” So I asked if he recommend that I have both surgery’s done (toe shortening and remove neuroma). I also told him what Dr. #2 had said about the toe shortening. At that point he said “I don’t have time to stand here and discuss this with you, you are freaking me out with all your questions on complications, I think you are doing too much research and reading all the horror stories.” I then asked what his recommendation was? He said “because you are so afraid of complications you need to just have the neuroma removed.” He then immediately left the room and sent in his nurse. It was very awkward.
Now what? The reason I am doing research is be I know more about the foot and all the various procedures than I have ever wanted to know and I’m sick of doing research. I am not afraid of surgery. I know there are complications with any medical procedures. I have had bunion surgery which was more painful the first week than ACL surgery. However, I do not want to go through an unnecessary procedure that will cause more problems than what I am currently having. Is it so unreasonable to want a 2nd opinion. Am I being overly paranoid, when I cannot get 2 doctors (neither 2 POD, nor 2 Orthos or any combination that specialize in ankle and foot to agree on treatment protocol.
Note: I have never been on any blog sites. And if I went onto any sites I would not publicly name any doctors in my blog. I have no desire to bash any doc regardless of how much I may not like their personality. There are risks with any medical treatment and there are various approaches to treatment. I just want to feel comfortable that I am seeing the correct doctor for my particular situation.
Currently, I am leaning toward just correcting the neuroma. I know this is a simple procedure, but still, I don’t want to screw up my foot with unnecessary or incorrect surgeries.
Questions: What are your thoughts on the different ways to treat a neuroma
1. Surgical: transverse ligament release using EDIN or MIND procedure only when there is no “macrosonic thickening or pseudoneuroma” (kobyguard procedure falls into one of those)
2. Surgical: Neurectomy – removal or nerve transaction strategy
3. Radio Frequency ablation – which is new to podiatry but has been used for other parts of body – hard to find a doc that does this
4. Cryosurgery also a newer procedure – I believe
5. Alcohol injections
What are your thoughts on the problem with my 2nd metatarsal. Based on the articles on your website, this is a surgery that should either never or rarely be done, and your article states that there are other alternatives for correcting or helping with this issue. Can you tell me other procedures that can be done.I cannot wear any type of insert, in a closed shoe, because it puts pressure on the toe and I get that electric jabbing pain. The Hapad metatarsal pads are only comfortable with sandals. The extra padding in closed shoes (new balance) puts too much pressure. I only wear new balance and rarely buy new shoes because they are painful to break in (my current shoes are over 2 yrs old). If I wear any other shoe (flat boots, flats etc) I get the jabbing nerve pain and the next day my ankle hurts and other times my calf muscle is sore for several days.
Update March 17 2014 – During all this research I started searching for doctors that do the Radio Frequency Ablation RFA. This procedure Burns/cauterizes the nerve (those are my words not his) and he felt we should leave the nerve alone. He believes this will solve most of my pain and we might, at a later date, be able to fashion some orthotics to relieve the pressure that I put on my 2nd toe—that is if the ligament release does not solve the problem altogether. Out of all the doctors I have seen this one appears to have the most credentials as far as certifications. He is PDM, FACFAS, FAENS, FACCWS, CWS. He is on the board of directors at a local hospital (note: he does my procedure at a surgery center). He is also on various boards related to wound management and has been published in medical journals and surgical textbooks for research on peripheral nerve injuries and diabetic limb salvage. He also lectures nationally and internationally on the subjects of diabetic limb salvage, peripheral nerve pathology and other areas (this is all per his website and pamphlet).
Summary: Per this doctor and from my research Ligament release is minimally invasive and there is no risk of stump neuroma or numbness. I will be in surgery shoe for a few days and back to normal sandals after that. He makes 2 small incisions on the top of foot and offered to show me a video of the procedure (video may be online). I believe he uses the Koby Guard method. He did give me one final cortisone injection (the same meds as ortho doc used (doc #2). It has been a week since the injection and the pain is 95% better. I am back to doing my workouts, but nothing high impact (stationary bike, walking and weights). I am going back to one of my karate classes that is low impact (no jumping or kicks). My daughter and I are also getting bikes this week to add to our exercise options. I know the injection will only last for approx 4 to 5 months before the pain returns so hopefully I can get this fixed within the next few months.
Sorry this is so long, but you asked for a full history.

 

Submitted on 2014/03/22 at 10:09 am | In reply to Debbie Trexler. (original response)

Thank you for this letter. It is published in full (nearly) because it is the sad history of so many. I do not have to say that the practice of forefoot surgery is chaotic, because that is self evident. Most diagnoses and treatments currently used appear to be no more than random walk.

First, you are not being paranoid. I support your Internet research, and commend you for asking questions. This is your foot which you will need for the rest of your life, even more so as you age.
I admire your reluctance to be critical of individual practitioners. I have a certain sympathy for foot-and-ankle surgeons because (bye and large) they are doing (or trying to do) what they have been taught and what is in the text books. However the “science” behind foot surgery is impoverished, to say the least. But you know that, anyhow, by now.
So, that is just an introduction to reassure you that you do not need to justify your enquiries, and that your objectivity is commendable.

Foremost, you have not had a firm, supported, diagnosis. Instead you have had “opinions”. I would not let any of these people touch my foot, unless they provided hard evidence (“proof”) of the condition, and a verified method of treatment.

In other posts I have commented (not favourably) on shortening the metatarsal and Weil’. Please see those. Please also see Noxious Placebos.

Morton’s neuroma is very specific, for demonstrable mechanical / anatomical reasons. You do not have a “Morton’s Neuroma. Incidentally it is not a neuroma by all microscopic standards – That is until the nerve is divided or ablated by RFA! Then it becomes a true, painful neuroma.
I believe that none of these people have given you the correct diagnosis (about which I will write to you directly).

Why this coyness? Because the reality is so far from “accepted practice”. The explanations which I offer are difficult to promote to those who “will not hear or see”. I have run into many problems. Some of my “colleagues” attempting to protect their commercial turf, it seems, have made matters extremely difficult for me. I have had lectures terminated prematurely. However, slowly, and after many decades the more intelligent and less rigid (and less commercial) of my colleagues are beginning to offer support.

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