My Subtalar Joint Instability-Talus Impingement-Sinus Tarsi Syndrome

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This blog is my chronological diagnostic process of my ankle/foot pain for Sinus Tarsi Syndrome and Talus Impingement and/or Subtalar Joint Instability/pathology and in the end seeking an answer with the minimally invasive surgery. This blog picks up from my prior blog once I had become weight-bearing again on June 25th, 2013. I was enjoying my new freedom to walk after being in a wheelchair or on crutches for the prior 6-week non-weight bearing status which was a result of my Proximal Tibiofibular surgery that had taken place on 5-14-13. Please see for the complete story and all the recovery updates regarding that surgery.

After only a week of walking, I was so desperate to see Dr. Sheldon, DC to check my foot. I was feeling good in my lateral knee and I was very pleased with the results of that  surgery; however, I agonized over how bad my foot felt and I wanted to know why. Patience is not my best quality, but my determination is what does get me a diagnosis and ultimately the medical results I desire to achieve.  So below I am documenting all my various appointments so show my readers how much effort I do put into not giving up easily:

July 3, 2013 Dr. Sheldon, DC An extremity subluxation was discovered and adjusted in the left ankle anterior talus. I had been so out of alignment no wonder it so hurt to walk this past week.
July 10, 2013  – Dr. Sheldon, DC – An extremity subluxation was discovered and adjusted in the left ankle anterior talus. I had a few days of better feeling after last adjustment, but I needed it again this day.
July 10, 2013Dr. Alm, DPM – I went to the foot doctor and told him my ankle/Talus is not in alignment per just seeing my chiropractor.  “She has tenderness in the sinus tarsi of the left foot…she has a plantar flexed 1st ray, semi-flexible…she does have excessive lateral forefoot overload as evidenced by a hyperkeratosis under the 5th metatarsal head.” Dr. Alm put me in the Professional OTC line of Powerstep orthotics. Since my biomechanics changed after the Tib-Fib surgery, it was also the advice of Dr. Main, my Tib-Fib Surgeon, to start with new orthotics and new tennis shoes as your old shoes have a different wear pattern.

So I did as instructed with the new Tennis shoes and orthotics and Dr. Alm modified the OTC orthotic on July 17th with a temporary valgus tilt and a forefoot accommodation for my forefoot valgus. His continued diagnostic impression: “Chronic left ankle/foot pain with sinus tarsi syndrome, semi-flexible forefoot valgus with lateral column overload, lateral ankle instability.”

July 24, 2013 – Dr. Sheldon, DC – An extremity subluxation was discovered and adjusted in the the left ankle anterior talus. There was mild edema in my anterolateral talofibular joint. I was having problems with my ankle wanting to turn while riding my horse and I was having intermittent spasms in muscles coming up my anterolateral leg. I was feeling a little better by now on the underside of my foot with the new tennis shoes and orthotics.
July 30th, 2013Dr. Shirzad, my Foot/Ankle Specialist with Northwest Orthopedic Specialists in Spokane. I went to see him as a follow to my last appointment in April 2013 to let him know how well I had done from the Tib-Fib Surgery and to seek his opinion and help with my ongoing ankle pain. In my prior blog, I discussed the arthroscopic ankle surgery had had done for me on 8/31/11.   Here are some of his examination findings: “Examination today reveals a well-healed proximal tib/fib joint incision. There appears to be stability at the proximal tib/fib joint. With evaluation of the ankle, she does not have a significant amount of laxity with anterior drawer and talar tilt testing. It is fairly similar to the contra-lateral side with talar tilt and anterior drawer testing. She has some mild pain and tenderness with palpation of the lateral ankle ligaments along the insertion of the fibula. She has more pain and also some swelling around the subtalar joint with in the sinus tarsi area. She has no pain or tenderness with palpation of the peroneal tendons at the level of the distal fibula; however, approximately six centimeters proximal to the distal tip of the fibula, she does have slightly more pain with palpation. …She has difficulty in terms of performing ankle eversion.” Dr. Shirzad performed a diagnostic injection of Marcaine into my subtalar joint. 

A Marcaine injection is a wonderful diagnostic tool. I had the best night of my life in regards to walking. I was able to enjoy a walk around several blocks with no pain. The injection was given at 5pm and starting wearing off at 11pm. By 1am I was crying as all my pain came back.

Aug. 7th, 2013Dr. Alm performed a diagnostic Marcaine injection in the sinus tarsi.  The location of this injection was different from Dr. Shirzad’s. I did have some pain relief very similar to the subtalar joint injection; however, between the two different injections, I concur for myself that I had overall better results from the injection straight into the subtalar joint as compared to the sinus tarsi region.
Aug. 14th, 2013 –  Dr. PZ Pearce – Champion Sports Medicine, gave me a  Celestone Cortisone Injection into my peroneal tendon sheath. This did give me some immediate relief of some associated symptoms in that area of my left ankle/foot; however, I still did not have relief of  my symptoms related to the malalignment or subluxation of the Talus.
Aug. 20th, 2013Robert Paull, PT, OCS – Apex Physical Therapy, Spokane, WA.  I was referred to Mr. Paull  by Dr. Pearce for his expertise in custom orthotics for athletes. After a complete review of my history and current symptoms, it was Mr. Paull’s opinion that I seek out further diagnostics before spending the money on custom orthotics at this time since I had already been in custom orthotics and modified OTC professional orthotics and my symptoms were really no better.
Aug. 21st, 2013 – Dr. Sheldon, DC- “She continues to have pain in her left ankle. She has been wearing an ankle brace on her foot to try an stabilize her talus. She has a constant pain in her lateral medial talar joint and she has constant pain distally to her fibula. Her talus moves well on the medial side of her ankle.” An extremity subluxation was discovered and adjusted in the left ankle anterior and lateral to medial.


Stabilizing Left Ankle Alignment & Pain Control with CAM Walking Boot
Stabilizing Left Ankle Alignment & Pain Control with CAM Walking Boot

Aug. 21st, 2013 – Dr. Alm, DPM- I saw Dr. Alm later in the day after being adjusted by my chiropractor. My pain level was done as I had put on my CAM walker boot in order to try and maintain/hold the chiropractic adjustment. Dr. Alm also did a Lowdye taping session of my foot. He also wanted me to use his modified Powerstep orthotic inside the walking boot. He wanted me to use the CAM boot for 2 weeks and keep tape on my foot. At this point I told Dr. Alm I was appreciative of everything he had been doing for me; however, I was going to Dr. Brockbank in Spokane for a 3rd opinion on any possible surgical interventions to correct my constant subluxed/malaligned Talus bone.
Aug. 27th, 2013Dr. Brockbank-Spokane Foot Clinic, Spokane.  Prior to this initial appointment, I had written Dr. Brockbank an extensive email of my history and the exact reason I was seeking out his opinion. I had first found Dr.Gregory Brockbank, DPM, FACFAS, as a Qualified Surgeon listed on the website:  for the minimally invasive extra-osseous talotarsal stabilization procedure. Then I asked both Mr. Paull, PT and my family doctor about Dr. Brockbank and they too recommended him. I set off to see him and be evaluated for the HyProCure Surgery with great hope that some surgeon in my local vicinity(4 hours one way from my ranch) could help me. Even though I am abundantly thankful for all my prior out-of state surgeries and their great success in making me a more whole person, I was truly tired of the extra expense for travel that the thought of doing one locally would just be great. See my home page for all those stories.

So I had my initial appointment with Dr. Brockbank. Here are his findings:  “X-ray 2 views of the foot and 2 views of the left ankle show a supinated foot structure with low lying 5th metatarsal and plantarflexed 1st ray. There is mild pain upon palpation of the lateral ankle joint. There is no pain with palpation of the ATF, CFL, PTF. There is pain with palpation of the peroneus longus, peroneus brevis, left. The anterior drawer sign is negative. Talar tilt is negative.”  His assessment: “Sinus tarsi syndrome left, peroneal tendon pathology left, pes cavus foot structure left, left ankle instability subjectively, pain in Limb”  He proceeded to order a 3T MRI to assess the sinus tarsi and peroneal tendon pathology. He wanted me to return to his office right after another chiropractic adjustment to see the difference in my ankle/foot because I had informed him what he saw this day was my ankle/foot in a non-adjusted malaligned state of being.  The 3T MRI is more powerful to see the details deep into Sinus Tarsi and Subtalar Joints of left ankle/hindfoot.

Aug. 28th, 2013 – Dr. Sheldon, DC -“She wore a boot to keep her ankle stabilized after the prior adjustment. Initially she had intermittent spasm in her anterior ankle and lateral shin. She also had intermittent sharp pain in her anterolateral talus and sinus tarsi region. She had anterior shin pain that kept her up last night and had to take a prescription.” An extremity subluxation was discovered and adjusted in the talus, lateral to medial.
Aug. 28th, 2013My Youtube video Dr. Sheldon, DC adjusting lateral impingement of Talus

Between 8/27 and 9/3/13, I was convinced that the HyProCure Surgery would help me.  So I continued to read everything pertaining this surgery and then I decided to call the corporate office of GraMedica from reviewing their website:   I quote the following paragraphs from the Company History Page of their website:

GraMedica® was founded in 2002 by Dr. Michael E Graham, a successful, Michigan-based doctor of Podiatric Medicine. In his practice, Dr. Graham specialized in the correction of foot and ankle instability, a root cause of many secondary conditions throughout the body. It had long been known that the underlying cause of many foot and ankle problems is excessive hindfoot motion. Frustrated by the limitations of available treatment options on the market, Dr. Graham was determined to improve patient outcomes by providing a revolutionary solution to answer this challenge. Dr. Graham invented HyProCure®, an Extra-Osseous TaloTarsal Stabilization (EOTTS) Device.

 This pioneering device is placed deep into the canalis portion of the sinus tarsi re-establishing the normal pivot over which the talus (ankle bone) glides, thereby properly re-aligning the foot and ankle bones and restoring normal function. HyProCure® received FDA approval on September 16, 2004. The first HyProCure® placement took place on September 22, 2004. As more and more doctors and patients gained awareness of both the condition and treatment, the company experienced rapid growth in July 2011. GraMedica® received FDA clearance for its second implantable device, osteo-WEDGE™, a revolutionary treatment option for moderate to severe bunion correction.

After expressing in great detail the situation with my ankle/foot to one of the executive sales assistant’s of GraMedica, she then forwarded my information on to inventor/founder-Dr. Graham. I am sincerely grateful that he took a moment to hear my story and he sent a message back through her and I quote: “He counsels that you need to make an appointment with a HyProCure Master Surgeon, even though you will have to travel in order to so. Masters are not only accomplished surgeons, but believers in the far-ranging positive health effects of correcting the mis-aligned foundation that is talotarsal dislocation.  In short, he believes that consulting with a Master Surgeon would be worth the inconvenience of the trip. ”

Here is one of my favorite articles by written by Dr. Michael E. Graham titled: “Recurrent Reducible Talo Tarsal Dislocation”

I proceeded to find a Master Surgeon from the website.  I found Dr. David Gent, DPM, ACFAS, Master Surgeon in Bremerton, WA (outside of Seattle) as the closest doctor to my location. I contacted their office and I was well received on the telephone and they gave me an appointment for Friday, 9/6 on the exact day I needed. My husband and I were already going to be in Seattle for his annual business educational seminar and the doors opened for me to meet Dr. Gent.  Being that Seattle is a 7-8 hour drive from my ranch, I certainly did not want to make a separate trip if I didn’t need too.

Sept. 3, 2013 – I cancelled my scheduled MRI for this day and returned to Dr. Brockbank with my frustration that a local hospital was going to charge more than I could afford for the 3T MRI. I would normally do business in Spokane with Inland Imaging my preferred Imaging Center; however, they do not have a 3T MRI and I would have to go to the hospital and pay their higher rates. Without ever first seeing Dr. Brockbank’s chart notes, I had sensed he did not consider me a candidate for the HyProCure surgery at my initial appointment with him on 8/27/13.  Because of this I could not justify in my mind the co-pay expense of this MRI if Dr. Brockbank was not on the same page with me regarding surgical consideration.  Dr. Brockbank reviewed the above video of my adjustment and at this appointment he explained: “She will be seen by a podiatrist in Seattle and if he feels comfortable with the surgery and she feels good about it then I feel she should go forward and have this done by him. I feel the implant may not help her foot and may make the condition worse. The pronatory adjustment performed by the chiropractor seems to help her instantly so I do not know how an implant which limits pronation would help her condition. Discussed with the patient that I may be wrong with my assessment but this is my best judgement based on the information I know.”

I really did like meeting Dr. Brockbank  and his wonderful office staff and I told him I certainly respected his opinion. After all, you are paying for a doctor’s opinion and they are practicing medicine and not any one doctor has all the experience necessary for each patient’s case. A doctor has to rely on his training and his experience and I was not a classic case per Dr. Brockbank’s training or experience with the HyProCure Surgery. He was newer to this surgical product and believed in it very much, yet he did not have case history like that of a Master Surgeon rating with the GraMedica Corporation. It is therefore my patient to patient advice, that we all seek out several opinions pertaining to what we are dealing with. Besides God and modern-day diagnostics, no one knows what is going on in our body better than ourselves. I strongly believe in the inner small voice of God and His love for me and His divine direction in my life.   So I was inspired to proceed to see my chiropractor the next day with the plan on him doing another set of x-rays right after he adjusted my left ankle/foot. I so desperately wanted to see if there was a difference on x-ray to prove my point of the subluxation/misalignment of my Talus and how my pain levels would change from before and after an adjustment. I wanted to have this information to take to Dr. Gent in Seattle.

Sept. 4th, 2013 –  Dr. Sheldon, DC – An extremity subluxation was discovered and adjusted with the anterior misalignment of her talus.  Here is my Youtube video of X-ray comparisons of Talus position with X-Ray’s by Dr. Brockbank, DPM pre-adjustment, and post Adjustment X-ray with Dr. Sheldon, DC

I agree with Dr. Sheldon that there is a definite change of my bony structures of the left ankle/foot between pre/post adjustments. My condition is so chronic that the bones shift and get stuck creating a supinated stance. Then after adjustment my foot is more neutral in stance and does have mild excessive pronation in gait.  Here is another video done that day of the actual adjustment. This time it was for anterior impingement and my other adjusting video above was for lateral impingement of the talus on the calcaneus (heel bone).

Dr. Sheldon, DC adjusting anterior impingement of Talus

I close this blog knowing beyond a shadow of a doubt that my Talus does not stay in neutral alignment whatsoever. My pain symptoms change for the better after an adjustment and will return within a few hours upon walking. My pain initially starts as more of a spasm up the anterior/lateral muscles of my leg and then the swelling increases in the lateral ankle and progresses around the entire ankle. I also know that the Marcaine injection did bring pain relief to the Subtalar Joint. I am left to think that I have two issues going on: 1. Talus on Calcaneus instability, and 2. Pathology in the Subtalar joint. I am forever grateful to Dr. Sheldon, DC for going the extra mile in helping me with my videos.

My next blog will pick the story up from here as I adventure on to Seattle.
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