Sunday, August 29, 2010

Musculature of Club Feet - What is Known, and What is Not

I recently undertook to chew on a rather amazing graduate dissertation about genetic research  into the eitioligy of talipes equino varus. It's called "Analysis of Variation in Clubfoot Candidate Genes, by Audrey R. Ester, of the University of Texas Graduate School of Biomedical Sciences at Houston. Most of it is quite above my head, but I tend to rather relish tackling things well above my head from time to time. (And sometime end up well below my feet.)  Usually, I do manage to, at minimum, "get the drift," and many times, actually grok the item at a decent enough lay level that I can afterward follow the conversation, as it were. And sometimes, just once in a while, mind you, I am able to take that limited comprehension and use it in service of deepening my understanding of some associated topic or field of study. I'm kinda kinky that way, I'm told.

But the most interesting part of Dr. Ester's paper is at the beginning. She starts with a brief recap of what constitutes a club foot, and then follows with a section on the current research on the muscular issues related to talipes, especially the nature and possible causes of the lower leg muscular atrophy most clubbies tend to have. And there is some very interesting stuff in this section, so I am going to quote liberally from the paper, and I am providing a link to the paper so you can attempt to tackle it yourself, should you be as kinkily inclined as myself.

Where it seems appropriate, I have inserted word definitions, to aid the reader with deeper understanding of the material. These are bracketed by [ ]. I have also removed the references from the quoted portions, but these can be examined by reading the full paper.

"Musculature and tendons of clubfeet"

"Clubfeet are also characterized by hypoplasia [Underdevelopment or incomplete development of a tissue or organ] of the calf muscles, which often persists throughout life; however there are conflicting studies about muscle placement, fiber density, and even muscle size...... In general, Irani and Sherman concluded that muscles of clubfeet are underdeveloped and smaller when compared to unaffected limbs. Because the
calf muscles have found to be hypoplastic,  they have been the focus of several histological [The study of the form of structures seen under the microscope. Also called microscopic anatomy] studies in clubfeet."



"In 1977, Isaacs et al. investigated the types, number, size, and direction of muscle fibers in individuals with clubfeet. This study concluded that clubfoot calf muscles are “grossly abnormal”, with higher numbers of Type I fibers, and both types of muscle fibers were larger than controls. Type I muscle fibers are also known as slow twitch muscle fibers and are redder in color because they have a higher myoglobin and oxygen content. These fibers are used in long-term activity because they resist fatigue, as opposed to fast twitch (Type II)
muscle fibers, which are used during short bursts of activities, are more fatigable and can only receive energy from glycolysis [is the metabolic pathway that converts glucose, C6H12O6, into pyruvate ]. In addition to higher numbers of Type I muscle fibers, Isaacs et al. found evidence of denervation [ interruption of the nerve connection to an organ or part] in calf muscles of clubfoot. The larger muscle fibers imply that atrophy [is defined as a decrease in the mass of the muscle; it can be a partial or complete wasting away of muscle] is not the reason for smaller muscles, but might be caused by a neuropathy. ...

Fukuhara et al. performed histomorphometric [the quantitative study of the microscopic organization and structure of a tissue (as bone) especially by computer-assisted analysis of images formed by a microscope] and immunohistochemical [or IHC refers to the process of localizing antigens (e.g. proteins) in cells of a tissue section] studies on 16 ...clubfeet and 27 normal feet (seven normal feet from unilateral patients and 20 feet ...of the same age range as those affected). This study found that the bone malformations were secondary to ligament and collagen changes. The tibialis posterior ligament was found to be enlarged, and the orientation of the collagen fibers was disrupted. .... This supports data from previous studies that suggest that calf muscles in nonsyndromic [not part of a syndrome] clubfeet are abnormally small.

In 1998, a prospective study was performed by Loren et al. in which muscles of children with clubfoot were examined histologically, and further investigated if surgical intervention impacted these histopathological findings. About half of the patients with clubfeet showed abnormal muscle morphology. Twenty percent had fiber type disproportion [Congenital fiber-type disproportion is a disorder that primarily affects skeletal muscles, which are muscles the body uses for movement. People with this disorder typically experience muscle weakness...] , and 30% had fiber size variation (>3:1 ratio). The clubfeet with abnormal muscle morphologies had an increased risk for clubfoot recurrence and a second operation (5.6 fold increase). "
 .
"A histological study of clubfoot in 2006 reported on 431 muscle specimens obtained from 68 patient surgeries. This study gave very different results with 86.3% having “no discernible pathology”. Atrophy and an over-abundance of type I muscle fibers was found in 12.8% of the specimens. This study was much larger than the Omeroglu study and was a better representation of the average clubfoot compared to normal musculature. Other case studies have reported an additional muscle coming out of the soleus [one of the calf muscles] muscle. There have also been reports of a flexor digitorum accessorius [an accessory, that is, extra]  longus muscle that is aberrant in children with clubfoot. These case studies involve small numbers of clubfeet and from individual collection sites. In addition, many of these evaluated the “clubfoot deformity” but do not
discriminate between idiopathic clubfoot and syndromic clubfoot, and so these clubfeet might have different musculature due to syndromes (such as a neuropathy). A large-scale comprehensive study in idiopathic clubfoot patients is needed to validate these findings."

So, what does this all mean? First, it shows that there is more behind the musculature atrophy of club feet than merely the aftereffects of serial casting, bracing, and long period of non-weight bearing may produce alone (or rather, in combination.) [Quick aside - non-weight bearing during various growth stages in childhood means less pressure on the growth plates (epiphyseal plates) at the ends of the long bones of the leg, which alone can cause variable degrees of atrophy. When this occurs under unilateral conditions - that is, on one side - it can also induce some level of leg length difference, as the non-weigh bearing limb has limited growth during such periods.] The section also illustrates that, "the jury is still out," that is, there are some contradictory studies, and therefor, there needs to be more, and probably different kinds, of studies to further understand what is going on with club foot related atrophy.

At both a developmental level and a genetic level, there are factors that affect the muscle fibers themselves, causing these fibers to be less developed (hypoplastic.) There is also some intimation these changes may or may not be amenable to improvement by exercise, but this seems to be more difficult to determine who might be impacted by such efforts - it seems the percentages aren't all that high. To refer back to " Type I muscle fibers are also known as slow twitch muscle fibers and are redder in color because they have a higher myoglobin and oxygen content. These fibers are used in long-term activity because they resist fatigue, as opposed to fast twitch (Type II) muscle fibers, which are used during short bursts of activities, are more fatigable..." Don't be too confused by the apparent contradiction of " higher numbers of Type I fibers,..." A higher number of such fibers does not translate to "stronger', or more durable. Any change from a "norm" is seldom a good thing. Atrophy is sometimes reversible, but if the cause is a disease or genetic factor, there will be minimal improvement, and in the long term, a higher potential for increased weakness.


As I have mentioned in several prior posts, there is a unique parallel to post-polio syndrome, though the causes are different - both seem to show increased muscle degradation with age. It could be a more rapid, age-related break-down, or long-term overuse, but what is most important for us clubbies is how this may potentially affect our quality of life, and what additional costs may be associated with the aspect of post-club feet.

Finally, the last line in the above-quoted text -  "A large-scale comprehensive study in idiopathic clubfoot patients is needed to validate these findings." Amen, I say. But when, and by whom? And I would add, in post-club foot patients, as well. Because if the findings are validated in histological studies and later confirmed through other types of studies with infants and children still in treatment, the one certain way to validate such a theory it to study post-club feet muscular degeneration. This would have the effect of determining what, if anything, might be done differently during initial treatments - surgeries, casting, bracing, etc., to reduce such degradation in future generations of people who live with post-club feet.

I urge you to go and read this paper, at least as much as you are able to. I will confess that once I got to the actual genetics analysis part of the paper, my eyes took on the look of a crazed cop who'd run out of glazed donuts. You can see the paper here.

Thursday, August 26, 2010

Prolo Check-in, and Other Distractions

It is now 5 days after my last prolotherapy session. The pain has almost completely subsided, about as long as it took after the second session. The knee is feeling much stronger, but its far too early to say anything about the effects on my feet, as we only just started that part of the process. I'll keep you all updated on the progress. You can also go here to learn more about prolo.

My shoe guy, Salvadore, is now into his mid-seventies. He just had to go in to have a portion of a lung removed (life-long smoker, unfortunately.) He's back home, and says he will start working again next week, but I don't know - I tried to tell him its time to retire, take it easy, but he's too dedicated to his customers, and not one of his five sons wanted to go into the business.

Anyway, I am coming to terms with the fact I need to locate another shoemaker, who is willing to work with me around my specific needs. And my preliminary search was a real bomb. You know, at one time, there were thousands of shoemakers in this country. Today, I think the number is in the low hundreds, if not less. Me, I'm gittin' old and creaky, so I'll probably squeak by. But all you youngsters out there? When the feet really hit the fan? I do feel for you - its gonna be tough getting the right footwear. As you can see over on the right hand bar, I am trying to constantly update and expand the Resources/Links section, to help respond to this impending crisis, but I need all your help in doing so. Please send me links to shoemakers, pedorthists, etc., who have helped you out. Maybe together we can keep them busy enough to hire and train more shoemakers. Do your part for the clubbies of the future!!

OK - back to work.

Sunday, August 22, 2010

Ouch. Get Centered, My Tuckus!

OK, so, yesterday, I did my third prolotherapy session, for my right knee. Only this time, we upped the ante - we also got started on my feet. Just the sinus tarsi on the left, but allover this on the right foot. Meaning, (hand swirling in large circles) ALL THIS. And I really thought I'd prepared properly, see? Fully loaded MP3 player and 4, count 'em, 4 dilaudids, whacky stoned, my spousal at the wheel. The doc LAID ON the lidocaine (ten million bees stinging all at once - fun. No, really.) But I tolerated it, yes I did. Looking at the lovely photo of some South Seas island on the ceiling, doin' that breathin' thing, blasting seriously cool tunes.

And then he started. Oh Holy Shinola. The worst session yet, 'cuz do boy was goin' DEEP. Especially in that old sinus tarsi. I have to be honest here - I screamed like an eight-year-old girl getting her first Barbie. And folks? No, over here, look this way - yep, that's right, over here! I did that about thirty times. Now, this was the most pain meds I've taken yet for these sessions, but maybe it was the humidity, or maybe my nerves are so seriously smacked that it's gonna take full-blown general anesthetics to go through another session like that.

Thing is, I know I'm totally over-enervated in those areas, so it should really come as no surprise. Maybe I can stop off at the dentist first, and get hit across the back of the head with a tank of nitrous. Wake me up when its over, eh?

OK, enough b-in and m-in - I can tell the therapy is having an over-all positive effect, so I am going to stick with it. But seriously, if I'd had a gun, there'd a been a bang, kids. I mean, I gave Jamie Lee Curtis a real run for her money, as scream queen. Poor doc. Musta thought I was gonna smack him.

Sure did WANT to.

Thursday, August 19, 2010

Aw, Quit Yer Complainin', Victim!

We definitely live in weird times. It is suddenly the habit of people who are somehow frightened of the "other", be it because of color, culture, religion, class, or, need I even say it, disability, to attack the particular group they are frightened of, and make that group the "problem," rather than being capable of seeing how their own biases are in fact the problem. Case in point: I came across this little gem on another disability web site, and thought it was a perfect example, so wanted to share it with you all:

"
  1. Louis Michael Mount Says:
    Maybe if you all started dealing with your disabilities instead of whining about them all the time there would be some progress. No one wants to put up with some self-entitled complainer who thinks everything should be done for them just because of they are different than everyone else."
     
So. "whining", "self-entitled complainer", "think everything should be done for them (us)". Oh, and "started dealing with your disabilities." Where, oh, where to start? Mr. Mount here thinks trying to change laws, public attitudes, medical community attitudes, etc., is "whining." Apparently this fella thinks that exercising our Constitutional rights is "whining." And that "thinking everything should be done for them" isn't just another way to spin our demanding having access to the same options as non-disabled people already take for granted. Self-entitled? Apparently Mr. Mount feels that he would be "self-entitled" if he demanded adequate care from the medical community? Or is it that using phrases like self-entitled is a way to show his own superiority, or to deflect by casting aspersions the fear he has of what - possible contagion? Or, just sayin' here, is Mr. Mount merely being a self-entitled complainer, himself?

And don't get me started on "dealing with our own disabilities." Just exactly does he think the disabled community should do - wait for folks like him to "grant" us equality? That we aren't dealing when we are working to change the system to make it more responsive to us, after eons of being swept aside, marginalized by the so-called abled community?

We are hearing ad hominem arguments and attacks like this in many corners of our world these days, whether its in response to charges of racism,   or in calling people who are struggling for their share of the democracy we supposedly ALL should benefit from victims. Hey, I don't see myself as a victim - if I did, I wouldn't be taking steps to make sure that isn't what I am in the eyes of the society at large. And I strongly suspect this is true of nearly every "disabled" person out there. These kinds of attacks and ignorant rants don't tell us anything about ourselves. Rather, they tell us volumes about the writer/speaker. Mainly they tell us that, but for the fact they have not as yet encountered similar obstacles, they have no ability to empathize with anyone who isn't exactly like themselves.  Of course, it is always possible Mr. Mount is a self-hating disabled fella, has been known to happen.

That's his problem, his "victim-hood" if you will. It is NOT ours.

Oh, by the way: "different than anyone else?" Is Mr. Mount simply saying anyone who isn't "like him" is "different?" And the last time I looked, EVERYONE is different than EVERYONE else. So Mr. Mount, unless you know something about clones, and especially can prove that's what we are, or, you are, well, different works for me. Just as its worked for the entire world since the very beginning of life on this planet. And, if everyone were "the same," then either you, Mr. Mount, would also have a disability, or no one else would. Either way, what difference would that really make?


Wednesday, August 18, 2010

Calling Clubbies All Over The World!

Now, I know you folks outside the US are looking at this blog (I have my spies!) but I'm apparently not speaking your language. You should note, however, the Translation feature over there on the right panel of the blog. The All Powerful Oz, er, Google supplies this little gem, so you one single visitor from Laos (yes, I thought it was you! How's it going over there?) might be encouraged to take another look, and in your own language! How's that for service?!

And on a similar note - I would really like to hear from folks with post-club feet in other countries, or even uncorrected club feet. This is a forum for all of us who are dealing with the effects of our syndrome on our daily lives, and to gain insight, support, and ideas for dealing with that impact. So please, do weigh in here. What resources do you have, what resources do you lack? What have you done to get relief? What would you like to know about resources in other countries, whether you are going to travel, or just to see what else may be available?

Come on in - we don't bite. That's over on the dental blogs. :-)

Monday, August 16, 2010

The Perils Of Gumbo-Meds, or, How I Stopped Worrying and Learned To Love The Hot Sauce

So yesterday, woke around five, and did my once-a-year Major Seafood Gumbo Par-tay - ten to fifteen different kinds of seafood, okra, file - the whole twelve yards. Oh, and Trappey's. It gots to be Trappeys Hot Sauce for it to be really gumbo-licious, ya dig? So, as I said, on my feet for hours and hours cooking, schlepping, hosting, serving, and wow, who woulda thought? Right about seven in the eve? Total foot crap-out, down like a pound-o-sox, hadda take mucho meds, still didn't do the trick. So, had more gumbo today, more Trappey's (oh, yeah) and I realize its maybe like folk wisdom (or malarkey?) but right now? Feelin' groovy, baby. 'Course, coulda been the Red Stripe. Just sayin'!

Well, it may not work for you, but either it did work for me, or all that seafood has me hallucinatin'.

Oh, no! I guess I've become a cheap drunk!

Discalimer: I ain't gittin' no cases of Trappey's for consideration of mentioning this total maximum flavor ride and back-o-the-head-blowin' goody, but if they suddenly discover this totally groovy review of their excellent stash, and have an unshakeable urge to ship me a lifetim supply o' this devlishly good stuff, who am I to tell them whhat to do? No, really! Who am I? Three bottles down, and I can't even remember what I'm doing right now. And what are YOU lookin' at? Darn pooch thinks I'm gonna share this wicked stuff with him! Ha! I say, Ha!

(Did I just say that out loud? Really? oops. Oh, no, is it all gone? Oh, the agony!!!)

Friday, August 13, 2010

Hammer Time

A fairly common accessory to most post-club feet is the hammer toe, and the claw toe. As both cause the top of the second phalangeal joint to press against the inside of the top of the shoe, the eventual results are callouses, corns, and blisters, oh, my! There are, as you might imagine, numerous approaches to relieving the pain these little beasties can cause, from chemical, to surgical, to mechanical. Let's take a look, shall we?

Corns are those especially resilient little meanies that have a "core" to them. That is, they grow outward from near the bone, well below the epidermal layers. This makes them especially difficult to get any long-term relief from without resorting to unconventional warfare. There are many so-called corn removal systems, some of which work better on some people, but not so well on others. It's pretty much a try 'em out for yourself situation. One of the problems with the chemical solutions is the need for constant repeat applications, much of which just gets rubbed off the surface of the corn as soon as you put your sox on.

There are of course surgeries to straighten toes out, but here again, these surgeries work in some cases, and not so much in others. Despite what doctors like to tell their patients, the fact is that each of us has our own unique way of responding to such surgeries. I don't advocate against them, but just know the outcome may not be what it's sold as. Certainly where the hammering is very extreme, surgery will offer at least some percentage of relief. But where there is less rigidity of the deformity, there are other approaches to consider first.

Whether corns, callouses, or blisters (which are usually merely a precursor to a callous,) the other factor at work in promoting the growth of either is pressure - shoe pressure, of course. When the deformed digit raises the toe/toes, they have a greater propensity to encounter shoe pressure merely because they are raised higher than adjacent toes. But there is another factor at work here - the pathomechanical action of the toes during the various phases of gait. This is especially the case where there has been an anterior tibialis transfer, as the toes are used to assist the front of the foot with dorsiflexion, that is, picking up the front of the foot as the toes leave the ground during the toe-off phase of gait. This action is necessary to prevent the toes from dragging, and to position the rest of the foot to prepare for the heel to strike the ground on it's next heel strike.

The result is what is known as extensor substitution - using a different set of extensor-group muscles to provide the motion either impaired or lost to the group normally assigned this particular task. We can observe this directly with people with multiple sclerosis - they have difficulty with their entire lower extremity anterior muscle group, and the one way they can get their feet off the ground is by using muscles all the way up in the hip and pelvis to do the job. So when the toes are made to do the job of dorsiflexion of the foot on the ankle, their superior, or top group of muscles and tendons get a real workout, far more so than their inferior, or bottom group does. This overpowers the inferior group, and hammering or clawing are an inevitable result.

There are two distinct mechanical responses that can offer near-immediate relief from shoe pressure, however. The first, and certainly most obvious, is to stretch the area directly over the offending digit. Here is a youtube video that offers some help on how to do this yourself:






Now, this video only shows you stretchers that are used to stretch the width of the shoes. There are other devived that stretch the height, and these open at the sides instead of at the top, as the video shows. So it's important you get the right kind. And those little bump attachments? Very important to getting targeted stretching in the right place.

The best and easiest tool to use for stretching the top of the shoe without affecting any other part of the shoe is to use a ball and ring stretcher: See this web page as an example (not affiliated with this site, nor receive any considerations from same.) The trick to stretching a shoe is quite easy - you need three things - the stretching tool, stretching fluid, and a shoe material that is in fact stretchable. Many man-made materials offer little or no stretching potential, whereas leather uppers are always a good bet. As for the stretching fluid - you can buy some, or, you can easily and cheaply make your own. Merely mix 50% water with 50% rubbing alcohol. Apply liberally over the top of the shoe. I suggest applying it over the entire area, so as to prevent a stain, that is, the edges of the fluid applied to the shoe may remain visible, so by applying it over-all, this seldom will occur. Rub the fluid into the material, then apply the stretcher you've chosen. If using the ball and ring stretcher, you can either set the clamping mechanism and walk away, or "walk" the stretcher over the broader area to prevent the appearance of a "bubble" raising the top of your shoe. It may take several applications of stretching to make the change permanent - many materials, even leather, has some level of elasticity, and wants to return to it's original shape. So be persistent. Because one other thing to consider with stretching - this reduces or removes the pressure over the offending area, and thus reduces the need or at least the frequency for future chemical assaults.

The second mechanical approach is to both stretch, and add rocker soles to your shoes. The rocker sole reduces the need for extensor substitution by helping supply that motion to the foot during gate. No, it doesn't change the muscular dynamics at play, but it makes the need for those dynamics reduce, sometimes by a significant amount. If the foot is achieving what it needs to during toe-off, then the compensatory actions of the toes are less needed.

Finally, if you intend on using chemical means to pair down the callous or corn, consider first soaking your foot/feet in warm water with epsom salts, to get the skin as soft as possible, then using a callous blade to remove as much of the hardened tissue as possible, before applying your chemical warfare. You'll get better long-term results, as the chosen chemical agent will be better able to get down closer to the root of the "problem."

For more info on this, visit here. The most important thing is, be consistent with whatever approach you use - you'll have much better results. For even better results, consider seeing your local podiatrist to get the whole process started. They have the knowledge for both diagnosing and treating, which is especially important with differentiating between a corn and a callous - critical to taking the right approach with direct treatment protocols.

And don't forget the bottom of the toe/s! The toe lifts at the second joint, but also drives the first (end of the toe) into the sole of the shoe, so you will also have to consider adding a depression in the shoe insert or the forefoot extension of the orthotics you have. In very extreme cases, I have had to use a dremel tool to carve into the shoes insole to provide this relief. 

Oh, and whatever you do, don't take that old Three Stooges approach. Don't try using another hammer on the problem:-)