The 'Gap Sign'

During the whole period I had the cast on, my left foot hurt…and it hurt bad at times. When I went to go get my cast off I had little faith that my month long stint of cast life had improved the state of my injury. I told my doctor about my pain in the cast, and she recommended that I continue to wear a walking boot for another 4 weeks. I attempted to convey to her that walking around in a boot was going to do nothing for me. I wanted a more aggressive treatment. She offered an injection of Tormidal (NSAID) after 4 weeks if my foot did not feel better. I agreed and went on my way. Ironically, my foot hurt significantly more after the cast was taken off than before. 

The next three weeks were miserable, but the abnormal pains in my foot slowly began to recede. By week 3 though, my original injury still hurt. I scheduled a doctors appointment and got the injection into my joint. The injection was very painful and did not guarantee anything. I left the doctors hoping that the injection would relieve the pain at least till I could figure out my next step. Fortunately, after seeing that all possible conservative measurements failed at helping my foot, my doctor referred me to a foot and ankle surgeon. Finally! But of course I had to wait 3 weeks till the next available appointment. I waited and in the mean time the injection proved to subdue the pain in my foot somewhat. When the day came to go to my appointment I was so anxious that I was trembling. To make sure I provided a good case, I brought photo comparisons of the left and right feet along with a journal article about the ‘Gap sign’ <The gap sign> (signals a Lisfranc injury). At the surgeon’s office, I first talked with the doctor and told him my story. I then got a few weight-bearing x-rays. The doctor analyzed my past x-rays, MRI’s, and bone scan along with the new x-rays. He explained some key features he noticed in the imagery and then said he believed my tarso-metatarsal joint complex was unstable due to injury to ligaments between the bones in that area. Specifically, he told me the weight bearing x-rays showed a slight gap between my first and medial cuneiform. This was a tell tail sign of some variation of a Lisfranc injury. His words were like music to my ears. What he said to me was what I had been preaching to all the other doctors. I told him everything that I had been thinking about my foot: gap between my big toe, clicking and popping, and feeling of instability whenever I walked. He listened and agreed with most everything I said. Even going as far as corroborating my story with the x-rays and MRI. At that point, he told me that he suggested surgery as a viable option to fix my foot. Surgery is by no means something I was excited about, but I knew from the very beginning it was the only way to save my foot. I talked with the doctor about my options and I went ahead and scheduled surgery 4 weeks out.

I left the surgeons office pumped full of adrenaline. I couldn’t believe that a doctor finally gave me the diagnosis I had been saying all along. After some careful consideration and more research, I decided to get a second opinion. I was commended to a surgeon by a fourth orthopedist (yes fourth) that I saw. The visit with the second opinion went even better than the first. Not only did he clearly see that I had some variation of a Lisfranc injury, but he also was one of the leading surgeons in that area of research. He gave me his tentative plan for surgery and possible recovery outcome, and then without hesitation I scheduled surgery with him for 4 weeks out. Of course I called my first surgeon to let him know of my choice. He was in no way bothered or offended. The four weeks leading up to my surgery date were uneventful as far as my left foot pain goes. It wouldn’t be fun or interesting if my right foot didn’t start to act up though, right? Well that’s what happened. I was able to keep my right foot under control enough to go ahead with surgery as planned, and hat is where I am now.

The cast

By the end of May my pain still persisted, and I was at my wits end. I went to another orthopedic doctor in hopes they would figure out what all others failed at. Two words… déjà vu. This doctor referred me to get another MRI, which I cringed at paying for but thought this could once and for all show the doctors what was going on. I got my third MRI in 13 months the first week of June. Went back to my first orthopedic doctor (yes I know confusing) who told me that the MRI showed bone marrow edema in my first tarso-metatarsal joint. These MRI results were very similar to those back in November. Considering all the conservative treatment options I had gone through up until that point (e.g. boot, injections, orthotics, more boot time, more orthotics, and of course rest), she decided to put a hard non-weight bearing cast on me. I kind of felt like this was going to come at some point, so I wasn’t too surprised. However, I was in no way prepared to go home that day with a cast and crutches. The doctors logic was that with a non-weight bearing boot I would completely rest my foot and the bone marrow edema would be able to dissipate. I was not totally convinced a cast would solve my problem. Mainly because I still believed my injury was of the Lisfranc variety, and the only way to heal that injury was surgery. But as with most things human, hope can be a powerful tool. What little hope I had left, I placed in my doctor and my cast.

For anyone who has never had a cast and crutches, be aware that the first few days to week is extremely awkward, frustrating, and at times dangerous. Crutches make everyday tasks 20 times more difficult or in some cases down right impossible. After about a day of having my cast, I realized that it was put on too tight. It was so tight in fact that it cut off my circulation in my foot. Luckily, I was able to go back to the doctors to fix my cast. In some of the most unnerving 10 minutes of my life, I watched as the nurse (who was clearly ill trained for the job) sawed away at certain pieces of my cast. There were numerous times when her unsteady hand sawed too deep or drifted nipping my foot. With my cast loosened, I continued adapting to crutch and cast life. Making food, carrying things, taking a shower, and laundry were a challenge. Taking a shower on one leg may be one of the most difficult things ever. Especially if done without slipping or falling over (which did happen).

I find that nothing I do can ever be just straightforward. I somehow usually make things harder then they need to be for myself, and being on crutches was not spared. In an ironic series of events, I ended up hurting my right foot while on crutches (remember it is my left foot with the cast). It happened because I thought it was an ok idea to hop on one leg across my kitchen. I did this because I wanted a fast way to carry my plate from the counter to table. Hopping on my foot is never a smart choice, as it puts all the force through the bones and ligaments of your one foot. This is of course what happened to me. The top of my right foot began to hurt shortly after my little stunt. Like my left foot, the pain began slowly and then progressed into a deep throbbing pain after a few hours. The injury to my right foot nearly put me over the edge. I almost lost my mind. The thought of having injured my right foot similar to my left could have easily given me a stressed induced heart attack. What I feared most was happening…both of my feet were in pain. At first, I could hardly handle the anxiety, but fortunately I had (have) a great girlfriend who helped me out. For about one week, I just laid up in bed and prayed that my right foot would get better. I eventually went to the doctor who referred me to get a bone scan. The bone scan results showed that I had soft tissue damage on the top of my foot and a possible bone contusion on my heel. My right foot did start to feel better after about a week. However, the pain would come and go for months to come. Additionally, my stunt caused me to have plantar fasciitis.

Desperation

At my wits end and pretty much desperate, I decided to go see a chiropractor. The source of my injury was being over looked by orthopedics, so giving into desperation I thought maybe a chiropractor could figure it out. That idea lasted for about a week. The chiropractor did their hokie tests and gave me some half scientific explanation of what my problem was. Believe it or not they told me that the reason my foot hurt was cause my lower back and hips were out of alignment. They thought they just solved my problem. Cutting edge scientific equipment and the best specialized doctors misdiagnosed me, but with the chiropractors sketchy x-ray machine and some poking at my back they solved it? Of course, to really solve this problem they recommended 18 visits to get me back into alignment. How did they magically come up with 18 visits as the right number for me to be cured?... Still trying to figure that one out. I will admit though, pure hope and desperation drove me to agree to their 18 visits. After about the first three, I realized I had made a mistake. Unfortunately, I had paid up front for the visits to get a discount and couldn’t get my money back…chiropractor equals fail.

The chiropractor debacle drove me even further into frustration. The pain in my foot was still present almost all the time. My next step was to go back to where I started… my first orthopedic doctor. It had been six months since I last saw this doctor. I caught her up to speed on my adventures through the foot saga. I had high hopes that this time she would really be able to figure out what was going on. I had an MRI and x-rays which she could use, but my hopes were soon crushed… as always. At this point, my experience talking to doctors was like déjà vu. Every time I would try and convince them to look beyond the obvious diagnosis and treat my foot with a little more aggression. Once again I told my doctor about my theory of a variation of a Lisfranc injury. I even showed her a gap between my big and second toe that would form upon weight bearing. To me, this physical deformity was the key signal that something beyond a bone-marrow edema was wrong with my foot. My thoughts and reasoning for this injury were swept to the side. I believe my doctors saw me a young kid to not be taken seriously. This meant my doctor did not listen to me, and instead thought physical therapy would help. Frustrated, I participated in physical therapy twice a week for two months. I mostly did this to appease my doctor and show her that it would do nothing to heal my injury. Who would have thought, I was right. Physical therapy did nothing, and actually caused me more pain than not. The only thing physical therapy did was make me sound more like a broken record. I told my physical therapist about the gap between my toes, the location of my pain, and what made it worsen. Most of all I told him about my theory of a Lisfranc injury. As always, I got the look that said “yeah…yeah…ok kid. Sorry but you don’t know anything”.

It hurts

Just like the doctor said my symptoms reemerged after about 3 weeks. This time though, the pain was more intense. The onset of pain came after I was at the gym one evening. I was doing some leg presses when I noticed a slight pop in my top mid-foot. Immediately I became paranoid that I had torn something in my foot. At first there was no pain, but similar to the period after the century bike ride, the pain slowly grew in my foot over the next 24 hrs. Some slight swelling and discoloration over the dorsal aspect of my mid-foot appeared in the following days. The pain was a throbbing in nature, and felt as if I had a hot metal rod in place of my first metatarsal and cuneiform. Soon after this injury I made an appointment with the UVA foot and ankle center.

I thought that a new doctor may have some insight into my problem. After about two weeks, I had my appointment in mid-November. The doctor that saw me did not seem worried about my injury. He gave me a tentative diagnosis of a stress fracture or stress reaction. I tried convincing the doctor that this problem felt unlike a stress fracture and needed more thought. To appease me, he referred me to get an MRI. As much as I knew an MRI would cost me, I did not care. I knew that an MRI would be my best option to get a comprehensive diagnosis. I got the MRI about two weeks after my doctors visit, and returned to the doctor for a follow up a week later. The MRI showed that I had bone marrow edema in my first cuneiform, tarso-metatarsal joint, and first metatarsal. The MRI results were to no surprise to me. They actually explained my pain profile well. However, the imagery and my doctors interpretation did not provide a mechanism for causing the bone marrow edema.

Going back two weeks before my MRI… I had been reading some medical journal papers in an effort to get a rough diagnosis of my injury. I found many articles on an rare and commonly misdiagnosed injury called a Lisfranc injury. Many of the symptoms presented in patients in the case studies were similar to mine. In fact, even the physical deformation of my foot was in line with the deformity of a Lisfranc injury. 

Now going back to the doctors office… I asked the doctor what he thought of my injury being some variation of a Lisfranc injury. Almost without hesitation, my doctor and his resident (who was sitting in) brushed off that “absurd” idea. Because I did not have a classic mechanism of a Lisfranc injury (high impact) and since the MRI showed my Lisfranc ligaments intact, my doctor did not give any more thought to this idea. Personally though, I believed that I had some form of a Lisfranc injury. But what do I know? I am not a doctor. With hesitation I trusted my doctors diagnosis and accepted the treatment options he gave me, which were comprised of getting stiff soled orthotics with an arch support. Of course I had not faith that orthotics would help me any, and I let the doctor know this. Nevertheless, he told me that it was just bone marrow edema and would go away with time…I called bull crap.

The rest of November, December, and January I lived in pain. The orthotics did jack. I went back to the doctor approximately four times in that period. Every visit I explained to the doctor how I was having no progress and we needed to reevaluate my diagnosis. Instead, he thought I did not purchase the correct orthotics… After purchasing three different types of orthotics, I still had no progress. I was frustrated and mad by the beginning of February. The physical pain and psychological wear and tear was taking a toll on me. Everyday tasks became too painful for me to do. This made me depressed, anti-social, and unmotivated.

Autumn

After the pain in August, I decided to stop running for an extended period. Kept to stationary biking and road biking for exercise. These exercises did not pose a problem, and the pain did not reemerge. On Setp. 14, I participated in a 100 mile road bike ride. I wore clipless pedals for the duration of the race. I didn't explicitly notice any pain in my foot while riding. I also do not remember any specific incident that would draw attention for injury. After the bike ride though, my left foot began to hurt again. It started very slowly at first, and did not become a problem until about 24 hours after the end of the bike ride. My foot showed slight signs of swelling and discoloration over my top right midfoot region. I assumed I had reinjured my past stress fracture and immediately put the walking boot back on. I wore the walking boot for the remainder of Sept.

After wearing the boot and experiencing pain in my left foot for 3 weeks, I decided to go back to the orthopedics. I explained my situation and the doctor was perplexed. She said it was not a re-injury of my second metatarsal stress fracture (as it is near impossible to get a stress fracture in the same location as a previous fracture). Her diagnosis was that I was experiencing some sort of inflammation or arthritis in my tarso-metatsal joint. This diagnosis mainly stemmed from my MRI results in May 2015, which showed degenerative changes in this joint. My doctor suggested that to relieve the pain, and hopefully shut down the inflammatory process, she inject a cortisone shot into my joint. Being that I had no other options, I agreed. She continued with the procedure and told me I could experience some initial soreness and pain for a few days to a week, but that I would most likely experience relief of symptoms for 2-3 weeks. After that period, she said that my symptoms may reemerge. Then we would need to reexamine my foot to find an alternate prognosis.

About me and some background

At present, I am a graduate student pursuing a masters. I have been an avid runner for 8 years and biker and hiker for 6 years. In high school I ran cross country and continued running un-competitively through my undergrad. I stuck to 5 k's and an occasional 10 k. In 2013, a little less than a year after graduating from undergrad, my habits changed. Starting in February (very cold) I hiked from Springer Mtn., GA to Bennington, VT by June on the Appalachian Trail. The story that goes along with that is for another blog.

After hiking the trail, my conception of what was a short walk/run or long walk/run was altered forever. Having used my feet to go everywhere along the trail and in towns, I began to love the freedom of walking or running gave me. I finally realized that walking and running was an actual form of transportation. With this thought in mind, whenever I ran I just ran and ran. Exploring the woods or different towns and cities with my feet. I noticed that not only could I run further after my hike, but my legs were also strong (especially up hills). After only a few weeks of running, I my mileage went from the classic 3 mile run to 10-12 mile runs. The craziest part was that I was less tired after my long 10-12 mile run than my when I used to finish my 3 mile runs. 

A few weeks after I came home from the trail I moved to attend graduate school. I continued running and actually increased my mileage the end of that summer and fall. Eventually I began to run 10 k's regularly and then ran a marathon by the end of the fall of 2014. I not only finished the marathon feeling pretty great, but my time (2 hrs 57 mins) qualified me for the Boston Marathon. I was pumped that I had qualified for the Boston Marathon and that I had done so in my first Marathon. My running regime continued through the winter and early spring. I ran a 10 miler and a half marathon, and was pleased with my times. Then it happened... like most people I always felt like "no, no...it won't happen to me. I run right, I take care of myself...etc.", but it did happen. It caught me off guard and surprised me. It was a beautiful late April day. I did a short hike with some friends, which wasn't eventful. I should have taken more heed though... because I felt a sharp pain in the top of my left mid-foot at one point. This should have sent an an alarm off in my head, but it didn't. Instead, since I felt like the hike wasn't enough exertion for one day, I decided to go for an hour long run when I got home. The majority of the run went fine. It was not until the last 10 mins that I noticed the sharp pain re-emerge on the top of my left foot. Every time my foot hit the ground a sharp pain sprang from my foot up my leg. At this point, I knew I had screwed myself. When I got home I continued to walk around on my foot. Up until that point, I usually just powered through pain thinking that something will pop back in place and it will be better by morning...not so much. The pain grew through the night and the next day until my ignorance and naivety wore off and I accepted that my foot needed real help. Over the course of the two months:

• Orthopedic diagnosed me with stress fracture to my second metatarsal
• wore walking boot for 6 wks
• got walking boot off
• slowly began to get back into walking and running
• First did a few mins of walk jog around track. 
• After 2-3 weeks out of the boot I began to take short runs. 
• Progressed from 15-45 min runs by the end of July.
• Ran in 4-miler race at the end of July. 
• Noticed after the race I had a slight twinge in the top of my foot. Afraid I got another stress fracture. 
• The small sign of pain subsided after a day. 
• Didn't run for a few days after race. Continued running regime for about a week when two days after a run in mid-August the top of my foot began to hurt. 
• The pain increased over the course of 48 hours. Mild swelling and discoloration presented itself. Wrapped foot in ACE bandage and endured the pain with NASIDS. 
• Continued cross training without much of a problem. Pain subsided after 10 days.

And this is where my story starts now...

My story

An injury can be a physical and psychological burden, especially when presented over a prolonged period. My left foot has been a source of pain for over a year now. Over the course of the past year, numerous doctors have been unable to diagnosis my problem successfully. This has meant I was put through the gambit, as far as a orthopedic medical treatments are concerned (some very expensive), and unfortunately none provided any resolve. However, in the past month I may have finally found an answer to my problem. It is not an easy solution...it may actually be the least appealing, but from almost the beginning I knew it is the only solution. That's where I am now.