An upbeat chap from the West coast visited me last year. Now 38 years old, this elementary school teacher had undergone excision of a malignant tumor from a muscle in his right thigh when he was 32. PET scans continued to demonstrate he was cancer-free. He was looking forward to seeing some Broadway shows with his partner on the trip. He’d come to my office because of 5+ years’ ever- worsening right big toe pain, which had defied a lot of treatment (and didn’t jibe with the diagnoses he’d been given). His demeanor was at first curiously parenthetical.
His successful cancer treatment had given him a perspective. He told me how much he appreciated being alive, and was willing to accept the pain in his foot. By now he’d rationalized it as a type of atonement. After 185,000 patient encounters, it wasn’t difficult to sense the sadness he was suppressing deep inside. I had no faculty which could provide me with such a shield.
The first foot specialist he consulted had diagnosed rheumatoid arthritis, although the rheumatoid work-up came back negative. The doctor then proceeded to administer six unguided cortisone injections into the joint, one per week, without favorable response. The next specialist diagnosed osteoarthritis, though the range of motion in the joint was uncharacteristically (and to me even startlingly) copious, and serial X-rays remained negative for arthritis. This doctor tried two ultrasound-guided cortisone injections, again, simply into the joint. By now and after eight cortisone shots, his symptoms were markedly worse. The only offering which doctor number two could make by then was “take it easy”. Our teacher had to stop his tennis and jogging. He began to gain weight.
Two more docs said his problem was flat feet, and indeed, his right foot was flat. His flat right foot, even when he stood without walking, flagged something I would look for later in the exam. Each new doc made him two pairs of custom orthoses, a pair for business shoes, and a pair for sneakers. All four pairs looked remarkably similar: plastic arch supports which terminated short of his big toe joints. None had altered his symptoms. He’d had over 30 X-rays and a CT-scan: all negative, oblivious to the radiation exposure for someone who’d had lower extremity cancer. He brought all his imaging discs with him, including a recent MRI, which had been read by a radiologist and a podiatrist as completely negative for pathology about the great toe joint (my favorite kind of MRI). He’d also brought with him his affect of unchallenging willingness to accept any treatment plan. His well- grounded faith in doctors had arguably become his greatest problem.
OK, let’s clean the slate and get into this. Firstly, the tumor surgery and the onset of big toe pain were too contiguous to skip inquiry, especially as we’d racked our brains about any other possible provocation (different shoes, new or more exercise, trauma, previous problems there, etc.)…
So-o, what muscle was the tumor removed from? "The left adductor magnus."
How much muscle and tumor bulk was removed? "They said it was smaller than a plum." So not an irretrievable loss of strength.
Did you do any strengthening of your adductor magnus after the surgery? "A little, not a lot."
Any other things you’ve noticed? "Yes, I’ve noticed it looks like I’ve started to get a little bit of a bunion since my surgery. I think it happened after the cortisone shots."
OK Novella, brain time. What might the adductor muscle do (or not do, in this case)? Its function is to draw the body mass into a nicely balanced position right over the middle of the foot at the moment the foot pushes-off as we stride (ie, when our big toe joint chiefly bears full body weight). Muscles are shocked by surgery, and have to be rehabbed. Cutting out muscle bulk isn’t exactly helpful to strength either. He never did much adductor rehab. I tested his adductor strength…not good. If the adductor fatigues at push-off, the lower extremity, and particularly the foot, remain outside the midline of the body. Like standing with one’s feet apart, but in this case, just the right foot. And the ball of the foot (forefoot) gets most of this angle because that’s where we push-off from. The result, after years, was a right forefoot set at a high pitch with respect to the rest of the foot, like an aileron with respect to a wing. In medical terms, a “forefoot varus”. And his was not subtle. I approached his foot on the exam table like my favorite part of the turkey at Thanksgiving. His forefoot was at a 35- degree angle, almost positioned like a hand which could clap the opposite foot. The normal angle is 0 to 3 degrees. Unnoticed blatant stuff like this has exasperated me for 42 years. A main reason I write these case histories. Almost as disturbing is the indifference specialists so often retain for issues at disparate parts of the musculoskeletal system.
When a forefoot varus engages the ground at push-off, it causes significant pronation. As I watched him walk, the puzzle assembled nicely. He had a wide stance on the right side as he proceeded to the moment of push-off. Wow that forefoot pushed-off pronated. Subtly, he did not push-off completely on this side, but abbreviated his push-off. He by now had learned that abandoning some push-off would avoid him some pain. Pronation is a published cause of bunions. None of his pairs of orthotics addressed his right forefoot varus. There was no wedge under this electric blue neon sign of a foot imbalance on his orthotics to account for this. Only four pairs of boiler-plate plastic arch-supports, which had cost in toto upwards of $2500.
Time to look at the MRI. No fireworks explaining 5 years’ pain, no stress fractures, no arthritis, no joint inflammation. Just inordinate thinning of the mcl ligament. This ligament inhibits bunion formation.
As he’d had the issue for so many years prior to the MRI, it was “subacute”, or not inflamed. When things are inflamed, they literally light up the MRI. When they are not inflamed, you have to look more closely, and a bit of prescience doesn’t hurt, either. Thus it behooves point-of-service practitioners to become familiar with MRI, and not simply rely on the radiologist’s report. I’ve espoused acquiring this skill frequently in these case histories. It’s not difficult. It just asks practice.
So no permanent tissue damage. But significant thinning of the mcl ligament as a result of the cortisone shots, exploited by unfettered mechanical challenge to the spot. I’m going to hit my thumb with a hammer every day for five years. Please give me eight cortisone shots. OK Tom, finish your hands-on exam, make sure there are no weaknesses, inflexibilities, other malalignments which could impede the simple upcoming approach I would propose. The road was clear. He was otherwise strong, muscles flexible, and to his advantage prognostically, he had generally loose ligaments, which might eventually bode well for a loss of the forefoot varus someday.
I proposed giving him a prolotherapy shot. He agreed. This is a simple injection of dextrose (sugar water) diluted with sterile water for injection and lidocaine all in the same syringe. I inject it through a tiny needle, having used my ultrasound machine to locate where the ligament and bone meet. The prolotherapy irritates this junction, spurring scar production to fortify the ligament. This is the same ligament I’ve injected with prolotherapy for innumerable ballerinas who incur sprains here when their pointe shoes die, and for soccer players who sprain this joint when kicking the ball at the moment an opposing player kicks it from the other side. The shot works. Prolotherapy is not an anti- inflammatory injectable, like cortisone (exhaustively published to have the side effect of weakening joints). Prolotherapy is an inflammatory agent. And again, a property of inflammation is to source scar cells, or fortify joints.
But before the shot, I did something which I almost always consider unethical. Rationalizing, if we could get his adductor magnus stronger, he might in time lose the forefoot varus, as I’ve seen happen in other cases when circumstances are right, and then be able to enjoy his boiler plate orthotics, eventually more than the ones I was about to ask him I could make. I was about to propose a fifth pair, though the four previous sets didn’t help, fessing-up that within a relatively short period of time mine would likely feel uncomfortable! Who would dare make expensive orthotics for someone who might only need them for a relatively short time, unless there were extraordinary circumstance? This was a singular moment. As he walked with an abbreviated stride, compensating for the forefoot varus and adductor weakness, I couldn’t ken how I could to let the adductor exercises I would prescribe transcend academic and become therapeutically habituated to his normal gait, unless I could stop the pain at push-off with a forefoot-wedged orthotic. This would let the adductor magnus function through its entire range, as the forefoot wedge on the orthotic would enable him to stop abbreviating his stride in compensation. The wedge could not be incorporated into his present orthoses. But we had to stop facing this self-feeding monster.
I explained all this to our teacher. After traveling from California he was well in agreement to try, and to begin standing Pilates adductor strengthening, and continue this for 6-8 weeks after receiving his orthoses. He picked up the orthotics a week later, as we’d asked the lab to rush them. Put them in his shoes. I didn’t have to ask. As soon as he took a step, beautiful smile. Instant pain relief (these moments never cease to elicit my mixed emotions in case the relief doesn’t hold). I asked him to begin strengthening, and send a status e-mail me in 8 weeks. I received his e-mail in a few months. No pain. He’d switched to the original orthotics as I’d advised after about 6 weeks, as the ones I made him were becoming uncomfortable.
Two things had likely happened: he’d lost his forefoot varus as predicted, and the non-forefoot posted orthotics he was given by the previous doctors were protecting his very mild bunion (and fit better in the toe box of his shoes). A little detour to New York, but our California teacher was finally on the Road to Independence.