The big picture on inflammation, orthopedic inflammation that is
Many orthopaedic inflammatory diagnoses are mechanical problems first that create a normal inflammatory response. You might not be getting better because you are treating the wrong thing, the inflammation, and the underlying mechanical cause is unknown, undetected or being ignored.
Fix the mechanical problem and you fix the inflammation
This is where inflammation gets its bad name. If the inflammatory response is allowed to be recycled over and over as a result of recurring mechanical micro-trauma, then you develop an “itis”, which can result in annoying to debilitating problems and pain. These are the problems that can be elusive in diagnosis and often seem impossible to solve. They are definitely quality of life changers. This is often and generically referred to as chronic inflammation.
Just like in Groundhog Day, you keep waking up to the same problem day after day.
Of course there are identifiable, known abnormal types of external mechanical forces or repetitive movements that cause inflammation. We call this “overuse syndrome”. This can be seen in the typist who develops carpal tunnel syndrome or the tennis player with a poor backhand stroke who develops tennis elbow or the runner logging way too many miles per week who develops knee pain. With overuse syndromes we treat the inflammation to palliate the pain and we “shut down”, or modify, the “overuse” activity (the cause) and the problem usually resolves.
Then there is the inflammatory response to osteoarthritis or “wear and tear” type arthritis. This is a case where the underlying problem, the joint cartilage damage, is irreversible and the inflammation will typically get worse. Until surgery is required, treat the inflammation!
What about inflammatory problems that result from mechanical imbalance issues that are subtle and not readily apparent?
The problem is your doctor
I am talking about issues like tendinitis and bursitis that just won’t go away seemingly no matter what we do. These are the problems that we doctors far too often do not know or don’t care to ask the question “what is the underlying cause that is creating this inflammation?” Inflammation does not just appear by magic! For example, elbow problems (ulnar collateral ligament) in MLB pitchers are due to acceleration issues in pitchers attempting to retain their pitch speed. Is this all there is to it, just some dude trying to throw harder, or is it a compensation resulting from poor shoulder mechanics or even lower extremity mechanics as the source of velocity loss? Fix the real problem causing the compensation–the shoulder—and the elbow at least has a chance to fix itself. Cause and effect! Let it go too long, treating only the elbow, and the result will be Tommy John surgery. This kind of subtle mechanical imbalance is where your physical therapist and athletic trainers are particularly valuable. Sure, they manipulate, massage, crank, and dig on our bodies to great effect, but their skill in knowing and detecting the subtle remote, seemingly unrelated mechanical imbalances is where they really shine. Determine the cause and you can effectively solve the resulting problem or the “-itis”.
This is where we docs can screw it up. The primary cause is not known or detected, so we “blindly” treat only the end result or inflammation. And this happens all too often. We can make you feel better by treating the inflammation (with ice, rest, NSAIDS, etc), at least for a while. However, the inflammatory process rages on because the primary problem is not addressed. Now you have the orthopaedic version of Groundhog Day. Only treat the inflammation and you will usually lose.
The next time you are told you have a chronic inflammatory problem, such as lower back pain, Achilles tendinitis, greater trochanteric bursitis, etc., ask yourself, ask your doctor, or, maybe best, ask your trainer or PT what the hell is really going on here. Just make sure you listen.
Maybe the problem is you
Sorry to point this out, but you are often part of the problem. Here is the thing, we usually do know the underlying cause, but it is not so readily apparent to you. And you might not like the answer because, after all, you’ve got a serious problem that we fail to fully comprehend, and in today’s instant gratification society you just want us to make it go away so you can move on. Go ahead and symptomatically treat the inflammation with NSAIDs, injections, immobilization, rest, etc, so you can feel better now. But don’t stop there, especially when you’re feeling good, because your real problem is not gone.
Here is my recurring problem. The tightening of the calf is THE singular cause of twenty problems in the foot and ankle. To name a few, these would include plantar fasciitis, Sever’s disease, insertional Achilles tendinosis (Haglund’s), night calf cramps, Charcot midfoot arthropathy, 2nd MTP synovitis and subsequent hammertoe formation, and posterior tibialis tendon dysfunction. Lengthen the calf by surgical means, or better yet, lengthen the calf by stretching and these problems are solved because the “unknown” mechanical problem is reversed. Stretching calves is not sexy and it takes time and effort, but it works.
So, here is my point. When we tell you to stretch your calves to fix your plantar fasciitis or strengthen your core for your back pain or to strengthen you shoulder external rotators to fix your shoulder impingement listen and do it. No matter how illogical or disconnected the exercise might appear, it might be just that simple and it might be all you need to do to solve your real problem: your bad mechanics.
I’m 47, not 57, but type 1 diabetes for 36 years has probably accelerated the calf shortening problem. Am SO glad I found this blog! I am pretty sure I have “mortons neuroma” because my toes are showing the v sign with random pain and I get muscle cramps at night. So how long does it take for the calf stretches to start working? I promise I will keep them up! Thanks for your informative site.
Thanks for you kind remarks, otherwise you know you would make me angry.
The more common reason for toes to spread is a beginning of a hammertoe secondary to 2nd MTP synovitis. Regardless of whether it is a Morton’s neuroma or second MTP synovitis, calf stretching will very likely resolve your problem. It can take anywhere from 1-6 months so keep the faith. Here is my best recommendation for a protocol for the calf stretching.
You have an additional and very important reason to stretch everyday, you have diabetes. There is emerging data, much form me in my real life, that the primary underlying cause of diabetic foot complication are from a single underlying problem, the isolated gastrocnemius contracture. I am certain of this relationship, but this information may be many years reaching people like you. The medical industry, docs, ADA, etc. reject such a simple idea. And that, all joking aside, makes me very angry.
Stay healthy my friends,
I have discovered your blog with interest. I’m elderly (70), diagnosed with posterior ankle impingement, disappointed my 2nd cortisone injection of some 70 hours ago has not dissipated pain, or inflammation . I’m resting as much as possible but gloomy that this will reduce inflammation. My specialist sports medicine doctor has told me that it’s a vicious cycle, and that the inflammation is causing the impingement which goes on to cause more inflammation. She recommended not much activity at all for five days and then taking it gently for a few weeks after that, and that I go to a podiatrist attached to the same practice for orthotics. I am wondering if you think that the calf stretches you recommend are appropriate in this situation. I’d also appreciate any other advice stop this becoming a chronic issue because I will go become very depressed if I can no longer walk, practice yoga, go swimming, dance etc.
I will start off with by shedding a bit of doubt. Posterior impingement is unusual. Unless there is some obvious history of trauma, from an acquired point of view posterior impingement is typically an issue that has a root cause of a fibrous disruption of an os trigonum fibrous connection to the posterior talus or just a very large complete os trigonum. This can also be called . Please let me/us know what you are being told this “posterior impingement” is stemming from and I can elaborate more.
Back to your question. Interestingly, calf stretching would have no anatomic or logical basis to help with posterior impingement, which makes me angry. However, calf stretching should not make it worse, so you decide if you want to give it a go. Orthotics, an all too common knee jerk solution, will be a waste of time and money.
What really makes me angry, and I smell it in your case, is that a root cause is unknown. This Karen is what is wrong with our western medicine, “sick care, not health care”, system today. Posterior impingement is not a diagnosis, it is a symptom complex. Any treatment as such is palliative with the hope is just naturally goes away, and rest is part of that treatment. I don’t know about you, but I like to know what I am being treated for and that the treatment will “solve” the problem.
Einstein was questionable quoted as saying, “If I only an one hour to solve a problem I’d spend 55 minutes defining it and 5 minutes solving it.” Unfortunately, today’s medicine is just the opposite of that.
I look forward to your reply.
Stay healthy my friends,