This Little Piggy Went to Market, This Little Piggy Went Home...

Post-clubbies have one thing in common when it comes to footwear - they have little in common with non-clubbies. Fit, function, and fashion? Well, we are lucky to get two out of three. There is of course a spectrum - some, such as myself, have decided to go custom only, as this option affords the best degree of all three. However, it has the downside of being expensive. Some have figured out they can use some combination of athletic shoes and street shoes, within limits, of course. A few continue to try for the fashion option despite the disadvantages in the realms of fit and function. You could argue that these are exactly the same variables non-clubbies face/choose, but the degree of compromise clubbies have to face is significantly greater. I know this because my sig other can walk into any shoe store in the land and come out broke, whereas I go into any shoe store and turn around and come right out again, usually depressed I can't buy a set of loafers.

To make it even more interesting, those clubbies who wear AFOs or bulky foot orthotics are even more limited, especially when it comes to fashion. Nobody is happy to be considered a fashion dweeb, but we either learn to get over it, or it drags us down further. Personally, I've pretty much accepted the fashion write-off, as it is far more critical I get reductions in pain. This is why I will never have a future as a masochist.

The custom option, besides being expensive, is increasingly difficult to find. Most folks have to travel a significant distance to find a custom shoemaker these days, and unless that shoemaker is younger, they will eventually find themselves where I now find myself - looking for a new shoemaker. Salvadore, who was both my fellow shoemaker, and my personal shoemaker after I stopped doing the work myself, has finally raised his hammer for the last time (that's a shoemaker's pun.) I am amazed he held on so long - he's eighty, and unfortunately, he's got the Big C. And despite having five sons, none wanted to follow in their father's footsteps, so he leaves no heir to take over the business. As he was also doing substantial work for the VA, and returning, wounded vets, there are going to be a lot of hurting folks just over one person's retirement. But, as they say, se la vie.

On another note, I'd like to share something I've been thinking about for a long time. Most clubbies know that when they go see a foot doc for their ever-increasing pain, they are more likely than not to be told they need a fusion. Now, I've made no bones about my feelings on this issue, but I understand why this seems the only option - it will indeed, hwoever temporarily, stop the pain. But eventually, the ankles go, and then the knees, so in essence, a fusion merely trades pain in one place for pain in another. So, as the only tool in the tool box, it's a devil's bargain.

And, I even understand why most surgeons are reluctant to try other approaches - no real research and nobody wants to be the first through that door. But somewhere out there is a orthopedist or podiatrist who can think outside the box, and be willing to work with clubbies toward more realistic and longer-lasting solutions. To that end, I am calling on all clubbies to start talking to their doctors about the possibility of participating in a conference where both doctors and clubbies will attend, the aim being to 1) offer the clinicians a larger population of clubbies to examine and listen to so as to broaden their understanding of the variations in both function and lack thereof in post-club feet, and 2) brainstorm with us clubbies on other potential approaches.

So, here is my offer: if you find this a compelling idea, and are willing to work to make contact with your doctor/s and with other doctors who might find this an interesting idea, I will host such a conference in the San Francisco Bay Area. I will be responsible for bringing clinicians from this area into the mix, and to securing a venue and all the planning needed for this to happen. I will propose a tentative date of June, 2013, which should be more than enough time to spread the word, and to get initial responses that will justify going forward with this idea.

And I will also extend this idea to those out there who have children currently being treated. I think that despite what their pediatric surgeons may tell them, their kids are as likely to have future issues as not, and they may find it reasonable to learn about what might be possible for their children as adults.

So, my question to all you clubbies out there is simple - would you find this a good enough idea that you would make the effort to come to such a conference? Let me know.

I mean, there doesn't seem to be much reason to keep accepting the status quo, from my way of thinking.

Night Splints, Redux, and Some Meandering Mental Spelunking

So I've been wearing the dorsiflexion night splints for this heel spur/plantar fasciitis problem, and it is having some positive effect. The "first step" pain so often indicative of both conditions has lessened considerably. But when I've been sitting a while, well, here it comes again! Onward I plod.

The negative on the night splints is how they have caused me to regurgitate old memories. As a child, I had to wear similar night splints, as I've mentioned in a prior post. But now, I have dreams of that period, and they ain't pretty, ya dig? Though these present day splints are made of plastic and velcro, and are significantly more comfortable by comparison, getting up to hit the head in the middle of the night is nearly as bad as the first time. Hence the dreams, I suppose.

I recently read an article on folks who suffer from Charcot-Marie-Tooth's Disease. I remember making shoes for a number of such folks back in the day. I am struck by the similarities, not of the conditions themselves, per se, but how post-club feet, CMT Disease, and even MS, of how the conditions are experienced by those who have to contend daily with them. Chronic pain, the every day knowledge that you will only get worse (though without any firm timeline, degree of change, or speed of deterioration knowable by you or by the medical community,) the constant awareness of needing to plan your day so as to avoid any unnecessary efforts, a background buzz of staying at least moderately aware of the surfaces you walk on, the shoes you wear and their balance or lack thereof, and more.

I know for myself, and for many others I have made shoes and orthotics for over the years, it might only be a difference of one degree of wear on my shoes, or having to negotiate ten blocks of city streets with slanted sidewalks, to set off a long bout of both foot and, by extension, lower back pain (compensation at work,) though the effect of the slanted sidewalks can sometimes be offset by walking back in the opposite direction, but on the same side of the street (this just unbalances you in the opposite direction, and while no less problematic for my feet, can at least stave off the painful back a while.)

I have long been aware of how I notice the way in which other people walk - that's partly a hazard of those years of doing gait analysis - especially when I see their badly-worn shoes, or the women who wear those six-inch spikes and walk with a distinct wobble. I know from long experience working with such people when they get older, and the toll of that need for attention finally grabs their attention in unpleasant ways, that it could all be avoided. But when you do not suffer from chronic pain, there just isn't a problem, is there? There is a factor known as angolaglia, which means the willingness to bear pain whose cause appears to contribute to one's beauty. (See William Rossi's Sex Life of the Foot and Shoe, an excellent primer on all things shoe and foot fetish and the attendant psychology. Look it up on Amazon.) So after spending many years trying to "talk some sense" into (particularly) the women who do this slow, steady damage to themselves, I finally had my eyes opened by an elderly woman who responded to my suggestions by saying (quite bluntly, as I recall,) "young man," (I was, once,) "men do not pursue women whose body has no form, and whose walk has no motion." Well, she sure shut my mouth. Trying to talk sensibly to a woman about healthy shoes is like trying to convince an alligator to adopt a vegetarian diet. A complete waste of time.

In my case, there is no willingness to bear the pain, there is only its inevitability. And as for beauty? Ask my beautiful wife. I'm the furthest from objectivity when it comes to my glorious mug.

MRI's Don't Lie, Do They?

To begin, it is clearly no secret I've been dealing with these post-club-feet blues for a long time, so when I developed the heel spurs on top of everything else, it didn't really surprise me. And when the doc sent me for the MRI's, I thought I knew what to expect - a real mess. Well, that doesn't even begin to describe what they showed. In the report by the radiologist, I found it both amusing and upsetting to see a perfect example of how a medical professional can employ clinical language to say, basically, "those are the most fu**ed up feet I have ever seen, and I demand you keep them far away from me." Following is the Impressions section of the report, which is sort of like a synopsis:

1. SUBTALAR JOINT AND MIDFOOT DEGENERATIVE CHANGE WITH NAVICULAR CYCSTIC CHANGE/EDEMA AND FEATURES OF POSTERIOR IMPINGEMENT NOTED.

2. PLANTAR FASCIAL CALCANEAL SPUR WITH MODERATE THICKENING, PLANTAR FASCIA, AND WITH MINIMAL SURROUNDING SOFT TISSUE EDEMA.

3. DEGENERATIVE CHANGE, METATARSALPHALANGEAL JOINT, WITH VARUS ANGULATION OF METATARSALPHALANGEAL JOINT, FIRST DIGIT..

He also notes the appearance of an Achilles tendon tear, but feels it is less-than-remarkable in  light of all the other scary stuff.

(I suppose I should feel a bit insulted being characterized as a degenerate, but that's exactly what my seventh grade teacher said about me, too, so what the heck.)

So, I have two choices vis-a-vis the heel spurs/plantar fasciitis - keep going with the prolotherapy, or try a cortisone shot to settle it down, and maybe later have to do it again, or worse, surgery. I think I'll stick with the prolo (though my wife is beginning to think I may be a closet masochist, given the degree of pain the procedure causes one to endure. But I just keep telling her it builds character. ((of course, she simply reminds me I'm enough of a character already, so please don't do her any favors)))

But all this has made me curious (well, actually, I think it was heat stroke at eight years old that did that, but I digress.) Have you had heel spurs/plantar fasciitis? How did you deal with it? Let us all know. After all, we're mostly in the same sort of boat, ya think?

Heel Spurs, Redux

OK, so, today I go in for an MRI on both feet. I can't wait to see the film! Finally, a starring roll. In cross-sections, no less. Actually, it should be quite interesting. Given the number of surgeries I've had, there has to be a mess-o-scar tissue in there, which might make my doc a bit dizzy as he tries to make sxzense of it. That's right, sxzense, that is exactly what I meant. Or not.

So, I thought this would be a good time to try and enumerate all the surgeries, therapies, and hardware that have been applied to me footsies over the years, simply by way of something fun to do. That OK?

1. Manual stretching and serial casting, starting at two weeks of age. This continued until I was two or so.
2. Tendo-Achilles Z-plasty, to lengthen the Achilles, B/L.
3. Medial soft tissue releases, B/L.
4. Anterior Tibialis lateral transfers, B/L.
5. Dennis Brown night splints.
6. Surgery to remove a bone cycst on the dorsum of my left foot, that resulted in the rupture of my tensor retinaculum, a fascial band that holds the anterior tibial tendon against the foot. The result is that my left anterior tib bow-strings away from my foot, and makes it a perfect site for shoe irritation.
7. Dorsi-flex assit night splints. These had metal uprights and a steel plate along the bottom, with wide elastic bands that attached to both sides near the toes, and extended to the calf band. They were supposed to hold my feet in a dorsiflexed position all night. The fun part was sounding like Frankenstein's monster when I got up at night to go to the bathroom. I woke everybody, because there was no way to walk in stealth mode, ya dig? Plus, I tore through sheets at an amazing rate!
8. Twister straps. These were the ultimate form of torture. I wore them when I was in the third, fourth, and fifth grade, where they presented an especially delightful experience in gym class. You see, I had to wear a girdle. Yep, a girdle. The wide elastic bands attached directly to my brown, round-toed, orthopedic shoes (the height of fashion, dontcha know) on the outside near the front of each shoe. The elastic bands were then wrapped around my legs three times, spiral fashion, and then attached to a girdle under my clothes. That is, unless I was changing for gym class, where I got to put on a show for the class, whose expertise at humiliation and bullying was significantly better than my expertise in being a duck. (As in water off a ....) Plus, they left rather painful welts in a spiral around my legs - when I removed them at night, I remember the pain being enough to make me cry.
9. Those Damn Shoes - I hated them - nobody anywhere ever wore brown, round-toed laced high-top shoes - except me. Took a lot of crap for that, in case you were interested.
10. The last surgery (to date) involved the removal of two bone spurs on my left foot - one was posterior calcaneus, and the other posterior talus, and they clapped hands every step. The docs who did the cutting managed to sever the distal third of my sural nerve, making the outside, or lateral, border of my foot permanently numb. Marvelous!

Another memory - when I was little, and having casted feet, I remember vividly the process for removing the casts. After a few weeks, as you might suspect, my feet and ankles would be itching like the blazes. The technicians would use a cast-cutter to remove them - the cast cutter has a sharp, circular blade, but it vibrates instead of rotating. Let me tell you, once you got past the fear caused by the noise those things make, you quickly came to realize how much the crazy thing made you tickle. And I mean like crazy tickle. Then, after the casts were taken off, there was all that dry skin, and residue around the surgical site that was crusted on. They had to soak my legs, then use a stiff brush to get all that stuff off, and that, my friends, did NOT tickle - it hurt like the fires of heck!

Funny thing is - these days? All I wear are high-top, round-toed, lace-up boots. At least now, they're black.

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.