I made a pair of orthotics for this lifelong-athletic patient twelve years ago. She’d been happy with them ever since. After she began using them for distance walking, the long-term structure-related pain she’d had in the ball of her foot resolved. She never needed any orthotics for the soft turf of golf, for the non-impact sport of cycling, for tennis if she kept to Hat-Tru, or even for her dress shoes once we put the fire out. She appeared in my office early last year, worried she must by now be due for a new pair of orthotics, as these had gotten “so old”. At that time I asked if she had any complaints old or new. She said no. I looked at the orthotics. They were perfectly intact and undeteriorated. She and her orthotics remained in their 11 year-long equilibrium. I simply repeated the criteria she should watch out for which could signal the orthotics needed updating. And that was it.
She returned two months ago, stating she’d been experiencing heel pain. She hadn’t started any new activities, or otherwise recollected any trauma or distance walking without her orthotics. This time she was convinced she needed new orthotics. After we talked, I found that her heel pain was pretty much on the wane, although she was noticeably worried it might come back again. I methodically poked her foot, minimal heel tenderness, and not at her plantar fascia, but at the back corner of the heel which gets that first impact with each stride. I checked her orthotics…again perfectly appropriate. I deferred doing an ultrasound scan which is a bit costly, especially if circumstances don’t warrant it (although I use the scanner quite frequently for heel pain if the presentation portends it would help me organize the problem).
I found her calf on the involved side was a little too flexible. On her friend’s recommendation, she’d visited a different doctor just before this visit to me. He told her she had plantar fasciitis, and to stretch her calf, and by all means get new orthotics for sneakers, golf shoes, ski boots, cycling shoes and dress shoes, as the ones I made her only for her sneakers were “garbage”. The cost for these multiple pairs of orthotics would be about $3500, plus multiple $350 follow-ups at regular intervals. She would have to get five pairs of new orthotics annually, with no cost reduction.
My long-term patient came back to me scared, and in the hopes of saving some money. As we continued talking, I discovered that six months prior she’d been diagnosed with lymphoma, accompanied by a lesion which had been pressing on a spinal nerve. During that time, she’d experienced sciatic pain radiating frequently down her leg. The measurements I made of her thigh and calf showed considerably less muscle bulk (and less strength) on the side which had incurred the nerve pressure. All of this is not uncommon.
She’d then been placed on an experimental drug which had shrunk the lesion considerably and simultaneously helped her in her battle with the lymphoma. During this time, both her sciatica and her heel pain lessened considerably.
I asked her to discontinue stretching her calves. Why? Firstly, the presentation was highly uncharacteristic of plantar fasciitis. Secondly, her calf was not tight thus not in need of stretch. Third, I believed her continued stretching of that already loose and weak muscle, as advised by the previous doctor, was the cause of her perpetuating low-grade heel pain (and concern).
I showed her instead calf strengthening exercises, as well as exercises to strengthen the symphony of muscles from back to toes which are called upon as the body walks efficiently. I taught her how to overcome the deficiencies I saw in her gait with simple tweaks of her stride to force her to use her upcoming newfound strength with every step. She’d lost this strength due to the back lesion which was now resolved, and no one had told her she must do a little work to regain her strength. I advised her to continue with the old orthotics, and that she didn’t need several more pairs for all those shoes. She’d never required them prior to losing her strength. I didn’t see the reason to dovetail logic with a questionable multiple-orthotic prescription. I do not need a new car.
As she exited, I asked her to call me at two-week intervals. At the first phone call she told me her heel pain was completely gone. She was doing my exercises and walking with a slightly increased stride-length, as I’d advised. I told her to add elliptical to her exercise regime. On the day of her visit I’d already condoned Pilates, flat-pedal cycling and swimming. At her next call, again perfectly compliant and pain free, I told her she could use a cart for nine holes every other day, as she really wanted to get some golf in before the end of the season. The subsequent three times she played golf she walk the first nine holes and cart the second nine, and don’t forget to call me in two weeks.
Her third call, as I’d requested, was six weeks after. By now she’d sussed she could walk eighteen holes. I cautioned her not to start treadmill until I could check her strength and flexibility, and she was happy to continue her golf, elliptical, swimming, and cycling (and she’d snuck in some clay-court tennis). As I requested, she returned two months after that heel-pain visit. Her calf tone was perfect. I would have called her muscle strength surprisingly good, because it was, but I’d known her for a long time. The rapid increase in strength of this spiritually strong and determined 68 year-old woman failed to surprise either of us. She was happy. I told her to keep her athletic shoes updated, and very gradually return to full activity so she could stay out of a doctor’s office. Neither one of us discussed new orthotics.
Au contraire, I felt I should be paying her for the inspiration.