This is a message for all you young (or any age) doctors who were taught things in school. Such a stupid thing to say. We were all taught things in school. Wrong. Our professors pointed things out to us in school. But we didn’t learn things in school. We memorized things. We memorized facts, and we memorized advice. I can still instantly recite the selective auditory side effects of antibiotics taken off the shelves 30 years ago. They were evidence-based facts. But as for advice, despite memorizing professors’ advice, I trusted little of the experiential facts they pointed out to me in school. I learned when I began treating patients. I experienced whether or not the points my teachers made were actually true. Sometimes my mistrust was well-founded as I applied their advice unsuccessfully to patients. Sometimes my mistrust was ill-placed due to my lack of understanding. The positive and negative results of my interactions with patients are what I have actually learned. Learning takes courage, confidence, and even a little brainpower.
I was recently visited by a physician from Kenya. He had read my website. He traveled to New York City to visit me. His physical activity had degraded from a triathlete/competitive squash player to a sedentary man who was afraid to walk more than two blocks. He’d had 8 years’ unrelenting pain in his left arch just behind his great toe whenever he’d walk more than 15-20 minutes. The pain was unmitigated by physical therapy, custom orthotics, local cortisone injections, shockwave therapy, camboot immobilization, or changes in footgear. I’m not surprised. Not one of the 21 doctors he’d seen in Africa and Europe could give him a diagnosis.
He’d had X-rays, ultrasound scans, CT scans, and MRI. Repeatedly. Not one showed any pathology at his complaint site. I’d booked him at the end of the day, so I could spend a lot of time with him. I palpated this horrible complaint site. No tenderness. I felt for soft tissue irregularity there...no bumps, welts, masses or defects. If anything, the muscle coat about his arch which invested his great toe was rather massive and robust, certainly not pathologic looking. This was curious.
He told me as had many that I was his last resort. But this time, there was no ring of desperation. That put me on high alert. I spent a lot of time in front of him looking at all the images. I found zero pathology at his complaint site. He began to cry. There was no chance I was going to give up, and I told him so. I delved further into his history. Important points I noted included he’d had some problems with low back discs causing left-sided sciatica since adolescence (he was 41 years old at the time of his visiting me), and he’d had several sprained ankles on this same side. He would recover enough after each sprain to not feel the need for physical therapy, and as a physician who seriously trained at triath and squash, he didn’t have time for physical therapy anyway. He now substituted all that exercise time with physical therapy trying to treat this problem.
I checked his calf flexibility...quite hyper-flexible, not tight at all. This prompted me to test his calf strength. Here was a formerly robust athlete. I checked his right calf first, resisting him pointing his foot down as I asked him to “push me off my chair.” He very successfully overcame all the strength I could muster. I then asked him to do the same on the left or involved side, being careful not to engage his toes which looked threateningly strong, but only the ball of his foot to purely test his calf. Alarmingly weak. Deep tendon reflexes symmetrical and normal. Hmmm....
I asked him to walk. This was a surprise. I’d expected his left heel to lag on the ground and not give me a robust heel-to-tip-toe stride pattern, as his calf was so weak. Full glory robust heel-to-toe push-off, both sides. Double hmmm...
I checked his hip rotations...both sides showed excessive internal rotation, with just enough external rotation to not cause hip pain. This meant he would have to use his feet a lot more to generate push-off power, as his hips couldn’t “lock” and help supinate or support his feet when they reached end-range internal rotation as push-off approached. I then checked his peroneus longus (a muscle which often weakens after a sprained ankle and fosters calf weakness as subsequent compensation, as you may have read repeatedly in other case histories on this site)...moderately weak.
What if this formerly-robust athlete, obviously stirred and on the verge of being shaken, who powered through a sciatic-induced calf weakness, had developed this hypertrophy (massiveness) in his toe muscles as compensation for the weakness in his calves? Could toes be generating heel-lift power? It was possible. But that still didn’t explain the pain, because my fine-tooth combing of his MRIs showed no pathology there. So it had to be a referred pain. I suspected it was the medial plantar nerve, because this nerve gives sensation to the muscle at the site of his pain. What if those massive toe muscles were causing a painful local nerve entrapment closer to his heel, radiating to the complaint site, from an area which was not imaged on any of his MRIs?
I asked him to have a stat MRI of the ankle. I called my radiology buddies and asked them to give him an appointment the following AM. The images came in online, and I was able to look at them over lunch. I looked carefully at the ankle images. As my radiology consultant also noted, there was no pathology, though those toe muscles were robust. Fortunately, my 2 hours every evening since 1994 looking at foot and ankle MRIs occasionally pays dividends. I looked specifically for the two muscles which surround that medial plantar nerve. Now the muscle which controls the lesser toes, the flexor digitorum brevis, was originating on his heel bone from an unusually-situated place up on the arch-side of his heel bone, rather than in the middle where it belongs. This was trapping his medial plantar nerve against the abductor hallucis (big toe) muscle, the very muscle at the site of the pain. I postulated that this process was causing referred pain to the complaint site as those robust toe muscles, compensating for the calf weakness, relentlessly popped his heel off the ground as he walked.
I called the radiologist who did the read. He is the toughest doc in that group, and It is rare for him to agree with me when I call for him to recheck his findings. I have learned much from him. But this time, it was not a matter of squabbling over pathology. I had been privileged to examine the patient, and I had a theory based on an anomalous (misplaced) muscle orientation. He looked, took out a couple of other patients MRIs and compared, and then agreed the muscle origin was misplaced. I then asked him to administer an ultrasound-guided injection of the local anaesthetic Marcaine into the region where the medial plantar nerve was getting entrapped by the two muscles. I called my patient and asked him to visit the interventional radiologist for the shot, and then return to me the next day with the results.
Again he wept when he came into my treatment room. My disappointment quickly absolved when he told me the procedure had temporarily relieved his pain, and he’d walked in NYC for nearly five hours before the pain returned. We had our diagnosis.
I therefore showed him exercises to strengthen his peroneus longus, to help him re-engage his calf, and calf-strengthening exercises using a dense ½ foam roller, which would let him use his calves to strengthen, without engaging his toes. I also asked him to begin Pilates, which would allow his core muscles to help generate heel-lift, to take some of load away from his toes. I asked him to build this strength gradually, and to e-mail me from Kenya in about two months’ time with a progress report.
He e-mailed me one month later, and again repeatedly, week after week stating unfortunately that his exercises were not paying off, he was worsening, and he was now having the pain after ten minutes walking. He also revealed that he’d continued seeing the same physical therapist he’d been visiting from before his initial visit to me. He said she’d changed some of the exercises I’d shown him, and she had redoubled her efforts in giving him toe strengthening exercises, calf stretches (but I tested his calves as hyper-flexible, oh no!) and jumping jacks. He was ready to return to NYC to get orthotics from me, as I’d seen some minor foot-balance irregularities which as a last-ditch effort I could address with orthotics different, but not that different, from the ones he showed me. I just didn’t think the differences were worth the trip. So I asked for her e-mail, trying to explain my rationale via an extensive letter. Her response was lukewarm at best, and I got the impression she was going to continue her treatment as she’d been doing for many months. She was just doing the things she was taught in school.
I e-mailed my patient, along with the document I’d sent his physical therapist, my rationale as to why he was worsening, and a new prescription for physical therapy, and asked him to seek a physical therapist who treats dancers, who would agree with my treatment plan. He found one. He contacted me two months later. Minimal pain after two hours walking, resuming running, continuing to trend favorably.
I memorized, but I did not learn anything in school.