I've Had It - They're Coming Off!!!

I really can't take it anymore - the pain, the frustration, the humiliation. I've tried to work through this for years, but I've finally reached the end of my rope. Hell, I've even thought of using a rope! Or worse. What could be worse than rope, you ask? Fire. Fire would be bad. It would really hurt. So, no fire. Or can you imagine, water? Deep, cold water? Me either. Bbbrrrrr.

No. I am going to do it with surgical precision. A scalpel, maybe some local anesthetic. Or not. Depends on how bad I want to remember the experience, what's it to you? Sorry. I'm just a little nervous around needles and stuff. Forgive me.

But I try to stay focused on the upside. Soon, it will all be over, and then, bliss! I won't ever again need to explain it to strangers, or excuse it with friends. I'll be able to regain more social activities, instead of always avoiding crowds. I may even be able to smile for the cameras once again. I understand I used to do that, when I was young. But I am not young. Not anymore. I have a sister who's young, and good for her. Or maybe I am already too damaged psychologically by all these years of dealing with this horribly deforming facet of my life. If that's the case, well, I already have a well-stocked wine cellar, so I can tell the whole world to just bug off. And I'll do it, too, believe me. But only if it comes to that, I promise.

Mostly, besides getting rid of the pain, I look forward to mounting the buggers on a wall plaque after the surgery. The doctor already promised me, and even suggested I have them bronzed. I thought that might be a little over the top, but I'll be happy to keep them on my desk in a specimen jar. Like a butterfly, or a frog. My wife is a little sickened by the whole idea, but she is glad I'm finally having them cut off. They were really starting to bother her. Or rather, all the grief they were causing me, that's what was bugging her. She just got tired of my years of complaining.

So, I go in next Wednesday. It's well past time - all the other so-called solutions didn't do anything to alleviate the problem. I tried soaking them, taping them, even using every over-the-counter remedy known to drug stores. Nada. Zip. So, enough.

Those damn nose warts are coming off!! Yeah!







You do know what day this is, don't you?







April 1


What, you thought I was talking about my feet? How would I ever be able to dance again?

St. Patty Sent Me. No Wonder I'm Feelin' Green!

Around the gills, I presume, at least by tomorrow morning.

Well, those heel spurs I was talkin' about? Got 'em. Bad. Hurtin' puppies. Real bad. Seems my shoe balance got off just enough, so back to the shop, and up on the hoist I go. Well, my shoes, at least. Did I say my doggies was screamin'? No? Well, they most certainly are, Ollie. And did I mention...sorry.

But see, the real downside for me isn't merely the heel spurs. Its what else they visit upon me. Namely, a subluxed cuboid. Now, I realize that sounds like some kind of an exotic drink one might order in Belgrade, but that would not be the case. Your cuboid is called thus because of it's shape, which is, well, cuboid. You know, like a cube. And not unlike a cube, its surfaces are not very, uh, shapely. I mean, they are just plain, uh, plain. Flat, for the most part. And why, you ask, is that interesting at all? Because the surface of a bone where it meets another bone, i.e., where it is a part of a joint, is defined in many ways by how its shape interacts with the shape of the articular surface of the bone/s it forms joints with. Articular, because it moves, that is, articulates. If the shape of the articular surface is well defined, then the motion it makes within its joint is both controlled and limited by the shapes of both bone's surfaces.

The cuboid, however, is very smooth, compared to other bones in the body, and it articulates with the calcaneus, and with the base of the fifth metatarsal, and with the lateral cunieform bone, in the mid-tarsal area. But it is the articulation with the calcaneus that is most vulnerable to subluxation, which is just a big word for dislocation, which is exactly the same number of letters, but who's counting? Now, once this bone subluxes the first time, it can do so again with greater ease on subsequent occasions. Which mine, apparently, tend to do, and which they are doing right now. Hugely so.

Allow me to describe the feeling. Let's just say, if I could have a choice between this and a root canal, I'd take the root canal. Because at least you know when its going to be over. The only good thing I could say is, I wouldn't hesitate to wish this upon Quadaffi. Maybe Donald Trump. But that's all. OK, maybe that guy who does the duck for that insurance company.

But not you. Oh, my, no. No, no, no.

What a Heel! Or, as Frank Zappa Once Sang, "Owie-Zowie Baby!"

Heel spurs are not what cowboys wear, lets get that straight right at the git-go, shall we? They are nasty little nippers that plague the gentle minds of men and women who, by simply rising from their place of rest and contentment, step into a daily world of pain and useless invective against gravity, or against whatever and whoever they encounter first that day. Essentially, they hurt like the bloody blazes.

There is of course some disagreement whether it is even proper to call them heel spurs, unless an X-ray shows an actual bony spur at  the insertion of the plantar fascia on the inferior surface of the calcaneus. This is because the location and the pain are often referred to as plantar fasciitis. Both have strongly associated symptoms and even the (non-surgical) treatments are similar. In plantar fasciitis, the sheath that the fascia runs through, allowing it to slide/glide as it shortens and lengthens becomes inflamed, causing that smooth motion to "bind," thereby causing even more inflammation, and, well, pain. No nice way to say it, is there?

The pain from plantar fasciitis is often focused near the insertion on the calcaneus, though sometimes it can radiate distally to the entire fascia. When the plantar fascia is especially tight, something that can occur for a number of reasons, like for a woman who wears heels all day, then takes them off late at night. Without a sufficient equivalent amount of time spent walking, and thereby stretching the plantar fascia, the fascia remains tightened throughout the night, as the feet are in a position of rest, sometimes amplified by the blankets weighing the feet down sufficiently to reinforce that relaxed position. Upon waking, the feet hit the floor, and suddenly have to stretch the fascia to it's fullest. One of the prominent symptoms of both plantar fasciitis and heel spurs is "first step" pain. And boy, do I mean pain. Nail driven at high velocity into flesh and bone about approximates the sensation, I'd say.

If an X-ray reveals an actual bony spur, surgery might be required, but there may be alternatives. The same with plantar fasciitis. One of the more unfortunate surgical "solutions" is a plantar fasciectomy, that is, removal of the plantar fascia. Get many second opinions before taking that route. Any surgical solution should only follow a complete exhaustion of non-surgical approaches.

Two initial approaches would include stretching, and ice massage. Stretching means both active and passive stretches. Active includes basic Achilles-type stretching, as this by extension causes the plantar fascia to stretch, as well. Seated on the floor, doing stretches with therapy bands is also suggested. Passive stretching means using something that will keep the forefoot dorsiflexed on the rear foot while you sleep. This usually requires a night splint device (there are many brands, some quite affordable,) that keeps the plantar fascia on stretch all night long. Talk to your podiatrist or orthopedist for suggestions on these.

Ice massage is quite simple - put an ice cube into a small plastic bag, slather some foot creme on the plantar foot, and gently rub along the length of the plantar fascia for ten to fifteen minutes two or three times a day. Any source of ice - cubes, packs, etc., will do, but the real trick is repetition, to help bring down the localized inflammation.

A simple palliative solution to get you through all the other therapies with at least minimal pain is a heel donut or U-pad. This is simply a somewhat firm pad with either a hole cut into the center, or cut into a U-shape, then placed inside your shoe or shoes (these things do sometimes occur bi-laterally,_ which will reduce direct pressure on the area around the insertion point. In very extreme cases, an additional pad of the same thickness (1/4") will help by raising the heels enough to prevent the plantar fascia from stretching fully on each step. But remember, these are merely palliative, and should not be used as complete solutions. Again, work with your doctor on such measures.

Just remember, whether heel spur or plantar fasciitis, you need to work to stretch regularly and properly - no "bouncing," - long, slow, and regular is best. Try to use lower-heeled shoes (gals!) and stay away from really hard heels, like leather or wood, which will help reduce heel impact to some degree.

Nobody likes to be all owie-zowie, baby!

Ch-ch-ch-changes!

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Hey, You! Yeah, You - With the Fat Pad!

One of the things I love about biomechanics and anatomy are the various terms used to describe things - motions, positions, body parts. The language is quite rich, and sometimes a bit strange, And sometimes, the words are perfect for what they describe.

Take "fat pad," for example. The term "fat pad" is used to describe the soft tissues on the bottom and sides of your heels. It is actually largely fatty tissue, and it does serve in fact as a pad. Without it, your heels would be mighty pointy, and barefoot walking would be, well, painful all the time. But good old evolution gave us some cushion in the appropriate places - bottoms of feet, and, well, bottoms, in general.

Sometimes, however, this fat pad starts to break down. It can occur for a variety of reasons, and not all are associated with weight gain, which would be an obvious cause, of course. It may merely be poor biomechanics, especially inversion or eversion of the calcaneus (heel bone.) This causes the impact, or strike forces exerted on the heel to be unbalanced. That is, the forces are less equally distributed. Over time, shorter if accompanied by weight gain, and longer, well, just depending (on the degree of pathomechanics,) the fat pad becomes "displaced." This doesn't mean it has to seek new lodgings. It merely means the tissues break down around the center of the point of impact, and "redistribute" itself toward the outsides of the heel. This becomes more noticeable as one gets older (logical - you've been smacking your feet on the ground longer, ergo...)

There are, as you may suspect, several consequences (thought you'd get off easy, did you?) First, and most obvious, pain, often chronic in and around the calcaneus. There may also be pain around the insertion of the Achilles tendon at the posterior aspect of the calcaneus, though that could be caused by a number of things. Also, a displaced fat pad makes success with orthotic therapy more problematic, as the device has a harder time controlling the calcaneal position during all the weight-bearing phases of the gait cycle.

And one of the other issues that is nearly certain (just hedging this a little, eh?) is the development of calloused tissue around the border of the heel where it rests (well, it doesn't really rest, per se. More like works against,) in the heel cup of the orthotic, which, if not attended to over time becomes thick and hard, then the sucker dries and cracks, and oh, hell, hurts like the blue blazes (invest heavily on a good aloe-based foot cream, and use liberally.) But a deeper heel cup on your orthotic can help alleviate that issue, to some degree. It can also aid the foot in staying properly centered on the orthotic, so you can get the best effect from their use.

And talk to your podiatrist or othotist/pedorthist for other suggestions on dealing with issues related to your fat pad - they can help deal with the issue in numerous ways.

Now, isn't that more about the fat pads than you ever wanted to know?

What? You thought I was talking about that totally cool phat pad owned by P. Diddy?

The Upshot, The Downlow, and The Whole Shebang

I was thinking today (not yesterday, though. It was a holiday for me,) that we clubbies, like most folks with handicaps, have a requirement the non-handicapped don't ever need to face. It's hard to imagine living without the constant reminder of our handicaps. For some, its the chronic pain. For others, it might be the social stigma. Or employment discrimination (it might be illegal, but who really pays attention to that, I ask you?) But whatever the primary focus, it just doesn't often happen we can go a day or so without being reminded of our limiting factors.

It was only when I was trying to explain to my sig-other about how the pain factors in to just about everything I hope to do in life that I could see the true distance across this divide. She, for example, thinks absolutely nothing (well, not exactly true - sometimes she thinks only) about going into a shoe store and freely obsessing over the latest John Fluevogs (I couldn't begin to describe them - look them up,) and then coming home to help her drool over them. Which is where I fail as a husband, I suppose. My shoes, after all, cost waaaaaaayyyyyy more than hers, and they don't come from a store. They come from my long-time colleague and fellow shoemaker, Sal. And I usually have to save up for six months to afford them.

You are probably wondering about now why I am going on about shoes, using it as an example of the divide between us handicapped and those nons. Its like this. Sal, bless his hard-working heart, has the Big C. Just couldn't stop smoking. And then there is the adhesives and dust inherent to the trade. And even though he has insisted on continuing to work, he has finally set a date-certain for retirement. I just gave him a deposit on what will be the last pair of shoes he will make for me. In six months, I need to find a new shoemaker. One that "gets it." One within a five-hundred mile radius, hopefully.

My wife just goes to the local malls and such. So she doesn't get how this is not merely a story of Googling for an answer. It's much, much harder than that. It takes an awful lot of mind-time, and really stokes the old anxiety boiler, ya dig?

I'd rather be shopping for a brain surgeon.

I think my wife hopes I find one.

Home on the Range of Motion

Range of motion is the term used to describe how many degrees of motion are available to any given joint. As there are many types of joints, each has an "average" range. However, many of us fall outside these averages, either with excessive motion, or severely limited motion. Joint motion is usually described by the degrees of motion available in each of the various cardinal body planes - frontal, transverse, and sagital - frontal (or coronal) slices the body front to back; transverse (or horizontal) slices top to bottom, or cross-sectional' sagittal (or antero-posterior) slices side to side.

Joints move both in a plane, or planes, and through a plane or planes. For example, your leg swing moves through the sagittal plane, but in the frontal plane, and to a lesser degree, the transverse plane. Most joints move in one plane and through two planes, but several move through all planes, and in multiple planes, as well. Shoulders, hands, and more to the point, feet, and several of its joints, occupy this other category. Most notable of all is the subtalar joint, which moves in three planes, and through three planes as a result. And of equal importance is the quality of motion available to each joint. Whenever a joint is inflamed, or in pain, its quality of motion is impaired.

But why is this important for clubbies to understand? Stay with me over the next few days as I go deep inside the subtalar joint, and what it means to you and me.

To Share is to Dare

This is a general post sharing a prior comment I responded to, because I think it is useful for all clubbies to keep in mind:

Ah, the tight Achilles - that kid always did drink too much (Trojan pun.)

We clubbies have tight one's to begin with (why couldn't we just have tight buns, instead?) The lengthening is actually a response to just that. But, and this is a critical "but", the fact they were lengthened does NOT mean they are no longer tight - quite the opposite, in fact. So, we need to be doing several things more regularly than non-clubbies need to.

1. Achilles stretches. There are many ways, but regardless of which style you use, there is one thing you MUST NOT DO! Bouncing stretches - these can cause micro tearing at the tendon insertion (where it attaches to the calcaneus.) Do your stretches slow and hold. Try to do them at least two different ways: the "push the wall" approach, and the "grab the toes" approach. Both have the added benefit of helping stretch your hamstrings, helping the Achilles by aiding the hamstrings in doing more of the work on extension (when the foot is maximally on the ground, just prior to the heel coming off the ground, is the point of maximum extension of the leg.)

2. If the Achilles is particularly painful, do ice massage before stretching, and after. Just use an ice pack and rub it along the lower length of the Achilles and especially around the insertion into the calcaneus. Helps to use a little skin lotion, to help the ice pack "glide" across the skin.

Take it slow - don't rush to achieve maximum stretch at the beginning - work your way up as the weeks progress. And it is very helpful to incorporate these stretches as a life-long part of your workout, because tendons are somewhat elastic, and have a tendency (no, not a pun,) to shrink back if you stop working at keeping them supple.

As for surgery? I'd try the massage and stretching for a while before thinking in that direction. You might even want to see a physical therapist for more focused exercises.

One more thing - in the worse case scenario, consider wearing slightly higher-heeled shoes for a while - this prevents the Achilles from stretching all the way to the end of its range, so you aren't hitting the pain point with every step. BUT! Don't use that as a substitute for the stretching - do both, and eventually you can go back to lower heels. And if you are wearing high heels all the time? Well, that's how they tend to get tighter. Let me explain:

Our shared condition is called "talipes equino-varus." Let me break that down - talipes - feet; equino - horse-like; varus - the direction the soles of the feet are pointing, or bent in. So, "equino" (not like wino, by the way,) means that the heel cannot reach the ground, because the deformity prevents it doing so. (Named so because a horse's foot appears as if the heel is up in the air and the horse is walking on it's toes.) There is another condition called "acquired equinus" meaning the foot, having been in high heels for many years, has shortened the Achilles to such a degree that the foot can no longer place the heel on the ground, and the person so affected walks on the balls of their feet. This same deformity occurred in the past among women in China whose feet were bound, resulting in what was known then as "lotus feet." Very painful, I can assure you. (Although, weirdly enough, it was considered sexually alluring - go figure. Plus, women whose feet were bound could not walk on their own - they were either carried in a chair, or were held up on both sides by servants, creating what was called a "willow walk" due to the fluttery gait so produced. I actually made a pair of shoes for a very elderly Chinese woman whose feet had been bound as a child. Sad. It was usually only done with women from wealthy families, which makes sense - somebody would have to pay to carry them around everywhere. Like all those limos in Hollywood, eh?)

So, what does this mean for clubbies? Regular wearing of high heels can actually shorten the Achilles over time, thereby potentially reversing all that surgery done to you as a child designed to lengthen them. So even if you go and have another surgery to lengthen them again, you won't be doing yourself much good if you put them right back into the high-heeled shoes.

But we gotta be sexy somehow, don't we? :-)

Gait Analysis Primer, or, The Way She Wiggle and the Way She Walk

The word gait refers to the act and action of walking, running, and other forms of upright ambulation, particularly how each body segment interacts and affects the other parts of the body, giving each individual their own unique "walk." From issues such as alignment, speed, and hip/pelvic travel (side-to-side), we can begin to understand where pathology may be hindering effective ambulation, from mere performance-related concerns, to significant pain and impairment.

When we put one foot in front of the other, a whole complex of muscles, nerves, ligaments, tendons, and bones and joints must work in some kind of harmony in order to move that foot ahead of the other foot, then repeat, over and over, thousands of times a day. The fact that we do ambulate in an upright manner makes it far more complex - bi-pedal stance is far more impacted by gravity than quadripedal is. Some have described human gait as the act of constantly falling forward, but always (mostly) catching ourselves in time, then repeating the process. There is some truth to this, but its actually quite a bit more complex than that. Gait analysis is the art and science of studying and refining this complex process with the aim of improving the outcome for the given individual.

In order to get a taste for how this works, try this the next time you are in a public place where many people are walking around. Select any other person at random, and position yourself to walk behind them for a block or so. And no, I am not promoting stalking! Stay back a minimum of twenty feet. Now, watch the way the person walks. Start at the level of their feet - what kind of shoes are they wearing? Shoes always influence our gait. High heels have the most significant impact, so you need to realize from the start that any gait analysis is usually done with the subject in their bare feet. Watch to see whether one foot appears to strike the ground or leave the ground in a manner different from the opposite side. This takes practice, but that's what we're doing, isn't it?

Watch to see if the heels of each foot "bounce" a little after the heel strikes the ground - this is often, though not always, a sign of a tight Achilles tendon. Observe how the feet are pointed in stance - are the toes pointed in, or out, or fairly straight ahead? Each of these possibilities impacts the over-all gait in different ways.

Now, go up to the hips. Does one side appear to move further to the side than the other during the same phase of gait? Does it rise more? Again, each of these may be indicative of some type of pathomechanical issue.

Move your gaze up to the shoulders - does one appear higher than the other? Do the arms swing the same amount, or even the same angles? Then the head. Does the upward movement that occurs as the heel of each side leaves the ground appear even, that is, the same for each side? Or does there appear to be a difference, and even a head tilt to one side?

OK. Now, try the same thing for people walking towards you. Make the same observations. Are you beginning to see the scope of this art, even a little? It takes a lot of training, and a lot of practice. The high tech tools that are often used for gait analysis offer deeper insight, but the core knowledge of gait analysis remains the training and skill of the clinician.

Next time, I'll expand this topic by looking at some of the specifics as they may apply to us post-clubbies. Until then, just explain to your significant other that when you are watching someone's hip motion, it's in the cause of science. Bet they've never gotten that excuse before!

Welcome, 2011! Care to Dance? Mind if I Limp Along?

I don't know about you, but I need a vacation from my vacation! Waaaayyyy too many things to do during the holidays, and insufficient will to do them with glee. But I regress...

Been limping a lot more than usual, lately, and it brought back fond memories of when I did a lot of gait analysis. Limping is much more than a sign of pain, you see. How we limp is one of several indicators of our overall pathomechanics, and can act as a signpost for the central cause of the limping itself. Of course, when we limp because we just stubbed our toe, there is little left to discover! But the case with us clubbies is seldom so simple. We may have a limb length difference (more common than you may imagine,) or the biomechanics on the left differs from the right, and the limp is a response to that difference, which may be the cause of the pain that brings on the limp. This is why it is so important to have your gait analyzed by a good biomechanist, because the real cause may be harder to pinpoint than you may suspect. Limps can arise from knee and hip/pelvis issues as much as from foot issues, and some limps are the result of neurological deficits, or, insults as they are described, such as stroke, or some other disease or accident-induced trauma.

I will be doing several posts in the coming months on this topic, focusing on specific kinds of limping and other clear pathomechanical signals that may arise from post-club feet. Stay tuned.

And Happy 2011!