Question
QUESTION: I had a modified kinder 11 months ago. Both the doctor and pt agreed that the tendon strength and function are good. However, I continue to have swelling by the surgical area. I can go a few days wearing good sneakers and my custom orthotics with minimal discomfort but as the week progresses, I end up with pain by the surgical site which is bad enough to force me to wear my custom ankle high gauntlet brace. Sometimes, if I am on my feet a lot - wearing my sneakers /orthotics, I end up with pain along the side of the foot extending into the arch which is reminiscent of my pre op pain.

Is this considered to be within "expected" recovery symptoms 11 months post op?

The doctor that did the surgery just says "wear the brace as needed." If the pain gets a lot worse or new symptoms develop, call. A second doctor said that the tendon function is good but if pain persisted, he would do a hyprocure and go back in to check the kinder. A third doctor took new X-rays and felt that a calcaneal slide and going back in the check the kinder was indicated. No one gave me a definitive dx or reason for the continued pain that would indicate the need for surgery to my satisfaction. I am not a doctor, but it makes no sense to go back in to "check the kinder" if the doctors all say that the function and strength are good and films show that the plastic anchor is in place. The three doctors are all well vetted surgical, board certified podiatrists

I went to the Hospital for Special Surgery to see an orthopedist that  specializes in posterior tibial tendon disfunction. He ONLY does foot and ankle surgery.  He ordered new X-rays.  These films were very different than those taken by the other doctors.  The X-ray technician was much more precise with positioning my feet than the others.  This doctor said that the reason I am having continued problems is due to severe pronation which is placing continued stress on the tendon.  He feels that without realigning the foot, my pain will continue and the foot will continue to deteriorate.  He is proposing a calcaneal slide, checking the kinder and possibly grafting a tendon from my foot if the posterior tibial tendon is not in good shape.  The doctor also said that my Achilles tendon (the more surface one) is extremely tight which contributes the the flat foot.  He wants to lengthen the tendon to allow the foot to move more normally.  Finally, he suspects that the first metatarsal is raised which also contributes to the problem.  He said that he would not be able to tell if it would have to be lowered until he was doing the surgery.  Post op, I would be NWB approximately 8 weeks followed by 6-8 weeks in a boot.  He also wants an mri before doing any surgery.  I guess that this doctor and one of the other doctors agree that the calcaneal slide is necessary.  The main difference is that the other doctor did not talk about the Achilles tendon.  The doctor I saw today did show me the X-rays and had a reason for the ongoing pain.  My head is spinning thinking about the number of procedures he is proposing.

Do these procedures make sense for correcting an extremely flat foot which is placing ongoing stress on the posterior tibial tendon (despite wearing good sneakers with custom orthotics)?

ANSWER: This Chicago, South Loop & Elmhurst Podiatric Orthopedist of AnklenfootCenters.com says.......

Dear Amy,

This is a very complicated fifth surgical opinion- Which is against my policy to answer any surgical opinion cases.
         That said -you seem like as nice person in need of help-so here goes......
Skip the first two podiatrists.
Take the results from the orthopedist and ask the third podiatrist what he thinks about lengthening the gastrocnemieus muscle(sometimes they can be stretched by exercise).
Also ask about the first metatarsal.
It's a toss-up between Podiatrist #3 & Orthopedist #1.
See who explains the above better.Look at the other patients in the waiting room and see if they are happy with their results. You may still need to wear orthotics after the surgeries.
The reason for checking the old surgery site is that there is pain there which may suggest tearing of of the anterior tibial tendon(which is the tendon that is advanced in a Kidner Surgery)
Go get the MRI to see if in can shed any light on the pain in the surgical area
The surgeries need to address the posterior tibial tendon dysfunction and the bio-mechanics of your problem. The surgeon needs to explain how the surgery will make you walk differently.
If they don't discuss the risks-don't do the surgery there.

We are specialists in posterior tibial tendon dysfunction problems and foot & ankle surgeries
Hope this helps!

Good Luck!

Dr George Tsatsos & Svetlana Zats
Podiatrist Chicago 60618 & Elmhurst 60126 Podiatrists
Board Certified in Foot and Ankle Surgery & Orthopedics
New South Loop Location-Chicago 60661
AnkleNFoot.com
Runnersdoc.com
BabyFootDoc.com

DISCLAIMER:
This information is offered as free advice and as general information. It may not be applicable to the specific questioner and his/her problem.  It is not based on actual knowledge of the questioner or his/her medical history and it cannot and should not be relied upon as definitive medical opinion or advice.  Reliable medical opinion and advice can only be obtained through hands-on physical contact and exam of the patient to establish an accurate diagnosis and treatment plan.  No doctor/patient relationship is created or established here and may not be inferred through answers on this site.  The questioner and other readers must consult his/her own doctor before proceeding or implementing any suggestions contained within this document and answers on this site.  The questioner is only to act upon his/her own doctor抯 orders and recommendations. By reading this posting which follows, the reader fully understands and confirms that he/she holds harmless this writer. If this is not fully agreeable to you, the reader, and/or you have not attained the age of 18 years, you hereby are advised to read no further.
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Dr George Tsatsos & Svetlana Zats
Podiatrist Chicago 60618 & Elmhurst 60126 Podiatrists
Board Certified in Foot and Ankle Surgery & Orthopedics
New South Loop Location-Chicago 60661
AnkleNFoot.com
Runnersdoc.com
BabyFootDoc.com

---------- FOLLOW-UP ----------

QUESTION: Thank you for your response.  My gut feeling was between the same two doctors as you suggested.  I did have pt following the modified kinder as well as after a proximal knee realignment.  The pt really did not make any difference in the tightness.  When my leg is straight, the ankle could not be bent back, however when my knee was bent, the range improved considerably.  The doctor said that this is indicative of the more surface tendon being problematic,  I am now at stage 11A posterior tibial disfunction.  The doctor that I saw today said that he would not be able to determine if a Cotton osteotomy would be indicated until he was able to actually visualize the area. It may not be needed but he wanted to tell me all of the possible procedures.  The arch has collapsed more since the modified kinder.  

The problem with using  podiatrist 3 is that his partner was the doctor that did my surgery.  I saw podiatrist 3 because four months ago, I was in a great deal of pain and the doctor that did my surgery was away for a week.  The partner showed me using digital X-rays how the alignment of the heel was off.  He felt that I would continue to have problems until the alignment was addressed. He wanted me to wear a brace for several weeks to calm things down and if problems continued then we would discuss details of the surgery in more detail. This doctors partner, the one who did my surgery did not feel an osteomy was indicated at this time.  Using podiatrist three could be very awkward to say the least. Podiatrist three has additional certification in rearfoot surgery.  The orthopedist only does foot and ankle surgery and is nationally known for posterior tibial tendon disfunction.  People come from other states to see him regularly.  I suspect either doctor would have the expertise to do the surgery.  

As a doctor how would it play out of you did surgery on someone who was subsequently seen by your partner who recommended a more involved procedure. Would it create an awkward situation if you did not agree completely with your partner?

Thank you again for taking the time to respond to my post.  I obviously have a big decision to make

Answer
This Chicago, South Loop & Elmhurst Podiatric Orthopedist of AnklenfootCenters.com says.......

Dear Amy,
The fact that you can achieve the required dorsiflexion of your foot with your knee flexed means that you have a chance to stretch the calf. Start the aggressive stretching exercises ASAP-You will know in a month or so if you can stretch it out. Look at people learning to do splits
Talk to the third podiatrist about your concerns. Assure them that you are not looking to sue,but only want the best possible treatment available to you for your continued foot pain.  Evaluate their attitudes.
Obviously he can't throw his partner under the bus -but if he feels that his partner did not use the best possible procedures-then the original podiatrist needs to show concern and some remorse. We are human and it's OK to say that the surgery did not work out as expected and for that he is sorry.
That's why I discuss ALL risks and rewards before any foot & ankle surgery .
If either partner feels that nothing was done wrong-then go with the orthopedist----but make sure you speak to the partner who wanted to do the calcaneal slide. Get the MRI and ask the other questions above for the additional procedures to at least understand why and if they may be necessary.

  We are specialists in posterior tibial tendon dysfunction problems and foot & ankle surgeries
Hope this helps!

Good Luck Again!

Dr George Tsatsos & Svetlana Zats
Podiatrist Chicago 60618 & Elmhurst 60126 Podiatrists
Board Certified in Foot and Ankle Surgery & Orthopedics
New South Loop Location-Chicago 60661
AnkleNFoot.com
Runnersdoc.com
BabyFootDoc.com

DISCLAIMER:
This information is offered as free advice and as general information. It may not be applicable to the specific questioner and his/her problem.  It is not based on actual knowledge of the questioner or his/her medical history and it cannot and should not be relied upon as definitive medical opinion or advice.  Reliable medical opinion and advice can only be obtained through hands-on physical contact and exam of the patient to establish an accurate diagnosis and treatment plan.  No doctor/patient relationship is created or established here and may not be inferred through answers on this site.  The questioner and other readers must consult his/her own doctor before proceeding or implementing any suggestions contained within this document and answers on this site.  The questioner is only to act upon his/her own doctor抯 orders and recommendations. By reading this posting which follows, the reader fully understands and confirms that he/she holds harmless this writer. If this is not fully agreeable to you, the reader, and/or you have not attained the age of 18 years, you hereby are advised to read no further.

Dr George Tsatsos & Svetlana Zats
Podiatrist Chicago 60618 & Elmhurst 60126 Podiatrists
Board Certified in Foot and Ankle Surgery & Orthopedics
New South Loop Location-Chicago 60661
AnkleNFoot.com
Runnersdoc.com
BabyFootDoc.com