Thursday, September 30, 2010

The Subtalar Joint, or, Everything You Never Wanted To Know About Where It Hurts

Ah, yes, the Subtalar Joint. Used to hang out there all the time, toss back a few pints, kick it with the hommies, play a little snooker. But then, it got too weird, ended up having to pay through the nose for a cheap laugh. Er, I mean, its that part of the foot of every clubbie that is usually the site of the worse pain. Looky here:


See this link!






So, the subtalar joint is the interface between your heel bone - the calcaneus, and the bone that sits on top of the calcaneus, called the talus. The talus is the bone that serves as the mortise of your ankle joint. The subtalar joint is the only joint in the body that moves through all three cardinal body planes, and thus imparts "tri-plane motion." This triplane motion is what permits the leg, and thus the entire body above, to rotate internally and externally against the foot while the foot is "pinned" to the ground. Without this ability, your other joints above the subtalar joint have to try and provide this same rotational component to your gait, which, most sadly, they cannot do. Its not that they don't want to - I'm sure even if you asked them nicely, they would have to hand their heads and tell you how sorry they are that they cannot aid you in your request. Its just that they are not "designed" to provide this kind of motion. Tsk.

So why do clubbies often have so much pain in this area? Two reasons, really. One is that due to our various surgeries and castings, we have a much narrower range of motion in our subtalar than does a normal subtalar joint. As we get older, this inadequate amount of motion begins to wear away at the cartilage of the joint, causing osteoarthritic changes, which increases inter-joint inflammation. And Voila! Pain.

Second reason - Due to those same surgeries, the various ligaments holding the subtalar together are compromised. Remember - they had to stretch one side (medial) and sometimes release (cut) some of those ligaments to get your foot/feet back into the so-called normal position. If you think about it, it means there was already damage done, even if for good reasons. Trauma cares nothing for motives - trauma is what it is.

This is why many doctors think a fusion is called for, because by stopping all joint motion, well, that joint stops hurting. Which of course is true, but... Remember what I said up there near the top? That this joint is the ONLY joint that provides this critical motion? And if you take away or limit that motion, then other joints will have to "take up the slack?" Except - there ain't no slack. What this means is that sooner or later (and mostly sooner) you have to look at a probable ankle fusion, then a knee fusion, and then, well, by then, your doctor is dreaming of giving you a voice fusion, ya dig? Essentially, you are trading one locus of pain for another. Just so you know.

This is why properly made foot orthosis and rocker soles can often slow the overall deterioration of the subtalar joint, by limiting the NEED for the joint to some degree, while permitting the gait to function closer to normal, while maintaining the subtalar joint as close to its "neutral" position as possible. This simply means to have the joint not at the end of its range of motion all the time. This can often allow you many more years of relative comfort. I say relative, because it is not a perfect solution. Its merely the lesser of two evils, in many instances.

I have had some short-term success having steroid injections in the subtalar joint, but I wouldn't recommend it for the faint of heart, or for the timid. It hurts. Like the blue freakin' blazes, let me tell you. They have to stick the needle quite a ways in there, and then the fluid has to push everything out of the way, and oh, criminy. Just one word of advise if you are planning on doing this - leave the gun at home. It's not considered polite to shoot the doctor.

I have noticed, over the years, that I get temporary relief by stretching and holding the foot back in the clubbed direction. Ironic, right? But this is one of the few ways to open the subtalar joint. Remember - the subtalar is at the end of its range of motion when the foot is maximally pronated, which is the case for most of us clubbies. By stretching the foot in a supinatory direction, you take the foot away from the end range, thereby temporarily relieving the constant pressure that causes the pain.

Of course, hot soaks, paraffin baths, hydrotherapy, hot tub jets, even ultrasound all can offer some temporary relief. But the goal should be to do whatever you can to get those puppies off their fully pronated thrones. So to speak.

We will be talking about this issue more in the coming months, hopefully with a couple of guest columns. Till then, try to stay out of the Fusion Bar and the Subtalar Joints. ya gotta cut back on the night life sooner or later. It is sure to catch up with you - ya ain't no spring chicken any more, right?

Saturday, September 18, 2010

An Offer You Can't Refuse - Well, You CAN Refuse It, But Why Would You?

Inevitably us clubbies end up at the doctor for something pertaining to our feet. And it is not all that unusual the doctor will tell you something that sounds like "well, your hornswoggle upsits is banging paltries with your shimaperatus, and doesn't look too good. You can either have three sessions of hotfreakinwhatsits therapy, or we can go in to do a series of tenopteratoron extensions, which may or may not result in partial or even permanent periastalsitic hemipleasia. Or, you could just wait and see how bad it can really get."

And you can either take this lying down, which trying to make sense of it is guaranteed to do to you, or you can demand a layperson's explanation, which may cause the doc to lay down and fall into a deep slumber, occasionally waking to ask for an ideal T-time. Or, you can take me up on my offer.

I am quite willing to act as an interpreter. Now, I don't speak Chechen, so if you're doctor is speaking to you in Chechen, can't help ya! But, in most other languages, I may be of assistance, with the aid of Google Translations, and my network of local orthopods and podiatrists, who I have trained lo these many years to speak in plain, simple, people-talk. And I will either post the translation here to share with all, if that is OK with you, or make it entirely between just you and me, totally private. Your choice.

Because I don't know about you, but when my doctor told me I was facing either partial or permanent periscoptic suprasemitic hairistalsis, it took me nearly a year before I could even leave the house.

Monday, September 13, 2010

Strange Goings-On Out On the Back 40

So it has finally happened. My shoemaker, Salvadore, has been forced into retirement due to poor health. He's had to lay down his hammer at the mere age of 80. Now, you might think I am being a little sarcastic here, and truly, I wish I could be, but this is actually Sal's attitude about the whole retirement deal - he wants nothing to do with it! This has always been my experience with the older generation of shoe makers - they usually drop dead at their "last." Its not because they wouldn't appreciate some well-deserved rest, no, not that at all. Its due more to two things - they never made so much money they could put much aside, and they are extremely dedicated to the happiness of their clients. You don't really see that sort of dedication to one's craft anymore. I don't really know if that's a good or a bad thing, though I tend to think its more bad than good. And that's not just because I am selfish about losing my particular shoemaker, though I am, of course.

Its also because, and really, folks, I never thought I'd reach the point in my own life where I'd say something like this, but here I go - its because those are the kinds of people who were my teachers, my mentors, and I think despite the reluctance of the modern world to have to actually get its hands dirty, there remains a noble and affirmative need for people with skill, craft, integrity to the product of their own effort. There is precious little remaining in our cultures that fits that definition. If I sound here like a fuddy-duddy, I will not apologize for it - I am only now old enough to understand the value we are losing, not in a trickle, but in a flood.

And for all the hateful talk about immigrants going around these days, I am proud to admit that each and every one of my teachers were themselves immigrants, who learned their craft in places like Italy, the Philippines, Guatemala, and Russia. They came here to build a better life for their families, they worked harder than anyone I have ever known in my life, and sadly, not a single one of each of these great craftsmen's children followed in their father's footsteps. Because there are easier, more lucrative trades and professions. Because their peers were headed in other directions. But, and this is where I think the difference is greatest between that generation and the last several generations, it was never just about money. It was about doing good by your fellow people, about creating something that would make a lasting difference in the lives around you. Nowadays, these just seem quaint, or naive ideas. Besides, they do that in China, right? Or Mexico? So we can all be wealthy entrepreneurs, or something, I suppose.

Anyway, I plan on buying Sal a case of his favorite drink, no matter what it is he likes, because he has done more than anyone I know to keep me upright and still able to walk. Even if it is with pain, its with far less than it would otherwise be. And its important, in my book, to thank a man like that.

Of course, I still have to find another shoemaker. But that's for another day. Right now, I'm hot on the trail of a special Philippino whiskey. I'm pretty sure he'll be willing to share.

Thursday, September 9, 2010

The First Talipes Beauty Contest!

OK, time for all those pretty Talipes Feet to come out of the closet - you know who you are!!! I'll warm up the runway with our first entry, lil' ol' me! Yep, I gonna bare it all, right here on the stage, so cover those kid's eyes, and get a gander! I urge as many entrants as possible to help us create a true gallery of Talented Talipes Peds. Come on, you know you want to bare it all - from the ankles down!

Left (or Liberal) foot, medial view

Right foot, medial view

Right foot, dorsal view

Left foot, dorsal view (note the dorsal fin, very useful for its natural habitat)
Close up, left foot, medial/dorsal view of surgical scar related to anterior tibialis transfer.

Well, our first contestant likes short walks any time of day, curling up with a good heating pad, and swimming in a sea of Tiger Balm. Ankle braces optional. He loves to dance, but is resigned to remain a mere butt-rocker for the rest of his days. He is anxiously searching for a swivel seat cushion to achieve his goal of breaking the Guinness record for number of hours butt-rocking to Motown tunes. Let's give a big hand to our first contestant, eh, folks?

Thursday, September 2, 2010

Swingin' the Club on the Back Nine

I had a conversation yesterday with a friend who had never asked me why I use a cane, and limp, and all the good stuff that must at some level make it obvious I am never going to be an Olympic contender (except perhaps in the consumption of a certain brand of dark chocolate......mmmmmm). And I, being the discrete individual I am known to be (yeah, by squirrels, maybe,) never got around to telling her about it. Sorta slipped my mind, I guess. So, I launched into a two hour diatribe about duck feet or something, and she was pretty polite about it and all. But eventually, she had to slap me and remind me I was caught in a overly-long digression, and even worse, I had repeated myself several times about the Magna Carta, or something. Mmmm, chocolate.

And I realized, its actually not that easy to explain post-club feet to the, well, uninitiated. You can either go the purely medical route, which always makes their eyes glaze over or, the over-done, boo-hoo, you mean you've never heard of club feet route, (which, if they are anyone of a certain age in the Bay Area, are quick to tell you of course they know about Club Foot, that totally hot orchestra that used to play wild music at the silent film festival, right? Yeach. You see my problem?

And to top all that off, how do you explain the whole deal, and then add, "oh, and each clubbie has a slightly different experience, depending on...things." And now ya gotta try and explain the "things," and man, by the time you're done, you swear the next time, you'll just tell them is an old war wound. Just to keep the conversation somewhere under fifteen minutes, so there's time to move on to, "Hey, did you see the new release of Avatar?" What, you think I want to talk about this all the time? Sometimes I like to talk about the first quantum moments after the Big Bang and how string theory makes it so much easier to understand, or maybe, how a hawser from the Titanic is different from a slipknot on the Andrea Doria. (Sorry, goin' sideways here.)

Actually, the best explanation I've come up with so far is to ask the person to imagine the ancient game of golf, back in prehistoric Scotland, when they still used those briarwood clubs that, well, actually looked like clubs! And then imagine those on the ends of your legs, and that buying Ferragamos was never going to be on your bucket list. And now, imagine a bunch of doctors basically thinking of your feet as Play Dough, and how they pull, and stretch, and slice and dice and stitch, and cast and brace, and do it some more. And finally, they tell you, "OK, Sally, out you go! You are pronounced normal. Buck up, and have a grand life. See ya!"

Of course, if they still don't get it. I just take off my shoes. The record so far is five point five seconds before the screams erupt. The doctors who see them never make it past two.

Man, I do need a scotch. And some chocolate. Mmmmmmmm.

Wednesday, September 1, 2010

Rockin' All Over The World, or at Least, Your Feet

A recent off-line communication with a visitor here gave me the opportunity to write up a little help file, as it were, for directing your pedorthist or shoe person on how to build rocker soles specifically for you, as opposed to some generic design, so here goes:


If you also need a lift:


If you are going to a custom shoe maker, ask them to put most of the lift inside the shoe - it makes for a more stable lift. You should also ask them if they understand rocker soles. They may understand them generically, but that is not the same as their being willing to work directly with you on the proper shape for you. This is an important distinction, I cannot stress it enough. You will have to be willing to spend a few hours during the final fitting stage. They need to create the midsole rocker, and leave the final sole off, until you test the shape, and allow them to make modifications until you both get the right shape. Here is what you want to achieve:

A real heel - rocker, that is

Your heel should be able to strike the ground as softly as possible, so the rear rocker angle cannot be too steep, nor too shallow, and should become level no sooner than, nor later than, the center of your heel. The shoemaker/pedorthist needs to see your stride length - this is important. The shorter your stride length, the shorter the length of the rear rocker, and the shallower the angle. By the same token, the longer the stride length, the reverse is mostly true. I say mostly because there are exceptions, especially where the foot has more limited range of motion. If you have had a fusion, the rear rocker shape and length is very critical, because it will actually have to substitute for the motion your fused foot can no longer provide. So - test, test, test, before they put on the final sole. Its shape should allow your foot to essentially "roll" onto the midfoot, with no sensation that your foot is "slapping" The idea is to reduce both shock and foot slap, that sudden motion right after the heel touches the ground, and then pitches the rest of the foot forward. The correct shape will also reduce stress on the knee.In the case of a fusion, it should also reduce that motion from point of contact all the way to full foot loading. That is, when the foot is fully flat on the ground, with neither the heel nor the toes moving.

Moving forward, and kick!


The forward rocker should be gradual, but steep enough in height that it allows your knee to naturally bend as you move toward toe-off. There should be no sense of your foot stopping just before it leaves the ground - there should be a smooth, fluid motion. The angle of the initiating point of the rocker, across the ball of the foot, needs to be no more than 15 degrees off the straight line of motion of travel (pointing straight ahead). If your feet naturally splay outward, that is, they are in an externally rotated position compared to the direction of travel, the rocker angle needs to not interfere with your leg and foot's actual angle of travel, or you will start having knee issues. And the actual point of initiation of the forward rocker should be just behind the line drawn between the center of your first and fifth metatarsal heads. The more outwardly rotated your leg and foot are, the more the shoemaker or pedorthist needs to move the medial point of the forward rocker further behind (proximal to) the first metatarsal head. The idea of the forward rocker point is to initiate heel-off just before the foot would do it naturally - not a lot before, but just before. This will eliminate the tendency to hyper-extend, or lock, your knees.

Your experience with a rocker sole should make walking seem far less effort than before. They can help reduce shock, and joint motion, and will help you get longer life from the shoes, as well, because they help distribute the weight more evenly as you walk.

And remember, you should have a rocker on both shoes, because otherwise, you will start having issues with the longer limb, or the non-post-club side, for you uni-lats out there, as well. So the lift must be in addition to the height of the rocker sole. Plus, it makes you taller!

If the shoemaker is reluctant to work with you on this, you may need to find another. Or, take the finished shoes to a qualified pedorthist to have them appropriately modified. The correct design of the rocker makes all the difference. If anyone tries to tell you that a "rocker sole is always the same shape for everyone," slap 'em with a cold fish, and keep on truckin'!

Finally, I will be getting some photos and drawings out of deep storage in the next week or so, and will post them below this article, so check back often. And consider making a copy of this post to take with you to your shoe folks. Don't worry if they get offended - its better for you to be certain they do it right!