Sometimes you have to be your own doctor

2012 ends for me with some positive health news. Problems I have been chasing for years appear to be on their way to resolution, or are at least in remission. The bad news is that despite the many physicians and specialists I have seen, overall I have had to become my own doctor. Such is the world of chasing annoying medical problems for middle-aged people like me in the 21st century.

The one physician I cannot complain about is my primary care physician, who is on the ball, at least about problems he can easily figure out, like my high cholesterol. I have been on a variety of statins, first Lipitor before it went generic, then Simvastatin because it was generic. My physician was on the ball enough to order me to get regular blood work after I switched drugs. It detected that the Simvastatin was causing muscle deterioration, so much so that if it had gone on much longer I would have ended up in the hospital. He saved my insurance company and me thousands of dollars and me from a potentially life threatening condition. So now I am back on Lipitor, which is now generic, with the only yellow flag being an increase in a liver enzyme, something that can happen when you are on Lipitor.

I have also been chasing my painful sciatica. Sciatica is a particularly baffling condition since there are so many possibilities for its root cause. Having it meant that sitting was painful and brought burning sensations down the back of my thighs. I’ve been dealing with it for years and have gone so far as to consider solutions like standing desks. Pretty much everything I have tried brought no permanent relief. When no relief was in sight despite seeing orthopedic surgeons and chiropractors, I ended up on the Internet. It seemed there were two possibilities: a herniated disk or piriformis syndrome. The latter seemed more likely and it occurs when the piriformis muscles in the leg constrict nerves exiting the spinal column. After a lot of traction at my chiropractor’s office and releasing pressure on the piriformis muscle it seemed to go away. Then like a doofus I thought it was gone for good, and stopped getting traction, only to have it come back with a vengeance. What works now is more traction, but this time getting it regularly so my L5 joint does slide back into a position so that it presses against the spinal nerve again. I am getting traction every three weeks now. I also have a special ergonomic chair at work that does not put pressure on L5, like many supposedly ergonomic chairs too, including Aeron chairs due to the drop at the back of the seat. The sciatica is not completely gone but most days I don’t notice it. Moreover, it looks like regular traction will keep it in remission and the key is to keep coming back for more traction at regular intervals.

I also have large feet and consequently a lot of foot related issues. These were originally numbness in the feet. My foot issues got more acute with a recent recurrence of plantar fasciitis on the left foot. Plantar fasciitis typically manifests it out as a burning feeling on the souls of your feet, although this time it was at the heel of the foot. This is a condition occurs when tendons are torn in the feet and it takes months to heal. So I have been wearing running shoes with lots of cushion in the heels. Four months later it is not quite gone, but it is nearly gone.

What to do about all the numbness in my feet? I had seen neurologists and confirmed neuropathies. My podiatrist speculated that my varicose veins might cause them. I had the veins removed on the right leg, where the problem was more acute, but it did not solve the problem. At one point I spent four weeks in a boot that immobilized my foot because the joint pain became excruciating. I was beginning to wonder if I would be better off without my feet. The metatarsal bones in my feet felt like they were not where they should be. Had something broken and moved out of alignment? Eventually my podiatrist agreed to have an MRI done of my foot. Everything was exactly where it should be, which would be good news except for the occasional excruciating pain. One thing that was noticed: muscle atrophy in the feet. So I was sent to a physical therapist and spent weeks trying to regain my balance and strengthening the muscles in my feet. With more muscle mass in my feet, my condition began to clear. It appears if I had done this to start with, I would have avoided years of pain and consultations. No one had the ability to figure it out, and it never occurred to my podiatrist to test the strength of the muscles in my feet. Moreover, the sciatic nerve cascades down into the feet. It is likely that sciatica contributed to the problem.

It seems like an informed and inquisitive patient is the key to solving these chronic problems, because our physicians for the most part can’t seem to properly diagnose these more complex issues. I found that pain is a pretty good motivator for action, but I feel frustrated because I had to piece it altogether, as well as prompt my physicians to get tests that I thought I needed.

Obviously, it shouldn’t be this way. However, I am at a loss on how to improve our health care system so that these probably typical experiences that I had are faster to get properly diagnosed. Whatever medical training our medical specialists are getting, it seems insufficient. They are good at seeing trees, but not so much the forest.

If the shoe fits, wear it

I need to add owning good shoes to my list of things I must do from now on.

Finding properly fitting shoes is no problem for most people. Go to Payless, find something that fits and feels sort of comfortable, spend fifty bucks or less and you are done. Finding comfortable shoes is harder. Sometimes you can find a comfy pair at Payless, and the younger you are the more likely they are to feel comfortable. Get up in years and even with a pair of custom orthotic shoes inserts (like me) and a pair of Payless shoes is still likely to feel uncomfortable, if not hurt. If you have larger, wider or narrower feet than average (like me), you often find yourself buying okay shoes instead of the right shoes.

That’s what I have done throughout life. I generally don’t shop at Payless, but have bought most of my shoes at DSW, where it is hard to walk out of the store without a good pair of shoes. However, even DSW does not normally stock unusual sizes. If you are a guy with long feet like me you can usually find a size 13, and sometimes a size 14 but if you want a 13 ½ then you are out of luck. Moreover, if your feet are size AA, like mine are, then likely whatever you buy will not feel snug. In my case, the right foot is size 13 ½ and the left foot is a size 14. When I slip into a size 14 at DSW unless I wear thick socks its extra width means my feet will tend to slosh from side to side. Size 13 is usually a wee bit too small; my toes end up right against the front of the shoes. This means that if I kick something with my shoe, it is usually a painful experience. What this has meant is I have bought size 13 shoes most of my life, because a size 14 was either too big or not in stock, and a size 13 ½ was simply never available. My feet have not been that happy with my pragmatic choices, but there did not seem to be a whole lot of alternatives.

Yet in any city of any appreciable size, if you search them out you can find stores that sell odd sized shoes. The Holy Grail is to find a store that has both odd sized shoes that are also well-constructed, well-engineered and attractive shoes. I struck out at the first store my podiatrist had on his list. I was told to try the store’s web site. The idea of buying a pair of shoes via the mail seemed a bad approach. Still, having dealt with more than my share of foot problems over the years, and with my new orthotics in place, I was determined to get shoes that both fit and were well constructed.

I finally found a shoe company that met my standards. Now I could kick myself for having settled for less for so long. Wearing shoes has finally become a comfortable if not welcome experience. I don’t mean comfortable in the sense that my feet now feet like they are walking on pillows. I mean comfortable in the sense that my feet now feel solidly anchored in my shoes, they don’t hurt from an active day of walking around, my toes don’t end up occasionally sore and squished and, thanks to these foot orthotics and a lot of chiropractic therapy, my chronic case of sciatica is largely gone. I am considering taking up running again, but I want to take things slowly. I am afraid that I will jinx things otherwise.

I never spent more than $100 for a pair of shoes before. This pair of “slim” size 14 shoes cost me $159 at a SAS Shoes outlet. Moreover, I discovered that Made in America can mean much better quality than Made in Some Third World Country. SAS stands for San Antonio Shoes. They are hardly alone in the high quality shoe industry, but they do not outsource their shoe making. Their shoes are meticulously crafted in their factory in San Antonio, Texas. It’s clear that whoever is making these shoes knows how to engineer shoes, and part of it is making them in half sizes, often going up to size 15, and making normal, slim and wide width shoes in all sizes. “Slim” is probably an A width, not a perfect fit but so close to my AA width that I cannot tell the difference. I’ve rarely been able to find a size 14 shoe, but never found a size 14 in a narrow width before.

Weeks into wearing this new comfy pair of shoes, I keep discovering features of this Pathfinder model that I bought that attest to its quality. One is the quality of the leather: soft, flexible and yielding around the sides but engineered with a sole just a tiny bit larger than most so that, at least so far, I’ve managed to not scuff them even once.  Inside I find that the shoe has a sturdy floor with partially aerated pads near the toes and in the heels.  The ringlets for the shoelaces are a brushed metal, and the shoelaces are wide, flat and nylon reinforced, which makes them easy to tie and unlikely to untie themselves. The shoe’s tongue has a small piece of elastic connecting it to the inner side of the shoe, facilitating proper placement and movement of the foot in the shoe. The stitching is well done and flawless. Aeration holes on the shoe facilitate the shoe’s ability to breath. My only complaint about the shoe is that it cannot be re-soled. But I do like the style because it allows me to wear it both casually and as a dress shoe.

People with unusual shoe sizes have always had problems finding the right size of shoe, but I am suspecting that Americans overall have elected to trade a shoe that fits for a shoe that is okay to save money. Now that I understand otherwise, it is unlikely that I will ever spend less than $150 for a pair of shoes again, unless maybe I am in San Antonio at the SAS Shoes factory outlet. I don’t see myself traveling to San Antonio any time soon, but if I do I have found a new destination.

It’s better late than never for me and maybe you as well. $150 is actually a reasonable price to pay for a comfortable and well fit pair of shoes. I am glad to know that in doing so I am employing actual Americans.

Some things are made better here in America if you don’t mind paying the actual cost to manufacture them here in America. I will not rue that cost anymore.

A day without pain

Daily pain is a fact of life for many of us, particularly as we age. Pain can range from acute (migraines) to the intangible but devastating (depression). Regardless of the kind of pain, pain is a warning that something with us is not right and needs fixing.

I have been dealing with the pain of sciatica for years. At least now I have a name for what I have been going through. It started many years ago with numbness in my toes, escalated into general foot pain, particularly when standing, then slowly migrated toward my spinal cord. For the last few years the sciatica was most painful on the backs of my thighs. As the day progressed, and particularly when I was sitting most of the day, the pain radiated from a slow burning sensation to an acute burning sensation. At its worst, it is sort of like sitting on burning matches. I did not like it, but I got used to it. It helped that in the morning I was pain free and it wasn’t until I engaged in more sedentary tasks that the condition progressed.

Regular readers may recall that I consulted various specialists. I endured shoe inserts, surface vein removal surgery, tarsal tunnel surgery, as well as other invasive and non-invasive tests. It was all for naught. Part of my problem was that sciatica is a syndrome. This is a fancy way of saying it was caused by lots of multiple factors, none of which could necessarily be pinned down. Trying to cure sciatica is thus a lot like trying to shoot a bull’s-eye while wearing a mask. It also means that physicians are of little use because they are as baffled as you are, just not honest enough to tell you.

Ibuprofen offered no relief. Physical therapy offered some relief, but could consume up to an hour a day. The best relief was to not sit, which was hard to do and stay employed. Doctors were willing to do deep tissue steroid injections at the base of my spine that might reduce the pain or make it go away for a while, but would not cure the problem. My spine was not damaged so spinal surgery would have been useless. I was driven to the mighty search engine Google to try to figure out what I had. The only thing that came up was a condition called piriformis syndrome. My prognosis for a full recovery: not great.

Today, while the pain of sciatica is still not completely gone, it is nearly gone. A few weeks back the chiropractor I see examined the soles of my feet when I complained that it felt like I had a flat stone under my feet after using the elliptical machine in the gym. He pressed certain spots and had me yelping in pain. “You need metatarsal pads in your shoes,” he told me. It took me about a week to see the podiatrist who said, “they will help but what you really need are custom foot orthotics”. The orthotics are on order but in the meantime I have metatarsal pads glued to my Superfeet shoe inserts. Those three-dollar pads have done more to reduce my sciatica than all the other treatment combined. I am hopeful that when the orthotics arrive the pain, which is now a very mild burning sensation that appears from time to time, will vanish altogether.

Yet I doubt custom foot orthotics alone is curing my condition. If I have piriformis syndrome then compression of the sciatic nerve near my piriformis joints (the joints that connect the hips with the legs) is part of my condition. How did this happen? According to Wikipedia many of us have a congenital condition wherein the sciatic nerve goes through the piriformis muscle, which can then compress the nerve. Exercise, particularly the weight lifting I was doing at the gym likely contributed to this problem. This weight also contributed to something akin to the collapse of the bones in my feet, making certain bones lower than they should be. This put more stress on certain parts of my feet, triggering pain. The custom foot orthotics should even out the foot pressure.

In addition, my chiropractor has been aligning my spine and loosening joints. My spine was bent a few degrees toward my right side, not that I never noticed. After three months of chiropractic therapy and a lot of traction, my spine is now straight, meaning that my body mass is now aligned evenly and symmetrical. Nerves that were stretched because my spine was not straight are no longer artificially stressed. It is hard to say for sure but these are also likely contributing toward my recovery. Body symmetry, in addition to helping people attract mates, is good for the body in general. Your body wants to be symmetrical. Over fifty-plus years my body symmetry changed. Regular jostling of my piriformis joints by my chiropractor have opened up those joints as well. Whether it will relieve pressure on the sciatic nerve remains to be seen, but it appears that enough pressure is being released. And by solving the pressure problems in my feet, pain signals are not regularly going back to the brain. All these are likely contributing to relief.

I feel tangibly close to going a whole day without pain. I cannot remember how long it has been since I have had a pain free day. My guess is that it has been at least five years. I remain frustrated by how incompetent our medical establishment proved to be to diagnose and treat my condition. However, I have a lot more respect for chiropractors now than I used to have. I know the medical establishment tends to look down on chiropractors with their fussy insistence on holistic medicine. For me, a competent chiropractor and lots of traction over many months seems to be solving my very complex problem that the medical establishment simply could not solve, and at a fraction of their hefty fees.

I am fortunate to be well insured. I know that there are millions of other Americans who are uninsured, and many of them are as old or older than me and dealing with chronic pain as bad, if not worse, than what I have been dealing with. For the most part, we cannot be bothered to insure them. If they cannot afford medical care on their Wal-Mart wages then to hell with them. It is more important to be principled than to collectively organize so all of us can get relief from needless pain and suffering. At some level, we appear to be a country for whom “personal responsibility” is effectively enshrining sadism toward the less moneyed among us. Having gone through years of often disabling pain, the only ones I feel a lack of compassion for are for those whose ideology keeps them inured from doing something to address  so much pointless suffering. Shame on them.

The Agony of the Feet, Part Three

(Read Part One and Part Two first, if you missed them.)

It’s been exactly five years since I first wrote about the agony of my feet. In the intervening years, I have certainly been probed, tested and even sliced open by plenty of doctors. I even underwent three surgeries last year hoping they would alleviate the chronic inflammation in my feet. My foot problem is not gone, but at least the agony has morphed into the occasional annoyance. For me, this is great progress.

I have learned a lot along the way, and not all of it is flattering to our medical establishment. My primary care physician was of little help. He never studied foot problems in any detail but was glad to refer me to specialists. The podiatrist said the pain and numbness, mostly in my right foot, could be a number of things. Initially he started with steroid shots injected into certain spots in my foot. They seemed to help a bit, but the symptoms recurred later with worse pain. I pointed him to my varicose veins, predominant in my right leg, and wondered if that could be the problem. The conservative approach seemed to be to remove some veins on the theory that blood was pooling in my feet and this was adding to the pressure there, thus causing the pain. One vein was cauterized last May. I spent weeks wearing compression stockings, which due to all the leg compression made the pain worse. Later last summer I had the more egregious surface veins on my right leg removed and spent more weeks in compression stockings. The surgeries did little to reduce the pain, but I must say my legs look great.

The podiatrist also sent me to a neurologist, who confirmed tarsal tunnel syndrome in my right foot and well as various neuropathies elsewhere. This eventually resulted in the tarsal tunnel surgery I had in January. If you have tarsal tunnel, this should mean that a nerve is compressed in your ankle, right? It seemed a reasonable assumption. However, after surgery and three weeks staying at home, at best I had only a little relief. I knew the surgery did not have a great success record, and sometimes it took months for symptoms to moderate, but I could think of nothing else to do. There was no one specialist to go to who could put it altogether. Each specialist saw my problem in relation to their specialized training only.

I did notice that the back of my thighs also felt irritated. Could the problem not be in my feet, but further up in my sciatic nerve? Could I be compressing nerves elsewhere and feeling the result acutely in my feet? After a follow up with the surgeon, I asked and received a referral for physical therapy to chase possible sciatica. Perhaps through the right kind of exercise elsewhere better results would trickle down to my feet. It seemed a wild idea, but it was worth a try. I had few other options.

It took only a few sessions with Donna and Rebecca (the physical therapists who worked on me) to realize this is where I should have started, not where I ended. Most likely, all the other surgery could have been avoided, along with thousands of dollars in medical costs. Granted, physical therapy is not a lot of fun and takes a lot of time. However, the proof is in the pudding. My symptoms are 50-70% improved compared to when I started physical therapy a month or so ago.

I had no idea that our nerves are sheathed inside tubes, and with the right stretching your nerves will slide inside these tubes. These exercises forced my nerves to move from their favorite spots, where they may have been stuck and thus more likely to feel compressed and inflamed. Good physical therapists (and both Donna and Rebecca are excellent) will note connections. It seems I have bad posture. It was nothing I gave much though to before. Of course, everything in your body is connected, so stressing and stretching nerves the wrong way (such as via slouching, leaning back in chairs, hunching over my desk or not sitting in an ergonomic position) were all contributing toward the major problem manifested in my feet.

Now I spend about an hour a day stretching my muscles. I do pinformis stretches. I do hamstring stretches. I do supine nerve glides and horizontal braces. I do leg marches. I use a tennis ball to massage my plantar fascia (the bottoms of my feet). I do calf stretches and pointing ankle-strengthening exercises. I do other exercises too numerous to mention here, all of which take a lot of time and are boring as hell but which seem to alleviate symptoms quite well. I am in good hands with Donna and Rebecca, literally, because they are often massaging my feet, legs and surgical scares with cream and very firm strokes. They are also big believers in ultrasound, which they use liberally on my surgical scar. Through repeated therapy, I went from having the tightest legs and ankles they had seen in six month to relaxed calves and feet like normal people.

I also pull on long, stretchy rubber bands, mainly to improve my posture by strengthening my back muscles. I also sit on big bouncy balls and place a ball between my legs while I lift my calves. I also learned how to properly get in and out of bed. Apparently, the way I had been doing it for the first 53 years was wrong. You have to roll in a certain way and drop your feet toward the floor while pushing yourself up with your hands. There are many secrets these masters know about how not to stretch my sciatic nerve.

A good ergonomic chair is also helpful for us desk dwellers, but sitting properly in any chair is also important. Sitting up straight still does not come naturally to me. However, I discovered that making sure my feet, knees and waist form right angles when I sit could relieve many symptoms. One thing I was doing wrong was sitting too high in my chair. This obtuse angle simply put extra pressure on the bottom of my thighs, aggravating the sciatica.

It all seems to come natural to physical therapists that as a class seem to be skinny, beautiful, have great skin and, naturally, great posture. They eat right too. No processed foods (it seems) for these specimens of great human health. They’ve got it all figured out, and they practice what they preach.

Are my foot problems solved? Not yet, but thanks to my excellent physical therapists, I am seeing great changes in a chronic problem that has dogged me for more than five years. Perhaps next time you have any muscular or nerve related problems, you should seek out a good physical therapist first. It may be all you need.