diagnosis/treatment plan

In the end, the decision is always in the patient's court, but perhaps if you would share the details, the opinions might not turn out to be as radically different as you think.

 

About one year ago, I had a modified kinder to address posterior tibial tendonitis (flexible flat foot) and an accessory naviular which had not responded to consevative treatments. I continued to have ongoing pain. The doctor that did the surgery tested tendon strength and took new films. He said that everything looked fine and just give it more time. I went back about three times with ongoing pain complaints to be told that it takes a wild for a tendon to heal. About 8 months post op, pain was increasing so the doctor prescribed a custom gauntlet brace. Intially, it seemed to help, but within a month, I was experiencing pain even wearing the brace if I was on my feet a lot. My arch appeared to have collapsed even more and when standing and looking at my feet in a mirror, the ankle was starting to tilt toward the ground. I went to another podiatrist who was certified in rearfoot surgery. This doctor said that the strength seemed to be good. Wait a few more months and if I still have pain, he would put in a hyprocure and redo the posterior tibial tendon work. He went on the say that stage two flat foot treatment was tricky. I felt that he was suggesting surgery without really providing me with a reason for continued pain. The third opinion was a foot and ankle ortho at a major orthopedic hospital. He took new xrays and did a hands on exam. He showed me the films and said that the allignment of the foot is causing the ongoing problems. He also ordered an mri which showed that I had severe degeneration of both the posterior tibial tendon and spring ligament. He treatment plan was tendon transfer to repair tendon, repair ligament aned heal slide. During the exam, he also noted that the achilles tendon was very tight (despite stretching) so lenghting he achillese tendon was also part of the plan. He said that there was a chance that additional proceedures would be needed but it was impossible to know until he was doing the correction. He described the proceedure as balancing all strutures of the foot so that you don't have either an over or undercorrection.

 

I suppose that the only why you might make a choice is to continue to obtain opinions from quality and qualified doctors to see if more than one concurs on the same approach. That doesn't necessarily guarantee the correct choice (and there may not be only ONE correct choice) but at least it might indicate that any one opinion is not totally off base. Actually, there is no difference in making a decision on this and a decision on any important matter where qualified opinions differ.

 

Thank you for your response. Does it suprise you that I got three such different opinions?

My gut feeling is that the ortho is the only person who was able to show me on the films that there is a structural problem (heel allignment) that is contributing to my pain. He is also the only person who ordered an MRI. The fact that the MRI from one year ago indicated that the spring ligament was normal and there was mild tearing by the insetion of the ptt while new MRI showed severe degeneration by both structures explains the increasing pain. The ortho felt that the modified kinder failed because while it repaired the tendon, it did not address the heel allignment. I have had a tight achillese tendon as long as I can remember. The ortho also feels that the tight tendon also plays a major role in the success or failure of tibial tendon issues/flexible flat foot.

 

No it does not. Medicine is as much art as science, and though clearly there are ways NOT to do something, there may be many ways TO do something. Opinions are called opinions because they are just that . . opinions. Which one is the best choice, I would have no way of knowing from simply your post. Perhaps, if I examined you, I might have a completely new and different opinion to add to the other three.

FOOT DOC

 

I just got back from an additional opinion. This doctor agreed with the orthopedist that the heel alignment was the root of the problem and the reason that the modified kinder did not work. Using the digital xrays, he superimposed a line showing how the ankle should be aligned vs how it is alligned now. His suggested apporach is silghtly different than the orthopedist but very close to it. I will decide between the last opionion and the ortho. I am leaning towards using the doctor that does three to four flat foot reconstructions a week vs three to four a year. In this case, I suspect that practice does make perfect.

 

I guess it is not impossible, but 3-4 flatfoot surgeries a week seems rather much to me. I wish you good luck on whatever choice you make.