This blog is focused on issues relating to adults with post-club feet. It has links and articles and surveys to help adults with post-club feet get the answers they've long been denied. We will not shy away from controversy, and may in fact get some dander up - so be it. There may be occasions for humor, and art. We do need these things, do we not?
You may recall my post about issues related to deterioration of the muscle tissues in the gastrocnemius and soleus muscles, the muscles that comprise the calf. That there seems to be a correlation between the muscle atrophy associated with club feet, and subsequent changes later in life. Well, it appears such tissue atrophy also occurs naturally, as this abstract reveals. But it still doesn't fully explain the differences found between (otherwise) healthy individuals, and us post-clubbies. And since the only current studies related to this tissue issue appear to be done vis-a-vis cadaver studies, I suspect none of us really wants to wait for our own chance to contribute to such studies, if we have to wait that long, and be in that bad of a condition just to make it in the study. I know I don't.
It seems to me an excellent study could be accomplished through simple MRI comparisons. Recruit as many post-clubbies as you can to first have an MRI done bi-lateral lower legs, centrally focused on the calf region. Add to this circumference measurements at one-inch increments from the center of the knee to the medial malleolus (that knob on the inside of your ankle,) every one inch, bi-lateral. Finish it off with a surgical history re: club-foot Sx, and type/number of castings used for your "correction." Oh, yes - age - gotta have that, and maybe sex - we all like sex, don't we? You don't? Oh, sorry.
Now, this study would show prevalence, degree, and age/sex relationships against degree of tissue deterioration. This could then be cross-compared to the results in the above-cited study by Fujiwara K, Asai H, Toyama H, Kunita K, Yaguchi C, Kiyota N, Tomita H, Jacobs JV. in:
Changes in muscle thickness of gastrocnemius and soleus associated with age and sex.
So, any grad students out there looking for a dissertation topic? You come forward with your interest, and I'll help you recruit subjects. The nice thing is, this can be done as a collaborative effort with local orthopedists and podiatrists who already see such people who would qualify as subjects.
Rough week. That last prolo session took a bit longer to recover from, mainly because we covered more ground, er, body surface area, I mean, that we did in prior sessions. So mostly I've been feeling totally arthritic - stiff back, knees, feet, shoulders, blah, blah, blah. If I'm sitting for as little as ten minutes, I creak when I stand up. Not too promising, ya dig? But I shouldn't really complain (well, maybe just a little) because I'm still working, still thinking, still doing my best to avoid all the hoo-haa in the nasty-political-shenanigans arena. Wake me when its over, please?
I met a young woman recently, who asked I not use her name, whose club foot has caused her great anxiety over both her mobility/activity levels, and her fashion-quotient. Athletic shoes do not make it at the clubs these days, apparently. (How did it come to this, where I hear words like "the young folk," and "what the kids like these days" coming out of my own mouth? Sheesh. Completely over the hill, I am.) The gals like them shoes, 'cuz they know the boyz gonna dig 'em. And honestly? I have no answer for this particular dilemma. When I was still making shoes, I lost count of the number of women who would say something along the lines of, "I simply cannot wear anything with less than a three-inch heel."!!! And when I'd point out it was those three-inch heels (not to mention the 4, 5, and 6 inch variety) was more than likely the cause of their current uglified feet - all gnarly and arthritic, and pre-shaped for the pointy toes, well, they'd spit their snake venom in my eye and shout, "Just make the damn shoes and stop telling me what I want."!!
Now, they did have a point - it wasn't my place to tell them what they wanted. But, it was my place to tell them what they were likely to get, being that it was in fact their spiky pumps that made comfort highly unlikely. Women most often buy shoes for the imagined sexy punch it will give them over the competition. So much so, in fact, they seem willing to bear almost any pain or discomfort in service of that imaginary happiness. There's even a name for this "condition," - Algolagnia: sexual pleasure from pain. Note that this is different (albeit perhaps only in degree) from masochism, which is defined as the recurrent urge or behavior of wanting to be humiliated, beaten, bound, or otherwise made to suffer. So we can note the "bound," and the "made to suffer" as being the primary parts of algolagnia, with the added notion of sexual pleasure. Now, it might seem silly to make such a point of this - after all, how could something that brings pain (high heels, pinched toes) also bring pleasure? Well, if you are in fact a masochist, its a no-brainer. But for most women, the pleasure is not direct sexual pleasure, per se, but indirect, as the sight of those delicious little black pumps bring the requisite associations to mind, and thus, to the cash register.
So, let me explain the physics involved. Essentially, its plain old Archimidean plane physics - the incline plane, to be exact. If you stand on a hill, you will eventually slide downhill. Placing the foot in this kind of relationship to the ground requires the means to hold the foot in the most stable position on that "hill," which means narrow, pointed toes, to hold the foot back, and keep the heel of the foot within the shoe. The higher the heel, the tighter the toes - you really can't have it any other way, at least for the pump. Now, add laces, and you can make the toes wider, but laces are, well, let's be frank about it (unless you name is Joe) - laces are patently NOT sexy.
But for us clubbies, we either come to terms with not being sexy, or redefine what that actually means, and how we want to express that part of our very human nature. Because, like I told this young woman, you want to run the marathon of your life - that is, keep active for the course of your natural years allotted - you better stay away from steep hills. Lots of "sensible shoes" out there now look pretty damn hot, ya ask me! She just needs to quit worrying about emulating the Brittany crowd, and shoot for the Burning Man milieu.
So, took a look at the visitor standings for this bitty blog, and was mildly surprised by what I found:
United States (US)
642
United Kingdom (GB)
125
Germany (DE)
20
New Zealand (NZ)
19
Ireland (IE)
16
Canada (CA)
14
South Africa (ZA)
13
Australia (AU)
8
Norway (NO)
5
India (IN)
4
Singapore (SG)
3
Philippines (PH)
3
France (FR)
3
Korea, Republic of (KR)
2
Russian Federation (RU)
2
Denmark (DK)
1
Finland (FI)
1
Netherlands (NL)
1
Greece (GR)
1
Lao People's Democratic Republic (LA)
1
Vietnam (VN)
1
Israel (IL)
1
Pakistan (PK)
1
Italy (IT)
1
Switzerland (CH)
1
So first, let me thank Hillary in Switzerland - good effort, but maybe tell a couple of friends about us. In lieu of that, you can send chocolate (I am always running out of chocolate.)
And I must admit to some surprise at finding the Lao Republic chiming in, though not in any real numbers, of course, but remember, you CAN click the Translate link at the top right and get all this juicy clubbie stuff in the language of your choice. We are strictly multi-cultural here - club feet do not recognize artificial boundaries.
And Greece? Just one? Come on, you supplied us with our own club-foot god, Hephaestus. Surely we can get a bigger showing from you folks, can't we?
Nice to see the Russian federation going neck and neck with Korea. We're pulling for you, folks!
And finally, a special shout out to Finland. Love the vodka, people! Nice bottle, too!
So to all you worldly clubbies out there, spread the word. Especially you, Switzerland. You don't want to stay in that bottom slot too long now, do you? Think Matterhorn, think Alps. Just don't expect me to climb it - I'm lucky to make it up a few flights of stairs, these days.
OK. been a mite quiet lately from this side-o-the-fence, many good excuses, but why bore you? You aren't a tunnel, after all, are you?
So yesterday I do the 4th installment of my prolotherapy. Most painful one yet, because I took less pain meds that I should have, so my fault. But now I know with great certainty I am NOT a masochist. No way in hell do I get any jollys out of that. No siree. But now, my doc and me? We're on first scream basis. No more of those icky formalities - we just jump right in there and stick those needles where they most want to go - straight through your lowest pain setting.
Seriously, we are continuing to go deeper into the sinus tarsi region, and also along all the original surgical scar areas. Did I say tender? Oh, my. But hopefully, when the initial inflammation subsides, (two-three days or so) I'll begin to see some distinct benefits, I'll keep ya'll informed!
Heads Up
Once again, I implore each of you to pass this blog on to others with post-club feet. I know there are lots more clubbies out there, but I also know how many clubbies want it kept secret, like thats gonna make things any easier. I mean, come onnnn! Hasn't ever worked before, and I doubt very much it will ever work at all. So send 'em on in - we don't bite!
In our last encounter, faithful reader, we spoke glowingly about the Subtalar Joint. So today, we will talk about what isn't really there. I mean, of course, the empty space inside the subtalar joint, better known as - wait for it - the sinus tarsi. Sounds like some high priest of the Mongolian steppes, doesn't it? You can almost hear the thundering echo off the distant mountains when you say it, right? No? Oh, well, let's talk about it, anyway, OK?
The sinus tarsi is defined by the space created between the calcaneus and talus.
When the subtalar joint loses cartilage, and compensates toward a maximally pronated position, which is fairly common in post-club feet, it is the sinus tarsi that becomes one of the primary locations for chronic pain. Usually, though not always, properly casted and constructed foot orthoses can provide a few degrees of relief by preventing the subtalar joint from reaching its end of range of motion with every step. Essentially, end of range of motion is where a given joint cannot move further in a particular direction, or cardinal body plane. An example is when you try to over-extend your elbow joint - eventually, you cannot make it go any further, unless you are trying to break it. In which case, it's probably going to hurt. Very badly.
Sometimes, the sinus tarsi can become so inflamed it is essentially "hot" all the time. The pain can be very debilitating. There are options, though each has only a limited amount of effectiveness. Orthotics, as mentioned. Sometimes, an injection of cortisone can break the inflammatory cycle long enough that the joint has time to settle down, but its somewhat hit-or-miss - sometimes it works, sometimes for only a short period, and sometimes it doesn't work at all. It seems somewhat dependent on the degree of inflammation, and the actual amount of range of motion available for the specific joint. The more motion available, the better the results.
I tend to go for the chain-reaction approach: soaks and massage, plenty of stretching of the joint in an inversion direction. Then the cortisone, and then newly casted orthotics. This last is because if you can capture the foot by casting it when it is at its most relaxed, it can be positioned better for the resultant orthotics made on that cast.
Cuboid Syndrome
The cuboid is the bone that abuts the lateral aspect of the calcaneus, and is so named because, well, its essentially a cube. It has the least amount of contouring of any other joint surface in the body, and this makes it very easy to become "subluxed." This is simply a fancy word for dislocated. In fact, the cuboid can be subluxed for a long time before anyone even knows it is the source of any pain. There are a few podiatrists, and maybe even fewer chiropractors, who have the skill to do proper adjustments to move the cuboid back into congruency. The interesting thing about these kinds of adjustments are that, when done properly, the relief is nearly instantaneous. You need to look around to find anyone whose properly trained, as foot adjustments are not in the standard curriculum of either disciplines - they are acquired through specialized training and certification.
The thing that causes the cuboid to sublux, of course, is chronic over-pronation, as this, in effect, torques the calcaneal facet of the calcaneal-cuboid joint away from the facet of the cuboid. This causes the ligaments, over time, to stretch sufficiently that the cuboid is no longer held in the proper configuration against the calcaneus. And when this subluxation occurs, it places even greater pressure on the sinus tarsi. The result? Big ouch.
An excellent description of Cuboid Syndrome can be found here.
So, next time you are hangin' with the clubbies at the Subtalar Joint, give a shout out to that old shaman, Sinus Tarsi. Just don't be downwind when he has to blow his nose.
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:
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?
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.
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.
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?
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.
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