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Message Number 258894
Re: Chronic Insertional Achilles Tendonitis/Retrocalcaneal Heel Spur View Thread
Posted by Nigel Jones on 7/16/09 at 09:26

I had the Op in September 2005 then had to go back in for another Op in the December as my foot was stuck in one position, since then I have had numerous physio to no avail the foot is still stuck, they now say my sural nerve is damaged, I was not told there was other treatments, if I was told I would never have had the Operation in the first place.

Result number: 1

Message Number 257307

Re: sural nerve pain View Thread
Posted by Dr. DSW on 5/06/09 at 06:33

Did your doctor attempt any injections or nerve blocks?

Result number: 2

Message Number 257306

sural nerve pain View Thread
Posted by darla on 5/06/09 at 03:55

i have alot of sural nerve pain in my foot it hapend after surgury on the foot i just want some thing to take away the pain do you know of any thing that will halp

Result number: 3

Message Number 257305

Re: Sural nerve along with TTS? View Thread
Posted by darla on 5/06/09 at 03:38

i havehad the pain for a year and i have numbness my doctor says for me not to have the the next surgery it would make thingd more pain full i had one surgery on my foot i just wish i could find something to take away the pain

Result number: 4

Message Number 256145

Sural nerve along with TTS? View Thread
Posted by emmie l on 3/21/09 at 20:00

There is a possibility I will have my Sural nerve cut at the same time I have Anterior TTS surgery. The sural nerve has caused me pain for quite a while. This nerve isn't released, it is cut to control symptoms. The cutting relieves pain but you have permanent numbness. I have numbness already so that won't be any different. I'm trying to make some decisions about this surgery. Has anyone had sural nerve issues along with their TTS?

I have had three foot surgeries which has contributed to these issues.


thanks

emmie

Result number: 5

Message Number 255935

Anterior Tarsal Tunnel View Thread
Posted by emmie l on 3/15/09 at 14:52

I have been diagnosed with Anterior Tarsal Tunnel which I understand is less common. It involves entrapment of the deep peroneal nerve. I just had a diagnostic injection which did help greatly so I will probably be facing surgery in the near future. My Nerve Conduction Study/EMG also showed some probable Sural nerve involvement and I believe this as I have pain laterally as well as numbness in the last two toes and down the side of the foot. has anyone had their Sural nerve released along with the TTS surgery? If the Sural nerve is entrapped is that considered a form of TTS? Will my recovery from Anterior TTS be any different than the 'regular' TTS?

sorry for so many questions!

emmie

Result number: 6

Message Number 254985

Re: Archilles tendonitis / autologous blood injections View Thread
Posted by Dr. Z on 2/10/09 at 21:07

Level 5 .21mj/mm2 Total energy flux density 604mj. Some need need a 2nd treatment for additional pain relief. Never use local infiltration with lidocaine in the treatment area. Use post tib, sural and post calcaneal nerve blocks. Read Dr. Furia article on this specific protocol. If you can't find it e-mail me and I send it to you.
I just saw a patient that I did ESWT on for insertinal AT. from 1999. Back then I used the orbasone ESWT device. Patient is still pain free.

Result number: 7

Message Number 254246

neuropathy - 5 years undiagnosed View Thread
Posted by tomo23 on 1/22/09 at 13:41

I am a male age 60,(5/8', 190lbs),and have always had high arches and substantial supination. As I got older and heaver, I started to have major problems with my feet. Five years ago - plantar fasciitis closely followed by what appears to be an injury to the sural nerve on the side of my right foot behind the 5th metatarsal. I can't wear shoes for very long because of the squeezing sensation they cause to the side of my right foot. Also, all of a sudden, anything pressing against either of my feet for more than about a minute caused generalized peripheral discomfort making me want to move my feet to interupt the contact. The discomfort is much worse when I am standing as opposed to walking, but walking any distance with shoes on, does aggravate the apparent injury to the side of my right foot and increases the uncomfortable sensations in both feet. The plantar fasciitis went away, but the other symtoms have remained. I have tried all sorts of insoles and even prescription othotics. Some help more than others, but not a lot. About a year ago, I started experiencing similar sensations in the backs of both hands, then up the tops of both forearms. the sensations in my hands and forearms are not constant. The sensations in my feet are present whenever I have maintained contact by shoes, floor or anything else for more than a minute or so. I also have hips that tend to rotate and need to be adjusted to keep them aligned. In the last 5 years, I have seen 3 podiatrists, 2 internists, 2 orthopaedists, 2 physical therapists and 1 neurologist. I have had many x-rays, and an mri. So far, no diagnosis. This has really become a quality of life problem. Any suggestions of where to go for help would be greatly appreciated.

Result number: 8

Message Number 253795

Re: Peroneal Tendon Subluxation View Thread
Posted by Dr. DSW on 1/08/09 at 08:07

Aron,
If you continue this dialogue I will delete your future posts, since it CLEARLY states in bold red letters on this message board that responses are to be from medical professionals only. Therefore, I anticipate your future cooperation. Thank you.

AnnShh,

I allowed Aron's post to remain because unlike many that post responses on this board, his post was accurate. A subluxing peroneal tendon(s) may be the cause of your symptoms and can be from a shallow groove or injury to this groove. There are several ways to surgically correct this depending on the surgeon's preferred choice. Also accurately mentioned by Aron is the proximity of the sural nerve which can became injured or entrapped in scar tissue.

He is correct that you must choose an experience orthopedic foot/ankle surgeon or experienced podiatric surgeon that has performed this procedure many times. Since your doctor is sending you to Baltimore, I have a suspicion he may be sending you to Dr. Mark Myerson, who is considered one of the best.

If you do have a subluxing peroneal tendon(s) this can sometimes be visualized in 'real time' imaging if you have a radiologist experienced in diagnostic ultrasound. The radiologist can actually see the tendon sublux with the motion you described during movement under ultrasound. If this is occurring, other than bracing, surgical intervention is the only real permanent option.

Result number: 9

Message Number 253791

Re: Peroneal Tendon Subluxation View Thread
Posted by Aron L on 1/07/09 at 22:46

AnnShh,
I am still in my cast from a repair of a subluxating peroneal tendon. Basically, I had no fibular groove for the tendons to sit in, so they subluxated on a regular basis. I did the PT, the CAM walker, ice, anti-inflammatories, and nothing helped. The surgery honestly wasn't that bad, but be prepared for a long stint on crutches. I had an arthrotomy, a radical reconstruction, and a repair of the subluxating tendon. I was on darvocet for about 6 days, then Advil was suffucient. I've been in the hard cast/splint for 3 weeks non-weight bearing, and I get it taken off tomorrow as well as getting the sutures removed. I'll be in the big black boot for 3 more weeks with partial weight bearing, and then into my shoes with full weight bearing. You surgeon of course may have a very different time frame for you, but that's what mine was.

I do recommend that you find an orthopedic surgeon that is highly reguarded, because the sural nerve runs right through the area of the incision, and it is very easy to have nerve involvement and then be stuck with numb, tingly toes. I was fortunate in having a great surgeon down here in Florida, and my pre-operative pain was gone immediately, and post-operative pain was gone in a matter of days(as long as the peroneus brevis didn't so much as twitch).

Sounds like surgery is the way to go if you aren't getting relief from PT - but I would definitely find the best possible surgeon you can.

Result number: 10

Message Number 253217

Re: Achilles Tendonosis ESWT View Thread
Posted by DR. Z on 12/17/08 at 10:57

Hi
This is very early to state there is permenent nerve damage. I have used Cryotherapy for sural nerve damage 2nd to EPF surgery . Did the needle hit the nerve?

Result number: 11

Message Number 253210

Achilles Tendonosis ESWT View Thread
Posted by Tamim on 12/17/08 at 10:17

I am ten days out of having eswt for severe achilles tendonosis. Was told it was a 90% success rate. Unfortunately I came out of it with nerve damage from the nerve block. Now taking Lyrica and not sure where this is headed. Is sural nerve damage treatable? I would appreciate any feedback anyone has to offer!

Result number: 12
Searching file 24

Message Number 248793

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by Lou Anne D. on 7/31/08 at 11:42

In response to your question about removal of the sural nerve, I had this procedure done on 3-08. Did you have your's removed? My husband and I were involved in a motorcycle accicent on 4-07 and it took a year before I was diagnosed with this problem. It is July 30, 2008 and I am still having difficulty with my foot and leg. The swelling has gone done considerably but I still have to wear a compression hose and ace bandage to keep it from swelling and also this seems to contain the pain somewhat. I am involved in PT three times a week and it seems as though I take one step forward and two backward most weeks. Please reply and let me know if you had this done and about your recovery. Thanks

Result number: 13

Message Number 248792

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by Lou Anne D. on 7/31/08 at 11:41

In response to your question about removal of the sural nerve, I had this procedure done on 3-08. Did you have your's removed? My husband and I were involved in a motorcycle accicent on 4-07 and it took a year before I was diagnosed with this problem. It is July 30, 2008 and I am still having difficulty with my foot and leg. The swelling has gone done considerably but I still have to wear a compression hose and ace bandage to keep it from swelling and also this seems to contain the pain somewhat. I am involved in PT three times a week and it seems as though I take one step forward and two backward most weeks. Please reply and let me know if you had this done and about your recovery. Thanks

Result number: 14

Message Number 247741

Re: Is this fasciitis? View Thread
Posted by Dr Cavazos on 6/19/08 at 07:29

True plantar fascitiis usuually resolves with traditional treatment or by itself after 4-6 weeks. i have found that persistent heel pain after 6 weeks usually is a nerve entrapment in the foot.Tarsal tunnel of the foot is different from a tarsal tunnel of the ankle. Pain on the outer foot usually is a nerve entrapment of the first brannch of the lateral plantar nerve or possibly a branch coming of the sural nerve. Ihave had the most success with cryoneurolysis because when it comes to nerve traditional treatments dont work and often make the condition worse i.e. orthotics visit www.cryoplantalis.com
-Dr. cavazos

Result number: 15

Message Number 247558

pain in lateral side of ankle View Thread
Posted by avi on 6/10/08 at 22:27

I have pain on lateral side of my right foot for ayear. From MRI it suggests that their is ligament strain. Also per EMG studies sural nerve reading is bit higher.According to Neurologist since i have no pin and needles it's not a cause of concern. I have mostly dull ache,bit of burning on lateral side of foot and under ankle bone. This pain is persistent and is not going away. Is there a way to figure out if it's sural nerve and what's treatment options ?

Result number: 16

Message Number 242239

Second opinion View Thread
Posted by jim on 1/21/08 at 08:19

I am seeing a DPM in Jacksonville, Florida, and after 7 years of unexplained pain from the back of my knee to the tips of my toes, this doctor may have found the cause. I have been diagnosed for the last 7 years with everything from PF to metatarsalalgia and everything in between. All MRI's Nerve Conduction Studies and Blood tests shown I was completely normal.

About 3 weeks ago I was referred to a diabetic wound care clinic and the DPM put me in for Ultrasound studies for my arteries and veins. The studies have shown that my lower saphenous vein is 3 times larger than normal. She believes this oversized vein may be compressing my sural nerve and causing much or the pain in my calf muscles, heel and forefoot. I had shown over 15 other doctors the bulge behind both my knees for years and asked if this could be causing the pain in my legs and they all dismissed it as a Baker's cyst, but now I know it was not a Baker's cyst.

The DPM wants to do a venous closure of the lower saphenous vein by placing a catheter into the vein and heating it up causing the vein to close. My question is, have any of you doctors ever had a patient with this kind of problem and would you do this procedure to try and fix the problem. I have bilateral saphenous vein bulging and bilateral leg and foot pain.

Jim

Result number: 17

Message Number 241232

Re: Burning Sensation in Heel During Stretch View Thread
Posted by Desertvu on 12/26/07 at 12:51

How about sural nerve entrapment, since the burning sensation may be produced by palpating behind and below the ankle on the lateral side?

Result number: 18
Searching file 23

Message Number 237548

Re: Curious Post Op Question View Thread
Posted by Dr. Ed on 10/11/07 at 22:21

Striker:

The sural nerve is the proximate nerve to the peroneal tendons. It is possible for that nerve to be damaged in such an operation.

Dr. Ed

Result number: 19

Message Number 237402

Radiofrequency Therapy View Thread
Posted by rob on 10/09/07 at 10:44

I have been diagnosed with heel pain probably involving the Sural nerve near the insertion of the Archilles tendon. An MRI showed there is swelling around the tendon and some trauma damage to the ankle joint.

My podiatrist has recommended RF treatment to neutralize the nerve. Can you give me some more information on the probable outcome of this treatment or are there alternative treatments?

I am in constant pain and anti-inflammatory drugs have not helped.

Thank-you.

Result number: 20

Message Number 236985

Burning Ankles View Thread
Posted by Ed T. on 9/30/07 at 12:16

I had tarsal tunnel releases 3/06 (along with peroneal brevis repair) and 8/06 as well as previous pf releases (have had diffuse bilateral pain since 1999). Was on crutches, walking boots, or rocker soles from 4/05, when both feet suddenly worsened, until 2/07 when I transitioned into normal NB shoes and old orthotics. Went through 6 or 7 sets/mods to orthotics since February and was making gradual improvement to foot pain when in late July both ankles rapidly developed pain/burning in lateral, medial, and lateral-anterior areas. Foot pain also markedly increased with accompanying neural signs. Returned within 2 weeks to rocker soles again which helped enough to allow me to move around the house. Only relief is in bed - I can't even sit with feet down without burning and entire plantar areas are painful to pressure. Have seen neurologists and they claim no neuropathy. MRI's to neck, back, and ankles/feet and nothing found.

Why the sudden onset of what seems like flareup of sural, post tibial, lateral and medial plantar, and superficial peroneal nerves?
Is it possible after not walking normally for so long and going through so many iterations of orthotics that I could have fired everything up? I never had ankle problems before these last 2+ months and am less able to walk now than ever. Thanks for any advice as to where to go or what to do. My GP and podiatrist/surgeon are stumped.

Result number: 21

Message Number 234858

Toe Pain View Thread
Posted by Ben on 8/24/07 at 09:40

What does a mild latency in the Sural nerve on an EMG mean? I recently developed pain at the tips of my third and fourth toes.
My podiatrist is trying to figure out the cause of it. They hurt really bad when I walk.

He said my x-rays looked normal and the only finding so far was this thing with the Sural nerve. Would this cause the pain in my toes?

I see him again in another week. What questions should I be asking and are there other tests I should ask about.

Result number: 22

Message Number 234187

Re: Surgeon is recommending a brace but offers no suggestions View Thread
Posted by Kate on 8/10/07 at 08:42

PN is idiopathic. I've done the gait training and muscle strengthening. Even the PT told me after my last repair in Feb. that I would roll again. I just can't feel enough of my foot and what I do feel is all about nerve pain. I can't feel anything on my heel and my common superficial peroneal nerve is completely gone. Sural comes and goes.

My ortho is often a bit abrupt (see my comment under surgery - I got an apology from him!) and he's young. He's real into computer stuff. I've looked online and there are countless options. I think that I will push for the referral to the orthotist who built my last orthotics as he's got a lot of experience and I don't have a clue.

I'm still humming 'Putting on the Ritz' as I clomp around.

By the way - anyone know of a way to handle the world's roughest fiberglass cast? I've deeply scratched my good knee and both thumbs already. Dang thing is the roughest cast that I've ever had (and I've had a quite a few).

Thanks to all!

Result number: 23

Message Number 234037

#12 is over and healing View Thread
Posted by Kate on 8/07/07 at 13:36

My cadaver graft is in place and I'm actually feeling pretty good other than lots of bone pain. I assume it is from the holes that were drilled into the bone. I've lost all sensation in my last two toes and the lateral side of my foot. Good old sural nerve was either damaged or is taking a vacation. It's not the first time for either.

I'm ticked at my surgeon tho. He told my spouse that he did stress xrays under anesthesia to rule out Munschausen's Syndrome since I've had so many surgeries but that the Xrays confirmed that I really was having a lot of ankle pain. Would have been nice if he had talked to me about this not to mention had my permission to discuss something like this with my spouse. Not to mention that he's done all 12 operations. It would seem to me that he was covering his hinder and blaming me. I plan on discussing this with him at my next visit.

Docs out there - what are the ethics here? If he really beleived that I was making up ankle pain and gross instability, in my opinion, he shouldn't have been scheduling surgery. And how would one fake instability anyhow? Isn't a positive anterior drawer test a little hard to fake?

Result number: 24

Message Number 233848

nerve pain worse, tests say all is OK? Huh? View Thread
Posted by Lori on 8/01/07 at 22:38

Thanks Dr. G.

Unfortunately, the nerve pain has increased by a lot. I saw a neurologist today. The sural nerve appears to be the problem area. Not so on the NCV test. The test was normal for both feet, yet I have slight numbness and a definite change in sensation. I'm very frustrated! The pain is intense (just starting Lyrica) and now it's continuous. It's getting hard to walk/stand for more than a few minutes.

I don't understand how the tests could be normal yet I have a LOT Of pain and numbness. Any thoughts from the Drs out there?
Thanks,
Lori

Result number: 25

Message Number 233680

Re: Multiple treatments for Baxters nerve pain View Thread
Posted by Dr K on 7/28/07 at 20:00

The reason that the pain is not alleviated using the stimulator on the first try is that the nerve may have several branches. I will always stimulate several areas and will typically find another branch. When I find that there is minimal numbness plantarly after the first nerve then I will continue to stim areas close by and almost always find another branch. When the other branch gets a good freeze, most of the medial heel will be numb. I have also found that upon exam, branches of the sural nerve are often involved laterally. If you are not getting relief the first time, I would consider examining the lateral area and freezing the sural branch to the lateral calcaneus.

I agree that there is art to Cryo, however, the importance of proper diagnosis and a strong understanding of the anatomy is truly the key.

Result number: 26

Message Number 233145

Re: Sorry - but my ankle is still troubling me...... View Thread
Posted by Dr. Z ( vacation) on 7/18/07 at 15:00

Might be the Sural nerve. This is a very small skin nerve that can become inflamed and or injuried after an ankle sprain. Its possible

Result number: 27

Message Number 232207

Re: Entrapped Nerves or Idiomatic Peripheral Neuropathy???? View Thread
Posted by LisaK on 6/28/07 at 20:33

Thanks. Well, I have done alll the conservative treatments, taping, NSAIDS, custom orthodics, walking boot, hard cast, medrol pack, injections.

Does the PSSD test for all nerves, sural nerve. What is the nerve that supplys sensation to the back of the heel (not the bottom of the foot)

Are the lateral calcaneal nerve and medial calcaneal nerve both affected by Baxter's entrapment or TTS? I have nerve pain on the outside of the calcaneal area as well.

Thanks,
Lisa

Result number: 28

Message Number 232184

Entrapped Nerves or Idiomatic Peripheral Neuropathy???? View Thread
Posted by LisaK on 6/28/07 at 13:53

I was orginally diagnossed with TTS and have all the classic signs, tinels sign, burning, severe pain, can't wear tight shoes. Recently began having other nerve pain on lateral side of ankle, bottom of foot where sural nerve comes in and back of heel.

1st NCV came back slightly abnormal for TTS, two months later had addtional NCV/EMG which all came back normal, it was the same Neuolorigst who did testing both times. MRI for ankles and back normal.

I am in severe pain, orignal TTS pain still there, but other nerves involved now too.

How is a diagnosis of a entrapped nerves arrived at? I have had all systemic tests done, no diabetes, etc.

Result number: 29

Message Number 232076

Lateral Calcaneal & Other Nerve Pain View Thread
Posted by LisaK on 6/26/07 at 12:00

I have been diagnosed with TTS, but for the past 2 months have experienced severe lateral calcaneal nerve pain, additionally on the lateral ankle ( sural nerve area). The very end of my heel (not the bottom) is so tender I cannot rest it on the bed, have to prop my calf on a pillow, also get pain radiating into my foot from pressure on the calf.

Can the lateral calcaneal nerve become entraped, how about the sural? What are treatment options.

Result number: 30

Message Number 231820

Re: Vascular Circulation Problems without Diabetes View Thread
Posted by VelmaK on 6/19/07 at 11:36

Thanks for the info. I have been tested for all systemic stuff such as diabetes, thyroid, etc.

My original diagnosis was bilateral TTS, but I am now experiencing nerve pain on the lateral side, sural and peroneal nerves, I believe, so trying to get to the bottom of the root cause, which is chalenging.

Result number: 31

Message Number 231793

Re: PSSD testing expectations/questions to ask View Thread
Posted by dr.g on 6/18/07 at 19:09

yes, I don't think we have a 'normal' value for the sural nerve, but the doctor can check it and compare it with your other foot.

Result number: 32

Message Number 231770

Re: PSSD testing expectations/questions to ask View Thread
Posted by VelmaK on 6/18/07 at 12:55

Thanks Dr. G.

Can the sural nerve be tested as well?

I have an appointment at the Foot & Ankle Institute in Santa Monica, CA. Is anyone aware of their expertise in PSSD testing or TTS.

Result number: 33

Message Number 231705

PSSD testing expectations/questions to ask View Thread
Posted by VelmaK on 6/17/07 at 12:21

I am traveling from Northern Cal to Southern Cal to get PSSD testing and consultaiton.

I want to get the most out of the appointment.

What questions should I ask? Also, can all the nerves be tested with PSSD, sural, peroneal, tibial? Is it standard to test all nerves or do I need to request this?

Any assistance is greatly apreciated.

Result number: 34

Message Number 231303

Re: PSSD testing in Northern California View Thread
Posted by VelmaK on 6/08/07 at 16:22

Thanks for the info on PSSD.

I am scheduled to see a Neurosurgeon at Stanford. My NCV/EMG tests all came back negative as well as my back and ankle MRIs, but of course I am still experiencing much TTS nerve pain, as well as other nerve pain on the lateral ankle area (sural nerve). The sural nerve pain is fairly new but the TTS has been there a while.

Since the NCV/EMG is the standard for MDs and mine are negative, what other diagnostic tests do MDs use for idenitfying compressed nerves or nerve problems?

Result number: 35

Message Number 230153

Pedorthist/Tarsal Tunnel Question View Thread
Posted by VelmaK on 5/18/07 at 17:37

What is the role of the pedorthist. Would it be helpful to go to a Pedorthist for TTS?

What type of shoe should I get for TTS, additionally I am now having nerve pain on the outside, lateral part of my ankle, nerve pain, probably sural nerve.

Any suggestions.

Result number: 36

Message Number 230120

Re: Tarsal Tunnel or L5 nerve in back View Thread
Posted by Dr. Ed on 5/18/07 at 10:44

TTS can cause pain on the lateral plantar aspect of the heel but not the lateral heel nor lateral ankle. If the pain is on the lateral heel or lateral ankle posterior (behind) the ankle bone (lateral malleolus) then you are looking at the sural nerve, L5-S1 nerve root or anything in between.

Dr. Ed

Result number: 37
Searching file 22

Message Number 229988

TTS or other diagnosis View Thread
Posted by VelmaK on 5/16/07 at 16:57

Seven months ago after wearing high heels shoes all day and then continuing the next day on my running regim ( 25 miles per week) both feet began burning, originally diagnosed with PF, then diagnosed with TTS bilaterally, NCV was just slightly abnormal in both feet. We tried casting in the worse foot, medrol pack, etc. My DPM, put me in front of a board or 8 Podiatric Surgeons, as a tough to solve case, all unanimously agreed it was TTS and that I needed release surgery. Marcain injection with small does of cortisone was given in left foot, not much relief which surprised the doctor.

Several days later I began having nerve pain in the outside of the ankle up the side of leg and also on the top of my feet. NCV/EMG test conducted again, testing sural and peroneal nerves as well, and back MRI all came out negative, in fact my tibial nerve tests improved, meaning no irregularity. MY DPM believes this is not TTS, but that my nerves are misfiring, and perhaps Chronic Pain Sydrome. I have a pain management specialist, anesthesiologist, and have been on Neurotin and Nortriptyline, no success, feel as I am just getting worse.

How accurate are the EMG/NCV for TTS and should I seek another opinion? I DO NOT want TTS surgery, but am in so much pain, at the end of my rope. Any input?

Thanks

Result number: 38

Message Number 227917

Re: Is Tinnels sign by itself a problem? View Thread
Posted by dr g on 4/16/07 at 19:53

You most likely injured your superficial peroneal nerve or the sural nerve. Usually they will heal with no intervention in 2-6 months. You should be careful for a while, you will be more susceptable to further injury (this is usually referred to as loss of proprioception).
You also shoud be considering an MRI at this point, the ankle may have more damage then originally thought.

Result number: 39

Message Number 227596

I missed a surgery - oops View Thread
Posted by Kate on 4/12/07 at 15:37

Oops I missed one - a redo of the ATFL/CFL. It was the most recent procedure. I don't even count the inclusional cyst removal or the removal of deep sutures that we hitting the sural nerve. Incision under 1' are just minor irritations even if they are deep.

Result number: 40

Message Number 227099

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by dr.g on 4/08/07 at 11:46

T.E.N.S. may also be a good non surgical alternative. If it works you could purchase a unit for about $100 and insurance may cover it.

Result number: 41

Message Number 227036

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by Dr. Ed on 4/07/07 at 18:18

th:
What types of therapy did you have? Another non-surgica loption is hyaluronidase which is specific for scar tissue.
Dr. Ed

Result number: 42

Message Number 227029

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by th on 4/07/07 at 17:04

Other options tried in the past 6 months are therapy, medication (including Lyrica) and now the cortisone. Isn't surgery the next step?

Result number: 43

Message Number 226967

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by Dr. Ed on 4/06/07 at 23:26

Why the rush to surgery? Consider performing the range of conservative treatment options before surgery.
Dr. Ed

Result number: 44

Message Number 226928

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by th on 4/06/07 at 10:50

Can you tell me what the surgery involves? I was just diagnosed with this. They tapped on my outer foot and I had tingling and then they put numbing medicine in my outer ankle and the pain stopped for a short while. Then they put some cortisone in the area and said to see if that helped. If not, we will discuss surgery. So far, it hasn't helped.

Result number: 45

Message Number 226259

Re: One week update... View Thread
Posted by kjewell on 3/30/07 at 05:59

Actually I was told on here that the procedure I had was a Dellon procedure...but I have no idea if my doc was a Dellon doc. My doctor was recommended to me by my Pain Management Specialist and is here in Delaware. My insurance was auto insurance so it may be covered a little different from medical insurance. I did have to travel to see this doctor, but only 45 minutes and it was well worth it. My EMG was negative, but my PSSD was definitely positive...have you had that done? I call it the one pin-two pin test because they use a wheel of pins and you have to tell them if you feel one or two (I only felt two like twice). For my age group there was a specific number in which I should feel the two pins (a specific distance apart), perhaps you should ask for this one. However, mine was a failure due to a multitude of issues arising from an accident. I still need work on my saphenous nerve and sural nerve. Good luck to you in your search!

PS my doctor is a Plastic Surgeon who is also a Peripheal Nerve Specialist...perhaps you could look and see if you have a Peripheal Nerve Specialist in your area.

Result number: 46

Message Number 226215

Re: Tarsal Tunnel Syndrome View Thread
Posted by dr g on 3/29/07 at 15:56

No ,they are different nerves. The lateral ankle is innervated by the sural nerve and branches of the peroneals. That being said, you may be trying to compensate by putting more pressure laterally or your problem may be entrapement higher up (knee or back).

Result number: 47

Message Number 222827

Re: TTS diagnosis, but pain is in outer ankles View Thread
Posted by Amanda on 2/17/07 at 10:26

I have had a complete workup of my spine - absolutely no problems. I also only take the medication - Neurontin for this problem. Does proximal mean farther away? I previously had a diagnosis of fibromyalgia, but I don't have symptoms of it now nor for a couple of years so I don't think that could be causing it. I think I do have fluid retention on the outer part of my ankle, but that's also where it hurts so my theory is that my whole ankle joint is out of alignment and is causing both tibial nerve and sural nerve problems. I had a ankle prolapse of my joint capsule which has resolved. What do you think?

Result number: 48

Message Number 222826

Re: TTS diagnosis, but pain is in outer ankles View Thread
Posted by Amanda on 2/17/07 at 10:26

I have had a complete workup of my spine - absolutely no problems. I also only take the medication - Neurontin for this problem. Does proximal mean farther away? I previously had a diagnosis of fibromyalgia, but I don't have symptoms of it now nor for a couple of years so I don't think that could be causing it. I think I do have fluid retention on the outer part of my ankle, but that's also where it hurts so my theory is that my whole ankle joint is out of alignment and is causing both tibial nerve and sural nerve problems. I had a ankle prolapse of my joint capsule which has resolved. What do you think?

Result number: 49

Message Number 222812

Re: TTS diagnosis, but pain is in outer ankles View Thread
Posted by Dr. David S. Wander on 2/17/07 at 08:18

It is always possible, though not common, that there is an entrapment neuropathy of both the tibial nerve and the sural nerve. However, when this does occur (rarely in my experience), I always look for other causes such as a systemic illness, neurological disease process, soft tissue mass in a more proximal location, or a more proximal cause such as a spine problem or radiculopathy.

That doesn't necessarily mean that there has to be some "horrible" cause to this problem, but I like to be cautious and rule out other possible serious causes since this rarely occurs in my experience. But, there can also be very simple causes to this condition such as local trauma, fluid retention, medications, etc.

Result number: 50

Message Number 222800

Re: TTS diagnosis, but pain is in outer ankles View Thread
Posted by Amanda on 2/16/07 at 21:47

I'd be curious to know this answer as well. I've had some problems with my tibial nerve and tingling on the bottom of my feet, but is a doctor asked me where it hurt, I'd immediately point to my outer ankle. I also have had some sural nerve latency on an EMG. Dr. Wander, what do you think? Could there be two entrapments on both sides?

Result number: 51

Message Number 221006

Re: To: Jen View Thread
Posted by dr nordyke on 1/29/07 at 00:59

Sorry for the delay in answering..I am seldom on this site...that is a loaded question and no way to answer without seeing how much dorsiflexion you have at the ankle with your knee extended and flexed. If you have a lack of motion at the ankle with your knee extended, as compared to your knee flexed, then you may benefit from this procedure. If you have the same measurments then your chances of success from EGR are less likely in my experience.

Complications range from a neuritis of the sural nerve, prolonged pain and swelling from the soleus being cut so to speak, and overall soreness from the procedure itself.

Thus..very important to be between the peritenon and the gastroc fascia.

Result number: 52
Searching file 21

Message Number 219064

Re: Bevious nerve of left foot surgery left me with nerve damage View Thread
Posted by Kate on 1/07/07 at 13:47

Ah, the beloved sural nerve runs next to the tendon (I've had bilateral repairs -one of them 3 times) and the first one left me with numbness...then the incision was re-used for ligament repair and voila - sensation returned.

Are you massaging the scar? It can release a nerve caught in the scar. I would think it likely that the nerve was moved during your tendon repair. My surgeon says nerves don't like to be moved, touched or looked at.

SO the short of it is to give it time and it might return or go see a neurologist.

Result number: 53

Message Number 218557

Re: neuroma and cryosurgery View Thread
Posted by Dr.Goldstein on 12/31/06 at 18:52

You did not ask questions, go back and read your statements CAREFULLY. Also why are you, a non-physician so concerned about what anyone else is doing? I use a nerve stimulator as I do extensive work on peripheral nerves, something you again no nothing about. How many tarsal tunnel cases has your supergroup done? Have they done achilles work for calcific tendonitis, sural neuritis, sinus tarsi syndrome? You think it is so easy, guess what, you don't have a clue MORON. Most poeple do not even attempt this. How do you think you isolate a nerve if there is a true nerve entrapment? You need to use stim to isolate it. remember if it was so easy an idiot like you could do it but you can't and thank god never will. I lovethat you got of the phone with one of the "doctors in my wife's practice". I did not know the practice was hers. Obviously you think it is. You sound like some of the other detractor's that have used false identities like know them, dr. parker etc. The training is far more difficult if you want to perform the high risk, high level procedures but again how would you know your wife's group most likely cannot perform them. Again a case of those who no nothing spouting off as if they were actually a doctor instead of a want to be equipment salesman. Anytime your supergroup wants to discuss cryosurgical techniques have them call on me or maybe they will here me lecture at an upcoming seminar or read my next publication.

Result number: 54

Message Number 216831

Re: Nerve transplant/transfer surgery View Thread
Posted by dr g. on 12/06/06 at 17:56

There are other docs doing this procedure,using typically the sural nerve (on the outside of your lower leg). I have not read any studies on long term success, but ii think if done correctly, probably also adding a neurawrap, it would work for any failed nerve surgery.

Result number: 55

Message Number 215886

Re: another new pain View Thread
Posted by MUF on 11/20/06 at 14:50

If you have altered your gait or just how you stand on your foot (in order to protect the TTS side) you may have irritated the tendons or nerves on the outer part of your foot. I know this all too well - look up peroneal tendons to see if this is a possible source. You also have nerves on the outer part of the foot that could easily become irritated as well such as the sural nerve.

Talk to your doc about this! If you've irritated the tendons, you need to get on top of it to settle them, or the nerve, down before it is a surgical type of problem.

Result number: 56

Message Number 211613

Re: sural nerve appt, any info suggestions View Thread
Posted by R. Parker, DPM on 9/28/06 at 11:58

The fact that you apparently have sural neuropathy does not speak to its underlying cause. The source or cause of the nerve dysfuntion needs to be determined. That should shed light on what and whether treatments may be effective in resolving your situation. What I would suggest is that you insist that the doctor clarify the purpose of whatever tests and examinations he/she administers, his/her evaluation of the results, his/her thought processes as to any diagnosis or differential diagnoses he/she might infer, what the treament plan will be and what his/her estimate of the success/failure rate in his/her hands would be expected.

Your responsibility is to get clear in your mind the entire story of your condition in minute detail, and to be able to relate it in a concise, succinct and non-equivocating manner (Some patient tend to continually make statements which, somewhere done the line they then modify or even retract. That is a needless waste of the doctors time and efforts. Say what your mean and mean what you say.)

Result number: 57

Message Number 211601

sural nerve appt, any info suggestions View Thread
Posted by scott from england on 9/28/06 at 11:21

hi all

going to see foot/ankle surgeon in two weeks any info on what tests i should be asking/denmading for would be apprecited, told me this nerve problem would either go or lateral part of foot would have no feeling, this has been going on for 1 yr now starting to drive me nuts and effecting all aspects of everday life, had emg and it was normal

any suggestions please

Result number: 58
Searching file 20

Message Number 208439

Re: any one else dealing with haglund's surgery? View Thread
Posted by Dr. Carl on 8/26/06 at 07:57

Haglund's deformity is not associated with or cause by spurs of the heel. It is an bony over-prominence of the posterior-dorsal and posterior-lateral portions of the heel. Surgery to correct this condition should specifically avoid trauma to the Achilles tendon and if the procedure is properly performed there is no reason that it would cause calcifications of that tendon. it is necessary also to protect the sural nerve from injury during the procedure as it normally courses just lateral to the Achilles tendon.

Result number: 59

Message Number 207816

lateral recurrent calcaneal nerve problems View Thread
Posted by scott from england on 8/19/06 at 10:19

hi there without going into too much detail here is abrief desc of my foot probs

1 fractute to calcaneal bone 10 yrs ago

2 pain started in heel to outside of ankle 1 yr ago

3 thought i had sural nerve problem had emg sural nerve seemed fine, told to carry on activities as normal only a sensory nerve

4 about three weeks ago went out on 10 mile trek(just walking) following day severe pain in 5th metarsal when iniating walking went to hosp had scan no stress fracture went to see ankle foot surgeon said i had stressed peroneal tendon.

5 it is now 3 weeks later now and i have original pain which seems to be where my sural nerve is but the branch leading off into heel which is lateral recurrent calcaneal nerve(my original stinging burning fuzzy pain)

iam at a loss now as one pain seems to replaced with another just wanted some info on this nerve problem,iam sure something is goin on in ankle/heel cud my problem be related to break 10 yrs ago just wondered where i shud go from here any feedback wud be much appreciated appreciated

thanks scott
my email is if any one cud send any info

laurascottskye at tiscali.co.uk

Result number: 60

Message Number 204602

Re: tts surgery and sural nerve entrapment? View Thread
Posted by Bryan W. on 7/18/06 at 18:13

no linda none like yours...you can read my whole story on the new forum and feel free to post yours there too if you like! Here is the link...
http://p4.forumforfree.com/tarsaltunnel.html

Result number: 61

Message Number 204209

Re: tts surgery and sural nerve entrapment? View Thread
Posted by linda m. on 7/15/06 at 09:00

Dear Bryan: The sural nerve in the foot runs along the outside edge out to the little toe. I did have entrapment of the main nerve, I believe.

Do you have any experience with postop symptoms like mine?

Thank you, Linda

Result number: 62

Message Number 204187

Re: tts surgery and sural nerve entrapment? View Thread
Posted by Bryan W. on 7/14/06 at 23:59

where is this "sural" nerve at exactly. did u have entrapment on your main nerve?

Result number: 63

Message Number 204115

tts surgery and sural nerve entrapment? View Thread
Posted by linda m. on 7/14/06 at 13:07

Fellow tts sufferers: I continue to struggle along--2.5 weeks post-op from tts surgery--suffering from a very painful cluster of symptoms that may indicate entrapment of the sural nerve. I have alternating numbness/shooting pain/spasms along the outside edge of my foot. My little toe has been either stiff as a board or incredibly painful since the surgery. (None of these symptoms were present before surgery.)

My doctor feels this is all nerve irritation from surgery which should gradually resolve...

Has anyone developed sural nerve entrapment as a result of tts surgery? If so, how did you treat it?

MANY thanks,
linda m.

Result number: 64

Message Number 203394

Re: Post ESWT pain View Thread
Posted by MichaelS on 7/08/06 at 17:00

I am begining to think my doc was wromg and I have nerve pain? Is it possible to get irritation of the sural nerve where it attached to the lateral back of the heel? It hurts just to touch there. Aches all day. The second sore spot is basically on the medial calcaneal tubercle, maybe a little medial to that. Also so to touch never mind walk.

Result number: 65

Message Number 202033

TTS- heriditary or not View Thread
Posted by Mary A. on 6/24/06 at 16:31



Sorry, it didn't link right. here is the exerpt:
Clinical and electrophysiological findings and follow-up in tarsal tunnel syndrome.

Mondelli M, Giannini F, Reale F.

Azienda Sanitaria Locale 7, Institute of Neurological Sciences, University of Siena, Italy.

The authors report clinical and electrophysiological findings in 59 patients with tarsal tunnel syndrome (TTS) and follow-up in 23 of them. The entrapment was prevalent in females; was bilateral in 6 patients and involved medial plantar in 7 and lateral plantar nerves in two cases. Eleven presented with other nerve entrapment syndromes or focal mononeuropathies, due to hereditary neuropathy with liability to pressure palsy or systemic diseases. The other 48 subjects had TTS without any other related entrapment syndromes: 23 were idiopathic cases, 13 had a history of local trauma, 3 had systemic diseases and the others had external or intrinsic compressions. The most frequent symptoms were paraesthesia or dysaesthesia (86% of feet) and pain (55%). Hypoaesthesia of the sole and weakness of toe flexion were evident in 74% and 22% of feet, respectively. Absence of sensory action potential or slowing of sensory conduction velocity (SCV) of the plantar nerves were present in 77% of feet; significant differences of SCV between affected and unaffected plantar nerves and/or between distal sural and plantar nerves were evident in 14%. Abnormalities of plantar SCV were therefore absent in only 9% of feet. Distal motor latency was delayed in 55% and electromyography showed neurogenic changes in 45% of sole muscles. Five cases (6 feet) underwent surgery with excellent or good results in 5, 4 of them also showing improvement in distal conduction of the plantar nerves. Nine were treated with local steroid injections, with good results shown in 6 patients. Nine other patients who did not receive any therapy showed a disappearance of symptoms or good outcome in 6 cases. The subjects with poor therapeutic results had S1 radiculopathy or systemic diseases. The authors underline that patients with connective tissue diseases should not be treated by surgical decompression because they may have subclinical neuropathy. Some subjects with idiopathic or trauma-induced TTS recover spontaneously. Surgical release should be limited to cases with space-occupying lesions and when conservative treatments fail.

Result number: 66
Searching file 19

Message Number 199922

Re: Has Cryo worked for diabetic neuropathy patients? View Thread
Posted by dr nordke on 5/27/06 at 00:29

Hi Steve,
I wonder if the main objective in this case is pain relief, that if you can pinpoint the main areas of pain, it might help without having to hit every single one of those areas. If the pain is broad in nature, then I think you are right.

The cryo in all likelyhood would not make it worse if a patient is currently on methadone for the pain.

I just did a case today for scar tissue and nerve entrapment that another surgeon sent me..along the course of the sural. I will let you know how it went.

Dr Nordyke

Result number: 67

Message Number 198924

Re: Has Cryo worked for diabetic neuropathy patients? View Thread
Posted by Dr. S . Goldstein on 5/11/06 at 15:31

Cryosurgery for diabetic neuropathy can be difficult because there are quite a few nerves involved. One may have to freeze the posterior tibial, deep peroneal, dorsal cutaneous nerves and the sural. Very few patients want to try this due to the amount of surgery needed. I would still want a patient to have a nerve conduction study prior to doing this to give me a baseline as to where the problems originate from. This type of surgery may need to be done in stepwise progresion. Thses cases are not like doing a single neuroma or a plantar fascial case they require alot of skill and expertise on the part of your surgeon.
Another comment to all: When doing procedures on any patient that has had prior open surgery, the recovery is far different as one is going through scar tissue and sorts which makes the procedure more traumatic so that one may have more bruising and discomfort than a routine cryosurgical procedure.
having done a large amout of revisional procedures on patients the recovery period can be far longer than a first time routine procedure.

Result number: 68

Message Number 197518

yet more questions View Thread
Posted by messed up foot on 4/15/06 at 14:06

Saw my neurologist about nerve pain and numbness. She is trying me on Lyrica (so far so good - great sleep!) and repeating my EMGs. Why bother on my one foot? Common superficial peroneal nerve was severed last year so these results will be a bit amusing.

Neuro is concerned that my 4th toe is so painful - but only at night. I assume that is the sural nerve??? Other foot has a flair up of my PF and the nerve pain is following the posterior tibial nerve from the base of my great toe into my calf with lots of tingling and numbness. I'm one week post steroid injections in the tarsal tunnel and no better. Neuro said that she'd recommend TT release but only if the EMG shows a problem since I developed lymphedema in my other ankle after TT release. My neuro is top notch and very conservative.

I'd like your opinion on her reasoning for my cascade of foot/ankle problems. She said that as we age (humph!) our tendons & ligaments get more rigid. When one fails or is stressed, others try to compensate and may also tear. Some heal and some become chronically irritated. In the process the associated nerves are irritate and compressed. She asked about other joints and sure enough, my knee is acting up from my new gait....

I really like my neurologist (Who by the way affirmed that nerve pain is horrible and not just in my head!)but the thought of more surgery is unbelievable. Is there any other conservative treatment for TTS? The last injection actually made it worse not better. I see her again in late May but I should know my EMG results next week.

Feet as such a bother!

Result number: 69

Message Number 196787

Re: EPF, Open Release, Peroneus Brevis Tendonitis View Thread
Posted by Ann on 4/02/06 at 20:25

Hi,

I am so sorry to hear about your pain. Like you I had surgery over a year ago. Had EMG (?sural nerve entrapment) MRI, count less cortisone treatments, 12 cool laser treatments. I have to tell you that I too have had this crazy thought of having the foot removed. Then I could run again ...I am so depressed about it. I now have pain to the later side of the foot, ankle, side of calf, and now the heel pain (were the heel spur is and pain at the incision site near the arch. i have ever "foot" boot known to mankind. I have given up. I am going on 14 months of this with no relief of deoctor that know what to do to help me. Will make an appointment with a pain clinic this week. i can sit in my car for 15 minutes and when i get out I am limping...same anytime I sit.

I read once that EPF was the most "abused" surgery. i really think I have scar tissue and calcaneal cuboid syndrome (know to be VERY difficult to fix.) Stay in touch!! You are in my thoughts.

Ann

Result number: 70

Message Number 196633

Re: Messed up foot-please respond View Thread
Posted by messed up foot on 3/31/06 at 10:29

My was the common superficial peroneal nerve (on top of foot) and it was outpatient. Back to work the next day with a sore ankle (incision). I'm not sure where your incision would be, but it is all superficial stuff.

One caution, when the removed by nerve and re-routed the stump to my fibula, my sural nerve got all riled up. In about 2 months, it calmed down but for the first couple of days, my 4 toe (aka Piggy had None) was very sensitive to touch. Plus, to this day, if I bump the ankle scar, it feels like I've bumped my toes. Clearly the brain is still working through this remodeling process. The skin on the top of my foot is numb but I still have deep pressure feelings so this was a WONDERFUL surgery for me.

Best of luck to you! Surgery is always a big deal, but it if stops that ugly nerve pain, it can be well worth it!

Result number: 71

Message Number 196494

1year and 1 month post EPFan still in agony. They wwant to do a Sual nerve release? View Thread
Posted by Ann on 3/29/06 at 21:49

Hi everybody,
Continue with latral, foot, calf and knee pain. Now have the start of a bunion and hammer toe from the the change in my foot to try and alter my walk to decrease the pain. after having every test and procedure doncluding col laser) they are almost positove it is sural nerve entrapment. i have also found that I am now have increased pain in the heal.

Any one had sural nerve entrapmwnt release?? Any success??

Also i feel that I need al long acting pain med and one for breal through pain. I hate to say it but i have had thoughts of just having th efoot removed. This had comletely altered my life as I knew it. No long distance running. Almost constant aching and throbbing. Waking up at night nd not be able ta fall back to sleep''''

Result number: 72

Message Number 196048

Re: cuboid joint fusion View Thread
Posted by Dr. Z on 3/23/06 at 17:58

Annette,
I though that you pain was around the ankle and involved the sural nerve.? Am I correct?

Result number: 73

Message Number 195987

Re: Cryosurgery / Plantar Fibromatosis View Thread
Posted by Paul T on 3/22/06 at 18:37

Dr. Wander: lets get some of your facts straight that are misguided. Dr. Goldstein was trained by Dr. fallat and learned his technique for PF and Morton's neuromas ans plantar warts PERIOD! Dr. Goldstein took it upon himself to to a step further and try Achilles Tendonitis, Tarsal Tunnel, Sural nerve Entrapements, Plantar fibromas, retrocalcaneal bursitis, keloids, to name a few that HE DEVELOPED. No one else was doinging these prior to Dr. Goldstein, he has trained over 60 other doctors more than anyone else. No one has trained more. He has shown other docotrs these techniques as opposed to keeping them to himself. He gives all he trains a complete packet of materials including op reports consent forms, marketing tool, etc. Larry Fallat gives NOTHING. Doctors that have trained with Fallat call him for better explanations as fallat does not even get on the phone. He gives hours of his time to others for free. Just ask people who have trained with him. Did you know he developed the trochar system that almost everyone uses? he developed them. Published articles, speaks on the subject has retrained others that were not happy with their original trainers. With closes to 20 approved trainers all the docs want to come to him. I did my due diligence BUT YOU HAVE NOT11 You sling around accusations and make comments when YOU HAVE NO IDEA AS TO WHAT HE DOES. You say he is not a pioneer he is the most saught after speaker on cryosurgery today and has done more than anyone to promote cryosurgery. You should be ashmed of yourself for your comments that are not backed up with truths. If you think I am lying speak to anyone he has trained as to the time he gives. YOU KNOW NOTHING ABOUT THE MAN BUT LOVE TO COMMENT. What advancemets hace you made in podiatry? When was the lkast time you published and on what topic? have you presented any original work? Does 1/3 of your patients come as far away as england to see you? Let us all see how WANDEFULL you are. You called me an idiot and beratted Dr. Goldstein, you used language and tones that Scott R said NEEDS TO STOP BUT YOU DON'T AND KEEP GOING ON AND ON! The guy has done more than anyone to advamce the field and you make derogatory comments. You call Crfyotech and speak to them about Dr. Goldstein and tell us what they say about him. Will you dispute them? Do they talk about some of the others like they talk about him. Why do almost everyone want to train with him? NOT A LEADER IN CRYO OR PIONEER? YOU MUST BE KIDDING!. He was aked to speak at the APMA again this year as well as the Westin in California they called him GET IT? I have stated facts without using the tone that Scott R said NEEDS TO STOP but yet you continue. YOU owe Dr. Goldstein an apology question is are you man enough to do it? Dr. Zuckerman was, kudos to him! Let us all hope Dr Goldstein will cool off calm down and return to his message board where his input is sorely needed.

Result number: 74

Message Number 195721

Re: Non Traditional PF? View Thread
Posted by Dr. David S. Wander on 3/18/06 at 19:24

Joe,

It is always difficult to try to "diagnose" someone over the internet, but simply by referring to the area you describe at the outside or lateral portion of your heel/calcaneus and your description of the pain radiating up toward the ankle and down the outside of the foot, it would sound like there is an involvement of either the peroneal tendons and/or the sural nerve. Without an examination it is difficult to determine if your pain is muscular or nerve related, therefore you should discuss your concerns with your treating doctor. Anatomically, the peroneal tendons and sural nerves are the structures of greatest interest and concern that you should discuss with your doctor.

Result number: 75

Message Number 195474

Re: What other nerve entrapments are there besides Tibial? View Thread
Posted by kb on 3/14/06 at 14:26

The common peroneal nerve can be compressed at the lateral side
of the knee causing symptoms in the foot. And the sural nerve
which is located on the outside of the calf and ankle can also become
entrapped. Dr. Dellon's website is excellent and if you have
any questions for them they have a spot to email them and they will get back to you. I recently had two surgeries and many nerves decompressed by Dr. Dellon.
KB

Result number: 76

Message Number 195156

Re: Help with sump neuroma View Thread
Posted by Dr. Goldstein on 3/08/06 at 19:15

I specifically stated "I am not acusing your doctor of anything " unless you mised that part or anyone else of doing anything for monetary gains if you read every word I said. ken malkin stated at a recent NJ seminar that medicare was looking into billing for the 64640 code as it should only be billed once to kill the nerve so why does it need 7 injections and say what you want after gary dockerys article was published a few years back this alcohol went flying off the shelf and that was all that pods were talking about at the seminars. I know of 3 podiatrists in nj that were audited by medicare for excessive use of the code and have paid back large sums of money. Also I cannot tell you how many pods said why should I by a cryo machine because i can give 7 alcohol shots. heard this numerous times. My answer is that alcohol does not treat plantar fasciitis, achilles tendonitis, tarsal tunnel, sural nerve entrapement, plantar fibromas and a host of other ailments cryo does or can. They were using the 64640 code. many many pods all over the country were doing this. I do not need the patient to the OR for neuroma surgery as I can do it in 10 minutes with a small dorsal puncture no sutures post op shoe etc thats why patients are seeking this procedure out because the recovery is much quicker so given a choice more patients are leaning this way whether you think so or not.

Result number: 77

Message Number 195155

Re: Help with sump neuroma View Thread
Posted by Dr. Goldstein on 3/08/06 at 19:14

I specifically stated "I am not acusing your doctor of anything " unless you mised that part or anyone else of doing anything for monetary gains if you read every word I said. ken malkin stated at a recent NJ seminar that medicare was looking into billing for the 64640 code as it should only be billed once to kill the nerve so why does it need 7 injections and say what you want after gary dockerys article was published a few years back this alcohol went flying off the shelf and that was all that pods were talking about at the seminars. I know of 3 podiatrists in nj that were audited by medicare for excessive use of the code and have paid back large sums of money. Also I cannot tell you how many pods said why should I by a cryo machine because i can give 7 alcohol shots. heard this numerous times. My answer is that alcohol does not treat plantar fasciitis, achilles tendonitis, tarsal tunnel, sural nerve entrapement, plantar fibromas and a host of other ailments cryo does or can. They were using the 64640 code. many many pods all over the country were doing this. I do not need the patient to the OR for neuroma surgery as I can do it in 10 minutes with a small dorsal puncture no sutures post op shoe etc thats why patients are seeking this procedure out because the recovery is much quicker so given a choice more patients are leaning this way whether you think so or not.

Result number: 78

Message Number 195069

Re: sural nerve pain + heel pain 4 months View Thread
Posted by Dr. Goldstein on 3/07/06 at 19:17

try geting a sural nerve block with some steroid and local anesthetic mixed together and see if the pain disappates. You may want to try some medications made to combat nerve pain as well such as neurontin, cymbalta, or lyrica.

Result number: 79

Message Number 195064

Re: sural nerve pain + heel pain 4 months View Thread
Posted by scott from uk on 3/07/06 at 17:29

thank you for reply just wondered why the pain is radiating into heel could it be something else, i can stand the pain and walk no problem sometimes its more comfotable to walk than just sit dont know if removal of nerve is needed at this time, i just know if the pain will get worse ?

Result number: 80

Message Number 195063

Re: sural nerve pain + heel pain 4 months View Thread
Posted by messed up foot on 3/07/06 at 17:13

Not a doctor but if they offer to remove the nerve, don't be the least bit worried by it! I had non-stop searing pain in my toes and the top of my foot. Nerve was severed and the pain is GONE. Yes, it is numb and that has some issues associated with it but that darn sural nerve (my sural was numb for a year after tendon surgery and woke up after ligament repair through the same scar) is not important to walking or anything else. Those of us with peripheral nerve disease (mine is from low thyroid) have learned to appreciate pain free. Look under Foot Surgery at postings by (I think) Ann for more on sural nerve stuff.

Good Luck

Result number: 81

Message Number 195061

sural nerve pain + heel pain 4 months View Thread
Posted by scott from uk on 3/07/06 at 16:41

hello there i was just wondering if you could give any details on sural nerve pain which i have in my right foot for 4 months(fractured heel about 8 years ago which has not given me any trouble at all until now) , the outside of ankle where the sural nerve runs aches causing pain to radiate to outside of foot and also pain into heel and also pins and needles feeling in my heel as well, i can give a lot more details if needed but just wondered what i should be doing to combat this, seen 2 podatrists who have now referred me to ankle/foot surgeon(on 20 march 2006) , i am after all the info i can on this as i have tried different shoes/trainers and orthotics.i am able to walk fine about 4 miles per day and will be going for a job as a postman in the future but iam very wary as i dont know if this can be cured/stay the same or get worse, any info whatsoever would be gladly appreciated

Result number: 82

Message Number 195046

Re: Dr for EWST View Thread
Posted by Dr. Z on 3/07/06 at 11:36

Sural nerve. TTS and possible baxters nerve entrapment Let her show you the pictures and her history

Result number: 83

Message Number 195045

Re: Dr for EWST View Thread
Posted by Dr. S . Goldstein on 3/07/06 at 11:30

are you thinking sural nerve disorder/disease?

Result number: 84

Message Number 194432

Re: EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by Dr. Z on 2/28/06 at 21:32

Ann,
If the local anesthesic stops the pain then this is a very good indication that surgery could be the solution. Surgical excision or possible cryotherapy for sural nerve entrapment can be very successful

Result number: 85

Message Number 194396

EMG then "Lyrica" med for sural nerve entrapment? Anyone on Lyrica View Thread
Posted by Ann on 2/28/06 at 18:55

Hi,

Now, a year after PF surgery and increasing ankle/top of foot and claf pain the docs think it is nerve entrapment. The my podiatrist want to trying blocking the nerve instead of "snipping" it.....Part of me just wants it cut. Plus the doc said it may take 3 nerve blocks:(

Thanks,
ANN

Result number: 86

Message Number 194353

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by messed up foot on 2/28/06 at 07:54

I tried to respond and it disappeared - sorry if this seems to repeat.

My EMG was normal and so were my MRIs. I give up on trying to explain how I can have torn tendons, ligaments and nerves caught in scar tissue with numbness and still have it all read as "normal". Surgeon disagreed with the radiologist and trusted his clinical judgement and examination findings instead. I seriously wonder if my last MRI was someone else's MRI. Surgeon was baffled and had another radiologist read it too. What he found in surgery was not what showed on the MRI.

Nerve pain stinks!

Result number: 87

Message Number 194352

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by messed up foot on 2/28/06 at 07:51

EMG was "normal" - the story of my life. MRIs of ankles were both read by radiologists as normal too. Surgeon disagreed on the first ankle and found significant damage along with nerve impingements. Surgeon was really baffled by the second ankle - said he saw nothing on the MRI but trusted his examination instead. During surgery, tendons and ligaments were found to be torn. Seriously, I wonder if it was my MRI?

I work in health care and I think that this points to the need for clinicians to use their education and clinical judgement and not always rely on the EMGs and MRIs. It adds to health costs and doesn't always tell the true picture at least in my case.

Best of luck to you! Nerve pain stinks!

Result number: 88

Message Number 194310

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by Ann on 2/27/06 at 16:34

Hello again,

Wow, I am lucky to only have one foot in pain. I am a juvenile diacetc since 12 (32 years) and no neuropathy (knock on wood).

I have to have an EMG prior to the sugreyy. Did you??

Thanks,

Ann

Result number: 89

Message Number 194265

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by messed up foot on 2/27/06 at 07:30

Once the nerve is removed, it's gone for good so be sure before you go for surgery!

My common superficial peroneal nerve was removed in the hospital and the end was re-routed into my fibula. Lord knows what mischief it will do in there but it was very simple surgery and the worst part is that every time I bump the scar on my ankle, my toe hurts. Yet, my toe is numb. Ah, the wonders of the nervous system!

I have unexplained PND now in both feet (no, I am not diabetic)and everytime the surgeon has even looked at one my nerves, it gets all funky. I've told him that he obviously gets on my nerves ;-). Now my good foot (a relative term) is in a cast from tendon/ligament repair and without explanation I can't feel my big toe. I'm waiting for the MRI report on my back but I'm also wondering if a newly discovered politeal cyst (Baker's cyst) is the culprit.

Aging is such a wonderful thing...NOT. If 50 feels like this, I can hardly wait for 60 and 70.

Result number: 90

Message Number 194223

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by Ann on 2/26/06 at 14:51

You Make me laugh!!! My pain is definitely in the ankle area radiating to the baby toe and especially up the side of my outer calf to the side and back of my knee. My hip also aches quite a bit but probably because of my alterer walking pattern. Did you have this done. The pod. I saw said that this nerve is superficial. Is it done in the hospital?? Did you have to have a nerve conduction test done first??

Thanks so much. Right now I have the lidocaine patch on, boot and am still so uncomfortable.

Ann

Result number: 91

Message Number 194219

Re: What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by meesed up foot on 2/26/06 at 13:21

Nope - removing the sural just ends your feeling to your little toe and a couple of other spots in your foot.

One thing that I found was that you can have myofascial pain up the outside of your calf along the peroneal muscles. You can also have some nerve impingement up by your knee. I found great relief from PT who put a lot (to the point of bruises) along the peroneal muscles.

Myofascial pain gets varied reactions from doctors - some say it exists and others say it is a ^#$ at # diagnosis (fill in your own explitive). Personally, I don't care. As I've said before - if dancing around a fire naked with a pyramid on your head makes the pain go away, try it!

Result number: 92

Message Number 194214

What does "removal" of the sural nerve entail?? Sign me up View Thread
Posted by Ann on 2/26/06 at 10:03

Hi,

Does the removal of the sural nerve relieve the pain that radiates up the calf??

After 12 treatments of Co2(cool) laser treatment to 4 spots on my foot ( 1 year post EPF) The lasered each area ove the incision site. I can't believe it but now 3 weeks post laser I have some intense pain to the inciosion site to the inner foot right at the end of the outer heal and arch pain again.

So unhappy and sad...

Ann

Result number: 93

Message Number 194184

Re: Good Providers View Thread
Posted by nicky on 2/25/06 at 18:51

Other than local simply means you block the posterior tibal nerve, sural nerve, and if you really want to stick to the letter of the code, 28890, drop a little Lidocane etc, into the anterior tibial nerve and you have a ankle block. Now I saved you a call to Dr Z'z celll phone. Stop all this back and forth and call 334-685-0095 and get setup with the most professional ESWT provider in the entire USA. More benefits are awaiting the podiatrist who calls this number than any other ESWT company can or will offer.

Result number: 94

Message Number 194180

Re: Good Providers View Thread
Posted by nicky on 2/25/06 at 18:21

Other than local simply means you block the posterior tibal nerve, sural nerve, and if you really want to stick to the letter of the code, 28890, drop a little Lidocane etc, into the anterior tibial nerve and you have a ankle block. Now I saved you a call to Dr Z'z celll phone. Stop all this back and forth and call 334-685-0095 and get setup with the most professional ESWT provider in the entire USA. More benefits are awaiting the podiatrist who calls this number than any other ESWT company can or will offer.

Result number: 95

Message Number 194161

Good Providers View Thread
Posted by Upstate Doc on 2/25/06 at 10:50

Dr. Z, Whick provider do you recommend for the Upstate NY Area? I've used the Ossotron for the past 4 years but have problems scheduling cases now. My success rate is wonderful w/ the ossotron but am skeptical about the other machines on the market. Don't you use the Dorney? I've had several vendors stop by but have not made a decision. What worries me the most is the new CPT code 28890 and the statement "other than local". I understand that a PT or Sural nerve block are considered regional, but my concerns are will the insurance companies coming back to us later saying we should have used a general and that it should have been done in an ASC or hospital. I have not heard or read a clear explanation on this. Empire was paying but i can't get a clear answer from them either.

Result number: 96

Message Number 194115

Re: 3rd opinion-"Seral" (?sp) nerve entrapment?? Dr Z I am confused View Thread
Posted by messed up foot on 2/24/06 at 15:46

the sural nerve is often harvested for nerve biopsies and you can live very well without it! I had another nerve removed due to a huge neuroma (from chronic ankle eversions) and while the skin on the top of my foot is numb, I rarely notice the loss of feeling. I have to be more careful for the rest of my life but compared to constant burning pain, the numbness is just fine with me. I have an issue with the sural on the same foot and if the pain didn't respond to Neurontin, the sural could jolly well go away too. Numbness brings its own challenges but it is MUCH better than pain!

Dr. Z, when a nerve is obviously misbehaving and really damaging one's quality of life, when do you typically end its existence? Just curious since it made an incredible improvement in my life and ability to sleep.

On a related note - the remnants of the nerve are now in my fibula but if I bump my ankle incision just right, my brain still says that my toes itch. It is actually pretty amusing!

Result number: 97

Message Number 194066

Re: 3rd opinion-"Seral" (?sp) nerve entrapment?? Dr Z I am confused View Thread
Posted by Dr. Z on 2/23/06 at 18:13

Ann,
That is alot better then the medial fusion procedure that other doctors have been talking about. You could have injections, and or cryotherapy fo the sural nerve entrapement . There is hope !!!

Result number: 98

Message Number 191990

Re: anesthesia requirements View Thread
Posted by Dr. Z on 1/23/06 at 22:09

Its real simple. The use of a posterior tibial nerve block and sural nerve block is a typical method for ESWT high energy treatment. This type of block is a regional block and not a LOCAL block . So if you are using a regional block you AREN"T using a local block. The use of the new CPT code NEVER indicated that the procedure must be performed in an ASC or Hospital. Could you have an insurance company start to challenge this definition Sure they can. If any do please contact Dr. Z and I will explain to them exactly what the definition is, in in one sentence. Just joking. A local block is where you inject into the skin and into the treatment site which never should be done with any ESWT.

Result number: 99

Message Number 190833

Re: Traction neuropraxia after facia release and gastocnemius recession surgeries View Thread
Posted by Dr. Goldstein on 1/05/06 at 18:11

I would suggest treatment with either oral Cymbalta or Lyrica two new neuropathy drugs to try and decrease the numbness you are currently experiencing. This maybe of great help at this stage. It is hard to put a time frame on the healing period. if symptoms persist worst case senario could be release of the sural nerve but that maybe jumping the gun for now. Sometimes a TENS unit can be of help as well.
dr goldstein

Result number: 100

Message Number 190821

Traction neuropraxia after facia release and gastocnemius recession surgeries View Thread
Posted by sabrina on 1/05/06 at 14:22

After suffering on and off for about ten years with heel pain and occaisional nerve pain I decided to pursue surgery. This is following all standard attempts to relieve the pain by conservative measures. Because I have had PF so long he recommended simultaneous facia release and grastrocnemius recession for gastrocnemius equinus. He felt this would give me a higher success rate than facia release alone. I had the surgeries on 12/20/05 and initially felt like everything had gone very smoothly. However about six days ago while my cast was still on I begin to get burning, tingling sensations on the lateral edge of my foot. I got the cast off and was given a CAM boot to where for the next 4 weeks and told to gradually increase weight bearing - I am still using crutches. For the last 5 days I have had constant pain/irratation on the lateral side of my foot from my little toe to the center of my heel. That region has also been almost totally numb. I get more pulsing pain whevever I reposition my foot when reclined, but continue to have almost non-stop paresthesia and numbness. My doctor said it was likely a traction neuropraxia of the sural nerve. Can please tell me how common this is and what kind of timeline I might expect to regain normal sensation in the region. Also if these symptoms continue to persist at this level what kind of treatment/pain relief is reccomended? Thank you very much for your time and response.

Result number: 101

Message Number 190027

nerve surgery was interesting View Thread
Posted by messed up foot on 12/20/05 at 18:45

Almost 3 weeks post op from the nerve surgery and I have discovered an annoying truth - if one cuts the common superficial peroneal nerve, the sural nerve gets all wound up and makes my skin hurt. Talk about annoying! Ortho said that there is no anatomical reason why this should work but it sometimes helps to inject the severed nerve with an anesthetic and the functional nerve will calm down. I passed on any more or any thing on this poor foot. Saw my neuro and she said the same thing but strongly encouraged me to let my foot heal with no more surgery or invasive procedures of any kind. It was interesting to hear that my neuroma was 10 cm long

I'm listening to her!

Will the green discoloration in my ankle ever go away? Seriously - it looks like Herman Munster skin and has since last February. 5 scars, lymphedema and green skin. I'm thinking of painting.

Result number: 102
Searching file 18

Message Number 189194

Re: Daughter/Me and Ossatron View Thread
Posted by Ed Davis, DPM on 12/07/05 at 19:15

John:
I actually have seen better results on the achilles with ESWT than on PF. I am a bit nervous about the Ossatron used on the achilles since it is a powerful machine with such a large ponderous head. I would prefer the better control that a variable intensity machine with a smaller head can confer, preferably the Sonocur or perhaps the Dornier. Some things that a large head may have trouble missing include the sural nerve which runs along side the achilles tendon.
Ed

Result number: 103

Message Number 188926

Re: Jen's ESWT View Thread
Posted by Steve W on 12/05/05 at 05:39

Preparation, Anesthesia and Procedure - A preliminary x-ray was performed to check for various things. A spur was prominent and significant thickening of the fasciia was visible. I palpated her foot marking the areas of greatest pain.

Her left foot was anesthesized by administering two nerve blocks: posterior tibial and sural. We have tried this with only one side blocked, but the patient could not tolerate the full duration of the procedure.

We began at the lowers energy setting and gradually increased over the first couple of minutes to the max setting (24Kv/110mJ at -6dB). We performed 3800 shocks at 3 per second so the procedure lasted about 25 minutes. Usually with Orthospec, the foot can be positioned prior to the procedure and can be left in the same position. In Jen's case, I did adjust throughout (strating near the insertion and working up) because in addition to the most significant area of involvement on the interior side of the insertion point, she has pain further up the arch as well.

Result number: 104

Message Number 187614

Re: peripheral neuropathy View Thread
Posted by Dr. Z on 11/16/05 at 20:32

Lyrica sounds very promising. I have used with some temporary success alcohol injections for this condition . The ones that improved that had release were sent to Johns Hopkins for release surgery by Dr Dellon. Dr. Goldstein, I really think this could be an area for cryotherapy. you treat the sural, PT, saphenous and peroneal at the ankle level.

Result number: 105

Message Number 187530

Re: Sharp pain back of heel View Thread
Posted by Robert J. Sanfilippo, DC, CCSP, ART on 11/15/05 at 21:04

Hello Sandy and a nerve entrapment (sural, peroneal, tibial, calcaneal) can cause pain in the heel. You can have EMG or NCV and they can come up negative. The thing about entrapments is that they get entrapped with specific movements or some other type of unusual trigger. So maybe you can find a superb diagnostician and someone who can actually treat the entrapment if that is your condition.

Result number: 106

Message Number 186764

New Codes View Thread
Posted by vince on 11/05/05 at 07:10

This is straight from the 2006 CPT code book. I got a look at it yesterday while my wife was in the dr's office:

0019T Category III ESWT involving musculoskeletal system not specified, low energy

0102T Category III ESWT lateral humeral epicondyle, high energy

0020T This code has been deleted

0101T Category III ESWT involving musculoskeletal system not specified, high energy

28890 ESWT, high energy, performed by a physician, requiring anesthesia other than local including ultrasound guidance, involving the plantar fascia

28899 unlisted procedure, foot and toes

I a conversation with my podiatrist later on in the evening I asked about the local-regional block ? this is what I was told. "If the block involves the foot below the ankle, sural, posterior tibial, and antoher nerve( I don't remember the name but I think it was the anterior tibial) on the top of the foot, it is a regional block becasue it affects everything below the ankle".

My ? is are podiatists considered physicians in all states?

This whole thing sounds to me as if orthopods wrote it.

Result number: 107

Message Number 186690

Re: Cryosurgery for neuropathy? View Thread
Posted by Dr. Z on 11/03/05 at 23:55

Here are two suggestion. Cryotherapy on the sural, Posterior tib, Deep peronal , Saphenous nerves. If no relief then Dr. Dellon release surgery
Just some thoughts

Result number: 108

Message Number 186671

Re: What's normal???? for post pf surgery??? View Thread
Posted by Geoff on 11/03/05 at 18:12

Dr, can you explain what sural nerve entrapment is, what part of the foot - is it on lateral side of heel.

Result number: 109

Message Number 186586

Re: almost 4 wks post surgery View Thread
Posted by Dr. Z on 11/02/05 at 16:36

You could be a great candidate for cryotherapy. I would injection th sural nerve with a local steriod and lidocaine if there is relief and it comes back then cryotherapy be helpful

Result number: 110

Message Number 186578

almost 4 wks post surgery View Thread
Posted by michelle m on 11/02/05 at 15:02

hello again
i am having problem with sural nerve which the outside of foot from heel to small toe is numb the perimiter of the of the numb area is very painful to the touch very sensitive i am still wearing a removable cast and told to wear it at night this pain which can be sharp shooting pain to having the feeling that from the knee down is tring to runaway it twitches and throbs
surgeon whats me to take pain med but i feel if there was someway to get the area to relax would be better
is this normaol post surgery or another problem
can it be corrected or might it be permanent
thanks

Result number: 111

Message Number 186463

Re: NEw CPT Code View Thread
Posted by Dr. Z on 11/01/05 at 18:36

Steve,
I was told a few years ago by Dr. Smith from the APMA that the the posterior and sural area are regional blocks. They are field blocks and not local blocks.
It is my understanding that the posterior tib and sural blocks are standard regional blocks.
It is possible that someone in the medical director's department could TRY to make this into a local block instead of regional block.
What would I do. I would do nothing at this stage. If you are trying to make sure all of your I's are dotted you can do a search on the internet and find the definitions.
I just pick up from my medical collection, a CD entitled Regional Anesthetic nerve block of the foot. IT shows the posterior tib and sural as a regional block. I reallly am not that concerned. The CD is by Dr. Ruch one of Dr.McGlamory partners from Atlanta Georgia. Very respected podiatric teacher and physician

If you want a copy of the CD just let me know and I will burn and mail you a copy. Very good teaching device for regional blocks.

Result number: 112

Message Number 186457

NEw CPT Code View Thread
Posted by Steve W on 11/01/05 at 18:14

Dr. Z, have you been able to verify the language in the codes I received with the books that were relaeased today? Assuming the codes are correct, I have been researching the term in the technical code regarding anesthesia. "other than local" will determine where this is done (in office or in the OR). I agree with you about the classification of a block. Despite the fact that it will be in the foot, a peripheral nerve blocks everything below the block, so I don't see how it can be interpreted as a local. However, many podiatrists seem to think that a PT and sural blocks would be considered locals. Any chance insurance companies would make that call? I assume it would be up to the medical director of each comapny. I have several podiatrist friends who are looking for a credible source that makes the distinction, but we've been unable to find any. We have made some calls to anesthesiologists in the area and hopefully they can find something solid for us. HT fought very hard to get language that would require the procedure be done in the OR. Fortunately Dornier fought that and I think the current language is a compromise by the AMA.

Result number: 113

Message Number 186381

Re: What's normal???? for post pf surgery??? View Thread
Posted by Dr. S . Goldstein on 11/01/05 at 08:52

based on the level of your symptoms you may have a sural nerve entrapment which would be separate from the tarsal tunnel that responds well to cryosurgery have your doc try a sural nerve block to see if you get relief

Result number: 114

Message Number 186198

Re: antibiotic (quinolone) and tendons View Thread
Posted by d fuller on 10/30/05 at 01:19

This is a list of citations begining in 1965 to date that deal with this "rare" adverse event. I present this not as an argumentative rebuttal but as proofs regarding my previous post. One would think if indeed this was a rare occurence we would not read medical journal articles concerning it each and every year for forty years. Nor does this list inlcude all such citations, only those readily available to the average person. Of special interest is the statements made at the 62 Meeting of the Anti-Infective Drugs Advisory Committee (circa 1994)where quinolone induced joint destruction (requiring complete joint replacement) is discussed as well as irreversible tendon and ligament damage. You will find that towards the end of this response. We find the same documentation when it comes to peripherial neuropathy as well which was first reported in association with Nalidixic Acid in the mid sixties.

1965

1. DE VRIES AC.
[SPONTANEOUS RUPTURE OF THE ACHILLES TENDON]
Ned Tijdschr Geneeskd. 1965 Jan 2;109:59-60. Dutch. No abstract available.
PMID: 14284979 [PubMed - OLDMEDLINE for Pre1966]

2. CROZZOLI NR, MANCA M.
[SUBCUTANEOUS RUPTURE OF THE ACHILLES TENDON. CONSIDERATIONS ON OUR CASE
HISTORIES]
Minerva Ortop. 1965 Jan-Feb;16:21-9. Italian. No abstract available.
PMID: 14303636 [PubMed - OLDMEDLINE for Pre1966]

3. VON GRAFFENRIED, ENGELER V, HEIM U.
[SUBCUTANEOUS RUPTURE OF THE ACHILLES TENDON]
Helv Chir Acta. 1965 Jan;32:253-6. German. No abstract available.
PMID: 14290218 [PubMed - OLDMEDLINE for Pre1966]


1969

1. Rosolleck H.
[Subcutaneous achilles tendon rupture]
Monatsschr Unfallheilkd Versicher Versorg Verkehrsmed. 1969 Dec;72(12):544-7.
German. No abstract available.
PMID: 4248859 [PubMed - indexed for MEDLINE]


1971

1. Auquier L, Siaud JR.
[Nodular tendinitis of the Achilles tendon]
Rev Rhum Mal Osteoartic. 1971 May;38(5):373-81. French. No abstract available.
PMID: 5092370 [PubMed - indexed for MEDLINE]

2. Krahl H, Langhoff J.
[Degenerative tendon changes following local application of corticoids]
Z Orthop Ihre Grenzgeb. 1971 Jul;109(3):501-11. German. No abstract available.
PMID: 4254811 [PubMed - indexed for MEDLINE]


1972

1. Nalidixic Acid arthralgia
Bailey et al (CMA Journal 1972; 107 601-605)

2. Dupuis PR, Uhthoff HK.
In vivo study of the effects of a synthetic steroid, betamethasone (16B methyl-9X fluoroprednisolone) on the calcaneal tendon in rabbits Union Med Can. 1972 Sep;101(9):1763-7. French. No abstract available.
PMID: 5075006 [PubMed - indexed for MEDLINE]


1976

1. Jouirland JP Les ruptures tendineusues. Le tendon normal et patholoqique
Seminar de Monte Carlo 13-14 February 1976


1980

1. Mason JO, Meagher DJ, Sheehan B, O'Doherty CK.
The management of supraspinatus tendinitis in general practice.
Ir Med J. 1980 Jan;73(1):23-40. No abstract available.
PMID: 7380640 [PubMed - indexed for MEDLINE]


1981

1. Jensen KE.
[Bilateral rupture of the Achilles tendon]
Ugeskr Laeger. 1981 Jul 6;143(28):1768. Danish. No abstract available.
PMID: 7292758 [PubMed - indexed for MEDLINE]


1982

1. Fink RJ, Corn RC.
Fracture of an ossified Achilles tendon.
Clin Orthop. 1982 Sep;(169):148-50. No abstract available.
PMID: 6809391 [PubMed - indexed for MEDLINE]

2. Cetti R, Christensen SE.
[Rupture of the Achilles tendon after local steroid injection]
Ugeskr Laeger. 1982 May 10;144(19):1392. Danish. No abstract available.
PMID: 7135524 [PubMed - indexed for MEDLINE]

3. Chechick A, Amit Y, Israeli A, Horoszowski H.
Recurrent rupture of the achilles tendon induced by corticosteroid injection.
Br J Sports Med. 1982 Jun;16(2):89-90. No abstract available.
PMID: 7104562 [PubMed - indexed for MEDLINE]

4. Newmark H 3rd, Olken SM, Mellon WS Jr, Malhotra AK, Halls J
A new finding in the radiographic diagnosis of achilles tendon rupture.
Skeletal Radiol. 1982;8(3):223-4. No abstract available.
PMID: 7112151 [PubMed - indexed for MEDLINE]


1983

1. Norfloxacin induced rheumatic disease
Bailey et al (NZ Med J 1983; 96; 590)

2. Kleinman M, Gross AE.
Achilles tendon rupture following steroid injection. Report of three cases.
J Bone Joint Surg Am. 1983 Dec;65(9):1345-7. No abstract available.
PMID: 6197416 [PubMed - indexed for MEDLINE]


1984

1. Chamot AM, Gobelet C.
[Achilles tendinitis: a pathology of confines]
Rev Med Suisse Romande. 1984 Oct;104(10):783-7. French. No abstract available.
PMID: 6515224 [PubMed - indexed for MEDLINE]


1985

1. Between 1985 and July 1992 100 cases of tendon disorders had been identified in France
Kessler et al (HRG Publication 1399, August 1. 1996)

2. Jones JG.
Achilles tendon rupture following steroid injection.
J Bone Joint Surg Am. 1985 Jan;67(1):170. No abstract available.
PMID: 3968099 [PubMed - indexed for MEDLINE]

3. 100 reported tendinopathies 1985-1992 France
In France, between 1985 and 1992, 100 patients who were being managed with fluoroquinolones had tendon disorders, which included thirty-one ruptures (Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)
http://www.studiomedico.it/allegati/achille.pdf


1987

1. Ciprofloxacin an update on clinical experience
Areieri et al (Am J of Med 1987 82 381-386)

2. 93 ruptures, 103 tendinopathies, 20 tenasynovitis, 1987-1997
Source: http://www.sma.org/smj1999/junesmj99/harrell.pdf


1988

1. McEwan SR, Davey PG. Ciprofloxacin and tenosynovitis. Lancet 1988; 2: 900.

2. Adverse effects of fluoroquinolones
Halkin et al (Rev Infect Dis 1988 10 258-261)

3. Ciprofloxacin and tenosynovitis
McEwan et al ( Lancet 1988 15 900)

4. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages


1989

1. Adverse reactions during clinical trials and post marketing surveillance
Janknegt et al (Pharm Weekbl Sci 1989 11(4) 124-127)

2. Arthritis induced by norfloxacin
Jeandel et al (J Rheumatol 1989 16 560-561)

3. Schumacher HR Jr, Michaels R.
Recurrent tendinitis and achilles tendon nodule with positively birefringent crystals in a patient with hyperlipoproteinemia.
J Rheumatol. 1989 Oct;16(10):1387-9.
PMID: 2810266 [PubMed - indexed for MEDLINE]


1990

1. Histologic and Histochemical Changes in Articular Cartilages of Immature Beagle Dogs Dosed with Difloxacin, a Fluoroquinolone
J.E. Kurkhardt et al (Vet Pathol 27;162-170, 1990)


1991

1. Rheumatolgical side effects of quinolones
Ribard et al (Baillere’s Clin Rheumatol 1991 5 175-191)

2. Perrot S, Ziza JM, De Bourran-Cauet G, Desplaces N, Lachand AT.
[A new complication related to quinolones: rupture of Achilles tendon]
Presse Med. 1991 Jul 6-13;20(26):1234. French. No abstract available.
PMID: 1831902 [PubMed - indexed for MEDLINE]


1992

1. Seven Achilles tendinitis including three complicated by rupture during fluoroquinolone therapy
Ribard et al (J Rheumatol 1992; 19; 1479-1481)

2. 704 achilles tendinitis, 38 ruptures 1992-1998 Netherlands
Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306

3. 100 reported tendinopathies 1985-1992 France
In France, between 1985 and 1992, 100 patients who were being managed with fluoroquinolones had tendon disorders, which included thirty-one ruptures (Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)
http://www.studiomedico.it/allegati/achille.pdf

4. Ribard P, Audisio F, Kahn MF, De Bandt M, Jorgensen C, Hayem G, Meyer O, Palazzo E.
Seven Achilles tendinitis including 3 complicated by rupture during fluoroquinolone therapy.
J Rheumatol. 1992 Sep;19(9):1479-81.
PMID: 1433021 [PubMed - indexed for MEDLINE]

5. Perrot S, Kaplan G, Ziza JM.
[3 cases of Achilles tendinitis caused by pefloxacin, 2 of them with tendon rupture]
Rev Rhum Mal Osteoartic. 1992 Feb;59(2):162. French. No abstract available.
PMID: 1604233 [PubMed - indexed for MEDLINE]

6. Lee WT, Collins JF.
Ciprofloxacin associated bilateral achilles tendon rupture.
Aust N Z J Med. 1992 Oct;22(5):500. No abstract available.
PMID: 1445042 [PubMed - indexed for MEDLINE]

7. Blanche P, Sereni D, Sicard D, Christoforov B.
[Achilles tendinitis induced by pefloxacin. Apropos of 2 cases]
Ann Med Interne (Paris). 1992;143(5):348. French. No abstract available.
PMID: 1482040 [PubMed - indexed for MEDLINE]

8. Olivieri I, Padula A, Lisanti ME, Braccini G.
Longstanding HLA-B27 associated Achilles tendinitis.
Ann Rheum Dis. 1992 Nov;51(11):1265. No abstract available.
PMID: 1466609 [PubMed - indexed for MEDLINE]


1993

1. Spontaneous bilateral rupture of the Achille’s tendon in a renal transplant recipient
Mainard et al (Nephron 1993;65- 491-492)

2. Boulay I, Farge D, Haddad A, Bourrier P, Chanu B, Rouffy J
[Tendinopathy caused by ciprofloxacin with possible partial rupture of Achilles tendon]
Ann Med Interne (Paris). 1993;144(7):493-4. French. No abstract available.
PMID: 8141519 [PubMed - indexed for MEDLINE]


1994

1. Royer RJ, Pierfitte C, Netter P.
Features of tendon disorders with fluoroquinolones.
Therapie. 1994 Jan-Feb;49(1):75-6. No abstract available.
PMID: 8091374 [PubMed - indexed for MEDLINE]

2. Armengol S, Moreno JA, Xirgu J, Torrabadella P, Tomas R.
[Ciprofloxacin as a cause of a behavior disorder in a patient admitted into intensive care]
Enferm Infecc Microbiol Clin. 1994 May;12(5):271-2. Spanish. No abstract available.
PMID: 8049295 [PubMed - indexed for MEDLINE]

3. Donck JB, Segaert MF, Vanrenterghem YF.
Fluoroquinolones and Achilles tendinopathy in renal transplant recipients.
Transplantation. 1994 Sep 27;58(6):736-7. No abstract available.
PMID: 7940700 [PubMed - indexed for MEDLINE]

4. Onieal ME.
Achilles injuries.
J Am Acad Nurse Pract. 1994 Mar;6(3):125-6. No abstract available.
PMID: 8003362 [PubMed - indexed for MEDLINE]

5. Scioli MW.
Achilles tendinitis.
Orthop Clin North Am. 1994 Jan;25(1):177-82. Review.
PMID: 8290227 [PubMed - indexed for MEDLINE]

6. Hernandez MV, Peris P, Sierra J, Collado A, Munoz-Gomez J.
[Tendinitis due to fluoroquinolones. Description of 2 cases]
Med Clin (Barc). 1994 Sep 10;103(7):264-6. Review. Spanish.
PMID: 7934295 [PubMed - indexed for MEDLINE]

7. Achilles tenditinis and tendon rupture due to fluoroquinolone therapy
Huston et al (New England Journal of Medicene 1994 331 748)

8. Royer, R. J.; Pierfitte, C.; and Netter, P.: Features of tendon disorders with fluoroquinolones. Therapie, 49: 75-76, 1994.)

9. Dekens-Konter JA, Knol A, Olsson S, Meyboom RH, de Koning GH.
[Tendinitis of the Achilles tendon caused by pefloxacin and other
fluoroquinolone derivatives]
Ned Tijdschr Geneeskd. 1994 Mar 5;138(10):528-31. Dutch.
PMID: 8139714 [PubMed - indexed for MEDLINE]

10. Prantera C, Kohn A, Zannoni F, Spimpolo N, Bonfa M.
Metronidazole plus ciprofloxacin in the treatment of active, refractory Crohn's disease: results of an open study.
J Clin Gastroenterol. 1994 Jul;19(1):79-80. No abstract available.
PMID: 7930441 [PubMed - indexed for MEDLINE]

11. Van Linthoudt D, D'Oro A, Ott H.
[What is your diagnosis? Bilateral Achilles tendinitis associated with
quinolone treatment]
Schweiz Rundsch Med Prax. 1994 Feb 22;83(8):201-2. German. No abstract available.
PMID: 8134743 [PubMed - indexed for MEDLINE]

12. Kawada A, Hiruma M, Morimoto K, Ishibashi A, Banba H.
Fixed drug eruption induced by ciprofloxacin followed by ofloxacin.
Contact Dermatitis. 1994 Sep;31(3):182-3. No abstract available.
PMID: 7821014 [PubMed - indexed for MEDLINE]

13. Guharoy SR.
Serum sickness secondary to ciprofloxacin use.
Vet Hum Toxicol. 1994 Dec;36(6):540-1.
PMID: 7900274 [PubMed - indexed for MEDLINE]


1995

1. Hernandez Rodriguez I, Allegue F.
Achilles and suprapatellar tendinitis due to isotretinoin.
J Rheumatol. 1995 Oct;22(10):2009-10. No abstract available.
PMID: 8992016 [PubMed - indexed for MEDLINE]

2. Szarfman A, Chen M, Blum MD. More on fluoroquinolone antibiotics and tendon rupture. N Engl J Med 1995; 332: 193[Free Full Text].

3. Magnesium Deficiency Induces Joint Cartilage Lesions in Juvenile Rats which are Identical to Quinolone Induced Arthropathy
Stahlmann et al (Antimicrobial Agents and Chemotherapy, Sept., 1995 pg 2013-2018)

4. Crowder SW, Jaffey LH.
Sarcoidosis presenting as Achilles tendinitis.
J R Soc Med. 1995 Jun;88(6):335-6.
PMID: 7629765 [PubMed - indexed for MEDLINE]

5. Pierfitte C, Gillet P, Royer RJ
More on fluoroquinolone antibiotics and tendon rupture.
N Engl J Med. 1995 Jan 19;332(3):193. No abstract available.
PMID: 7800022 [PubMed - indexed for MEDLINE]

6. Szarfman A, Chen M, Blum MD.
More on fluoroquinolone antibiotics and tendon rupture.
N Engl J Med. 1995 Jan 19;332(3):193. No abstract available.
PMID: 7800023 [PubMed - indexed for MEDLINE]

7. Norfloxacin induced arthalgia
Terry et al ( J Rheumatol 1995 22 793-794)

8. Fluoroquinolone Induced Tenosynovitis of the Wrist mimicking de Quervain’s Disease
Gillet et al (British Journal of Rheumatology vol 34 no 6 pg 583-584, Feb 1995)

9. Mirovsky Y, Pollack L, Arlazoroff A, Halperin N.
[Ciprofloxacin-associated bilateral acute achilles tendinitis]
Harefuah. 1995 Dec 1;129(11):470-2, 535. Hebrew.
PMID: 8846955 [PubMed - indexed for MEDLINE]



1996

1. McGarvey WC, Singh D, Trevino SG. Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a case report and literature review. Foot Ankle Int 1996; 17: 496-498[ISI][Medline].

2. Pierfitte C, Royer RJ.
Tendon disorders with fluoroquinolones.
Therapie. 1996 Jul-Aug;51(4):419-20. No abstract available.
PMID: 8953821 [PubMed - indexed for MEDLINE]

3. Hugo-Persson M.
[Rupture of the Achilles tendon after ciproxine therapy]
Lakartidningen. 1996 Apr 17;93(16):1520. Swedish. No abstract available.
PMID: 8667750 [PubMed - indexed for MEDLINE]

4. Therapie 1996; 51: 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance, 340 of tendinitis and 81 cases of tendon rupture.

5. McGarvey WC, Singh D, Trevino SG.
Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a
case report and literature review.
Foot Ankle Int. 1996 Aug;17(8):496-8. Review.
PMID: 8863030 [PubMed - indexed for MEDLINE]

6. Skovgaard D, Feldt-Rasmussen BF, Nimb L, Hede A, Kjaer M.
[Bilateral Achilles tendon rupture in individuals with renal transplantation]
Ugeskr Laeger. 1996 Dec 30;159(1):57-8. Danish.
PMID: 9012076 [PubMed - indexed for MEDLINE]

7. Jagose JT, McGregor DR, Nind GR, Bailey RR.
Achilles tendon rupture due to ciprofloxacin.
N Z Med J. 1996 Dec 13;109(1035):471-2. No abstract available.
PMID: 9006634 [PubMed - indexed for MEDLINE]

8, Ottosson L.
[An unexpected verdict by the HSAN in a case of Achilles tendon rupture]
Lakartidningen. 1996 Dec 18;93(51-52):4712, 4715. Swedish. No abstract available.
PMID: 9011717 [PubMed - indexed for MEDLINE]

9. Castagnola C, Suhler A.
[Tendinopathy and fluoroquinolones]
Ann Urol (Paris). 1996;30(3):129-30. French.
PMID: 8766149 [PubMed - indexed for MEDLINE]

10. Foot Ankle Int. 1996 Aug;17(8):496-8.
Partial Achilles tendon ruptures associated with fluoroquinolone antibiotics: a case report and literature review.

11. Fluoroquinolone induced arthralgia and Magnetic Resonance Imaging
Loeuille et al (The Journal of Rheumatology volume 23 no 7 , July 1996)

12. Fluoroquinolone Induced Tendinopathy; Report of Six Cases
Zabraniedkl et al (The Journal of Rhuematology 1996; 23; 3)

13. Quinolone induced cartilage lesions are not reversible in rats
Forster et al (Arch Toxicol (1996) 70; 474-481)

14. Maki T, Heinasmaki T, Riutta J, Tikkanen T, Laasonen L, Eklund K.
[Bilateral Achilles tendon rupture caused by oral fluoroquinolones]
Duodecim. 1996;112(19):1818-20. Finnish. No abstract available.
PMID: 10596182 [PubMed - indexed for MEDLINE

15. ENGLAND
130 reported tendon inflammation or rupture (England, France and Belgium, 1996)
The group cited 130 reports of tendon inflammation or rupture in people who used the prescription drug in England, France and Belgium. The FDA has received at least 52 reports of patients in the U.S. who have suffered tendon damage
(from public citizens 1996 petition)
Szarfman et al. recommended that the labeling on packaging for fluoroquinolone be up-dated to include a warning about the possibility of tendon rupture. In its recommendations on the use of
this class of antibiotics, the British National Formulary
suggested that "at the first sign of pain or inflammation, patients should discontinue the treatment and rest the affected limb until the tendon symptoms have resolved."
British National Formulary. No. 32, p. 259. London, British Medical Association, Royal Pharmaceutical Society of Great Britain, 1996.
{Notice how this labeling change has not be altered since 1996 and appears to have been copied word for word in every monograph.}

16. FRANCE
921 reported tendon disorders France
340 reported tendonitis, 81 tendon ruptures 1996, WHO
Adverse drug reactions with fluoroquinolones The French system of drug surveillance has analyzed the reports of adverse drug reactions (ADRs) to fluoroquinolones since they were launched. The frequency of reactions ranges from 1/15000 to 1/208000 case per days of treatment. Cutaneous disorders and tendon disorders dominate in France, whereas cutaneous effects and neuropsychiatric disorders are predominant in the UK; tendon disorders take up only the 5th position. Among the most unexpected ADRs are the following: 1- Shock 2- Acure renal failure Tendon ruptures represent 81 cases for 921 reports of tendon disorders which are related in decreasing order to pefloxacin 1/23130 case per days of treatment, ofloxin, norfloxacin and ciprofloxacin 1/779600 case per days of treatment. Age and corticosteroids increase the risk of tendon rupture. Therapie 1996; 51; 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance: 340 of tendinitis and 81 of tendon rupture. These cases were attributed to Peflacine, Oflocet, Noroxine, Ciflox. Tendinitis was characterized by a bilateral malleolar oedema associated with a sudden pain. Sometimes this oedema evoked phlebitis. The tendon rupture was generally preceded by a tendinitis but in half of the cases it occurred without warning.
Source: http://www.who-umc.org/newsletter/newsltr97_1.html (sic)


1997

1. Australia. The Adverse Drug Reactions Advisory Committee first reported tendinitis in association with fluoroquinolone antibiotics in 1997. The Committee has continued to monitor this adverse reaction, and has now received 60 reports of tendinitis, tensosynovitis and/or tendon rupture in association with these drugs. Ciprofloxacin was most frequently cited (55 reports), as well as norfloxacin (4) and enoxacin (1).
Forty-five reports described tendinitis alone, one report described tensosynovitis, and 14 reports documented tendon tear or rupture. Fifty-five of the 60 reports specified the Achilles tendon, including 20 which described bilateral Achilles tendon damage. All 14 reports of tendon rupture involved the Achilles tendon. The 58 patients ranged in age from 38 to 91 years (median: 69), with no significant difference between those with tendinitis and those with tendon rupture.
The daily doses of ciprofloxacin ranged from 500 mg to 2250 mg, with 46% of patients taking 1500 mg and 46% of patients taking 1000 mg daily. For those who developed tendon rupture, 57% were taking 1500 mg daily. Time to onset varied from within 24 hours after the drug was commenced to 3 months after starting, but the majority of cases of tendinitis occurred within the first week. Time to rupture was longer with a median time of 2-3 weeks. Known risk factors for these reactions include old age, renal dysfunction and concomitant corticosteroid therapy. In the cases reported to the ADRAC, 29 reports documented concomitant corticosteroid use, and in 21 of the other 31 reports the patients were aged 69 years or older. In the reports of tendon rupture, 12 of the 14 described either concomitant steroid use (9) or old age (9).
Prescribers are reminded to be alert for this reaction and to withdraw the fluoroquinolone immediately when symptoms of tendinitis appear in order to reduce the risk of tendon rupture.
[See also Pharmaceuticals Newsletter Nos. 7&8, July&August 1997.]
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)
Australia

2. 93 ruptures, 103 tendinopathies, 20 tenasynovitis, 1987-1997
Source: http://www.sma.org/smj1999/junesmj99/harrell.pdf

3. Danesh-Meyer MJ.
Complicated management of a patient with rapidly progressive periodontitis: a case report.
J N Z Soc Periodontol. 1997;(82):25-9. No abstract available.
PMID: 10483437 [PubMed - indexed for MEDLINE]

4. Poon CC, Sundaram NA.
Spontaneous bilateral Achilles tendon rupture associated with ciprofloxacin.
Med J Aust. 1997 Jun 16;166(12):665. No abstract available.
PMID: 9216589 [PubMed - indexed for MEDLINE]

5. Shinohara YT, Tasker SA, Wallace MR, Couch KE, Olson PE.
What is the risk of Achilles tendon rupture with ciprofloxacin?
J Rheumatol. 1997 Jan;24(1):238-9. No abstract available.
PMID: 9002057 [PubMed - indexed for MEDLINE]

6. Movin T, Gad A, Guntner P, Foldhazy Z, Rolf C.
Pathology of the Achilles tendon in association with ciprofloxacin treatment.
Foot Ankle Int. 1997 May;18(5):297-9.
PMID: 9167931 [PubMed - indexed for MEDLINE]

7. Tendons and Fluoroquinolones; Unresolved issues
Kahn et al (Rev Rhum [Engl. Ed.] 1997 64(7-9) 437-439)
(Rev Rhum [Ed. Fr.] 1997 64(7-9) 511-513

8. Fluoroquinolones tendinitis update Australia
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)

9. Toxic effects of quinolone antibacterial agents on the musculoskeletal system in juvenile rats
Yoko Kashida et al (Toxicologic Pathology vol 25 number 6 pages 635-643 1997)

10. Tendinitis and tendon rupture with fluoroquinolones
ADRAC (The Achilles heel of fluoroquinolones Aust Adv Drug React Bull 1997;16;7, Szarfman et al)

11. Effects of Ciprofloxacin and Ofloxacin on adult human cartilage in vitro
(Antimicrob Agents Chemother 1997, Vol 41; issue 11; pages 2562-2565)

12. Repeated rupture of the extensor tendons of the hand due to fluoroquinolones, Apropos of a case
Levadoux et al (Ann Chir Main Memb Super 1997, vol 16, issue 2, pgs 130-133)

13. Benizeau I, Cambon-Michot C, Daragon A, Voisin L, Mejjad O, Thomine JM, Le Loet X.
Tendinitis of the tibialis anterior with histologic documentation in a patient under fluoroquinolone therapy.
Rev Rhum Engl Ed. 1997 Jun;64(6):432-3. No abstract available.
PMID: 9513620 [PubMed - indexed for MEDLINE]


1998

1. Khan KM, Cook JL, Bonar SF, Harcourt PR.
Subcutaneous rupture of the Achilles tendon.
Br J Sports Med. 1998 Jun;32(2):184-5. No abstract available.
PMID: 9631234 [PubMed - indexed for MEDLINE]

2. Stafford L, Bertouch J.
Reactive arthritis and ruptured Achilles tendon.
Ann Rheum Dis. 1998 Jan;57(1):61. No abstract available.
PMID: 9536827 [PubMed - indexed for MEDLINE]

3. Kahn MF.
Achilles tendinitis and ruptures.
Br J Sports Med. 1998 Sep;32(3):266. No abstract available.
PMID: 9773187 [PubMed - indexed for MEDLINE]

4. van der Linden PD, van Puijenbroek EP, Feenstra J, Veld BA, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH.
Tendon disorders attributed to fluoroquinolones: a study on 42 spontaneous reports in the period 1988 to 1998. Arthritis Rheum. 2001 Jun;45(3):235-9.
PMID: 11409663 [PubMed - indexed for MEDLINE]

5. Blanco Andres C, Bravo Toledo R.
[Bilateral tendinitis caused by ciprofloxacin]
Aten Primaria. 1998 Feb 28;21(3):184-5. Spanish. No abstract available.
PMID: 9607242 [PubMed - indexed for MEDLINE]

6. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239)

7. Petersen W, Laprell H
[Insidious rupture of the Achilles tendon after ciprofloxacin-induced tendopathy. A case report]
Unfallchirurg. 1998 Sep;101(9):731-4. German.
PMID: 9816984 [PubMed - indexed for MEDLINE]

8. Voorn R.
Case report: can sacroiliac joint dysfunction cause chronic Achilles
tendinitis?
J Orthop Sports Phys Ther. 1998 Jun;27(6):436-43.
PMID: 9617730 [PubMed - indexed for MEDLINE]

9. West MB, Gow P.
Ciprofloxacin, bilateral Achilles tendonitis and unilateral tendon rupture--a case report.
N Z Med J. 1998 Jan 23;111(1058):18-9. No abstract available.
PMID: 9484431 [PubMed - indexed for MEDLINE]

10. Gabutti L, Stoller R, Marti HP.
[Fluoroquinolones as etiology of tendinopathy]
Ther Umsch. 1998 Sep;55(9):558-61. German.
PMID: 9789471 [PubMed - indexed for MEDLINE]

11. NETHERLANDS
704 achilles tendinitis, 38 ruptures 1992-1998 Netherlands
Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306

12. 42 spontaneous reports 1988-1998
Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239) June 2001
http://www.rheumatology.org/arhp/acnr/2001/0106.html


1999

1. Eriksson E.
In vivo microdialysis of painful achilles tendinosis.
Knee Surg Sports Traumatol Arthrosc. 1999;7(6):339. No abstract available.
PMID: 10639649 [PubMed - indexed for MEDLINE]

2. Mousa A, Jones S, Toft A, Perros P.
Spontaneous rupture of Achilles tendon: missed presentation of Cushing's syndrome.
BMJ. 1999 Aug 28;319(7209):560-1. No abstract available.
PMID: 10463901 [PubMed - indexed for MEDLINE]

3. Harrell RM.
Fluoroquinolone-induced tendinopathy: what do we know?
South Med J. 1999 Jun;92(6):622-5. Review.
PMID: 10372859 [PubMed - indexed for MEDLINE]

4. Gibbon WW, Cooper JR, Radcliffe GS.
Sonographic incidence of tendon microtears in athletes with chronic Achilles tendinosis.
Br J Sports Med. 1999 Apr;33(2):129-30.
PMID: 10205697 [PubMed - indexed for MEDLINE]

5. Lewis JR, Gums JG, Dickensheets DL.
Levofloxacin-induced bilateral Achilles tendonitis.
Ann Pharmacother. 1999 Jul-Aug;33(7-8):792-5.
PMID: 10466906 [PubMed - indexed for MEDLINE]

6. Zambanini A, Padley S, Cox A, Feher M.
Achilles tendonitis: an unusual complication of amlodipine therapy.
J Hum Hypertens. 1999 Aug;13(8):565-6. No abstract available.
PMID: 10455480 [PubMed - indexed for MEDLINE]

7. van der Linden PD, van de Lei J, Nab HW, Knol A, Stricker BH.
Achilles tendinitis associated with fluoroquinolones.
Br J Clin Pharmacol. 1999 Sep;48(3):433-7.
PMID: 10510157 [PubMed - indexed for MEDLINE]

8. Van der Linden PD, van de Lei J, Nab HW, Knol A, Stricker BHCh. Achilles tendinitis associated with fluoroquinolones. Br J Clin Pharmacol 1999; 48: 433-437[CrossRef][ISI][Medline].

9. 60 reported tendonitis August 1999
Fluoroquinolones tendinitis update Australia
Tendinitis associated with Fluoroquinolone therapy
(Pharmaceuticals Newsletters Nos 7&8 July & August 1997)
Australia
ADRAC Bulletin, vol 18, No 3, August 1999
Tendinitis and tendon rupture with
fluoroquinolones
The Adverse Drug Reactions Advisory Committee (ADRAC) first reported tendinitis in association with the fluoroquinolone antibiotics in 1997. The Committee has continued to monitor this adverse
reaction, and has now received 60 reports of tendinitis, tenosynovitis and/or tendon rupture in association with these drugs. Most involved was ciprofloxacin (55), but there were also reports with norfloxacin (4) and enoxacin (1). Fortyfive reports described tendinitis alone, one report described tenosynovitis, and 14 reports documented tendon tear or rupture. Fifty five of the 60 reports specified the Achilles tendon, including 20 which described bilateral
Achilles tendon damage. All 14 reports of tendon rupture
involved the Achilles tendon.
Source: http://www.who.int/medicines/library/pnewslet/pndec99.html

10. 421 reported tendon disorders and 81 tendon ruptures 1999
Therapie 1996; 51: 419-420 Tendon disorders with fluoroquinolones 421 cases have been collected by the Centre de Pharmacovigilance, 340 of tendinitis and 81 cases of tendon rupture.

11. Rev Rhum Engl Ed. 1999 Jul-Sep;66(7-9):419-21.
Suspected role of ofloxacin in a case of arthalgia, myalgia, and multiple tendinopathy.

12. Levofloxacin-induced bilateral Achilles tendonitis
Lewis JR, JG Gums, and DL Dickensheets 1999

13. Inhibition of fibroblast metabolism by a fluoroquinolone antibiotic
Williams et al (American Academy of Orthopedic Surgeons, 1999 Annual meeting, paper number 118, Geb 5, 1999)

14. Levofloxacin induced bilateral achilles tendinitis
Lewis et al (The Annals of Pharmacotherapy 1999 July/August, volume 33 pages 792-795)

15. Fluoroquinolone induced tendinopathy; what do we know?
Harrell et al (South Med J 92(6) 622-625 1999)

16. Ann Pharmacother. 1999 Jul-Aug;33(7-8):792-5.
Levofloxacin-induced bilateral Achilles tendonitis.

17. Schwald N, Debray-Meignan S.
Suspected role of ofloxacin in a case of arthalgia, myalgia, and multiple tendinopathy.
Rev Rhum Engl Ed. 1999 Jul-Sep;66(7-9):419-21.
PMID: 10526383 [PubMed - indexed for MEDLINE]


2000

1. Fluoroquinolone induced tendinopathy; also occurring with levofloxacin
Fleisch et al (Infection 28 2000 no 4 pages 256-257)

2. Infection. 2000 Jul-Aug;28(4):256-7.
Fluoroquinolone-induced tendinopathy: also occurring with levofloxacin.

3. Quinolone and Tendon Ruptures
Casperian et al (Southern Medical Journal May 2000 vol 93 no 5 pages 488-491)

4. Evaluation of toxicokinetic variables and arthropathic changes in juvenile rabbits after oral administration of an ivestigational fluoroquinolone, pd 117596
Johnson et al (AJVR vol 61 no 11, pages, 1396-1402, November 2000)

5. Rupture of the patellar ligament one month after treatment with fluoroquinolone
Rev Chir Orthop Reparatrice Appar Mot. 2000 Sep;86(5):495-7.

6. FINLAND
42 reported tendinopathies 2000
Finland:
Register of adverse drug reactions in 2000

7. The majority of ADR reports received among antibacterials concerned levofloxacin, which is a fluoroquinolone antibiotic. Fourteen of the reports were on tendinitis or rupture of the Achilles tendon. Tendinitis caused by fluoroquinolones was discussed in TABU for the first time in 1996. Since then the ADR register has received a total of 42 reports on tendinopathies caused by
fluoroquinolones, over a third of which were ruptures of the tendon.
The use of fluoroquinolones has in-creased by about 75% since 1996. Levofloxacin is responsible for the major part of this increase. It has been marketed in Finland since mid 1998.
source: www.nam.fi/uploads/english/Publications/Tabu/tabu22001_eng.pdf

8. Casado Burgos E, Vinas Ponce G, Lauzurica Valdemoros R, Olive Marques A.
[Levofloxacin-induced tendinitis]
Med Clin (Barc). 2000 Mar 4;114(8):319. Spanish. No abstract available.
PMID: 10774524 [PubMed - indexed for MEDLINE]

9. Casparian JM, Luchi M, Moffat RE, Hinthorn D.
Quinolones and tendon ruptures.
South Med J. 2000 May;93(5):488-91. Review.
PMID: 10832946 [PubMed - indexed for MEDLINE]

10. Gravlee JR, Hatch RL, Galea AM.
Achilles tendon rupture: a challenging diagnosis.
J Am Board Fam Pract. 2000 Sep-Oct;13(5):371-3. No abstract available.
PMID: 11001009 [PubMed - indexed for MEDLINE]

11. Kouvalchouk JF, Hassan E
[Achilles tendon disorders]
Tunis Med. 2000 Jun-Jul;78(6-7):462-7. Review. French. No abstract available.
PMID: 11043038 [PubMed - indexed for MEDLINE]

12. Ortiz V, Holgado S, Olive A, Fite E.
Ach illes tendinitis as the presentation form of Lofgren's syndrome.
Clin Rheumatol. 2000;19(2):169-70.
PMID: 10791635 [PubMed - indexed for MEDLINE]

13. Vavra-Hadziahmetovic N, Hadziahmetovic Z, Smajlovic F.
Phy sical therapy in conservative (functional) treatment of acute achilles tendon rupture.
Med Arh. 2000;54(2):121-2.
PMID: 10934845 [PubMed - indexed for MEDLINE]

14. Martinelli B.
Rupture of the Achilles tendon.
J Bone Joint Surg Am. 2000 Dec;82-A(12):1804. No abstract available.
PMID: 11130653 [PubMed - indexed for MEDLINE]


2001

1. Rev Clin Esp. 2001 Sep;201(9):539-40.
Achilles pain and functional impotence in a patient with chronic obstructive pulmonary disease with pneumonia. Tendon rupture caused by levofloxacin

2. Pharm World Sci. 2001 Jun;23(3):89-92.
Fluoroquinolone use and the change in incidence of tendon ruptures in the Netherlands.
van der Linden PD, Nab HW, Simonian S, Stricker BH, Leufkens HG, Herings RM.

3. Mennecier D, Thiolet C, Bredin C, Potier V, Vergeau B, Farret O.
[Acute pancreatitis after treatment by levofloxacin and methylprednisolone]
Gastroenterol Clin Biol. 2001 Oct;25(10):921-2. French. No abstract available.
PMID: 11852403 [PubMed - indexed for MEDLINE]

4. Csizy M, Hintermann B.
[Rupture of the Achilles tendon after local steroid injection. Case reports and consequences for treatment]
Swiss Surg. 2001;7(4):184-9. German.
PMID: 11515194 [PubMed - indexed for MEDLINE]

5. Adverse reactions to fluoroquinolones an overview on mechanistic aspects
De Sarro et al (Current Medicinal Chemistry 2001, 8, 371-384)

6. Fluoroquinolone use and the change in incidence of tendon rupture in the Netherlands
Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)

7. Tendon disorders attributed to fluoroquinolones; a study on 42 spontaneous reports in the period 1988-1998
Van Der Linden et al (American College of Rheumatology; Arthritis Care and Research 45; 2001 pages 235-239)

8. 1847 reported tendinopathies December 2001
Tabelle 7
Pharmacovigilance: Meldungen von Tendinopathien im Vergleich zu allen gemeldeten unerwünschten Arzneimittelwirkungen (UAW), Stand 17. Dezember 2001.

9. Meldungen Schweiz (IKS-Datenbank) Welt (WHO-Datenbank)
Tendinopathie alle UAW Tendinopathie alle UAW
Ciprofloxacin 8 (5%) 155 649(2,2%) 29 090
Fleroxacin 9 (1,2 %) 754
Norfloxacin 1 (1%) 91 163 (2,1%) 7536
Ofloxacin 2 (6%) 34 432 (1,8%) 23 990
Levofloxacin 32 (41%) 79 576 (7,8%) 7432
Moxifloxacin 18 (4,5 %) 4030
Source: http://www.saez.ch/pdf/2003/2003-02/2003-02-694.PDF
http://www.saez.ch/pdf/2003/2003-02/2003-02-694.PDF

10. U.S. ARMED FORCES
Spontaneous Ruptures of the Achilles Tendon, US Armed Forces, 1998-2001
Methods. The Defense Medical Surveillance System was searched to identify all incident ambulatory visits of active duty servicemembers with a primary diagnosis of non-traumatic rupture of the achilles tendon (ICD-9- CM code 727.67) and other tendon ruptures (ICD-9- CM codes 727.60-727.66, 727.68-727.69) between January 1998 and May 2001.
The most striking finding of this analysis is the sudden and significant increase in rates of achilles tendon ruptures beginning in calendar year 2000. The increase was manifested across all Services and in most demographic subgroups (table 1). Rates
of non-traumatic ruptures of several other tendons also increased during the period; and increases in ruptures of the rotator cuff were comparable to those of the achilles tendon.
Source: http://amsa.army.mil/1Msmr/2002/v08_n01.pdf

11. Nuno Mateo FJ, Noval Menendez J, Suarez M, Guinea O.
[Achilles pain and functional impotence in a patient with chronic obstructive pulmonary disease with pneumonia. Tendon rupture caused by levofloxacin]
Rev Clin Esp. 2001 Sep;201(9):539-40. Spanish. No abstract available.
PMID: 11692412 [PubMed - indexed for MEDLINE]

12. Malaguti M, Triolo L, Biagini M.
Ciprofloxacin-associated Achilles tendon rupture in a hemodialysis patient.
J Nephrol. 2001 Sep-Oct;14(5):431-2. No abstract available.
PMID: 11730281 [PubMed - indexed for MEDLINE]

13. Butler MW, Griffin JF, Quinlan WR, McDonnell TJ.
Quinolone-associated tendonitis: a potential problem in COPD?
Ir J Med Sci. 2001 Jul-Sep;170(3):198-9.
PMID: 12120977 [PubMed - indexed for MEDLINE]

14. Bharani A, Kumar H.
Drug points: Diabetes inspidus induced by ofloxacin.
BMJ. 2001 Sep 8;323(7312):547. No abstract available.
PMID: 11546701 [PubMed - indexed for MEDLINE]

15. Toverud EL, Landaas S, Hellebostad M.
Repeated achilles tendinitis after high dose methotrexate.
Med Pediatr Oncol. 2001 Aug;37(2):156. No abstract available.
PMID: 11496361 [PubMed - indexed for MEDLINE]

16. Oatridge A, Herlihy AH, Thomas RW, Wallace AL, Curati WL, Hajnal JV, Bydder GM.
Magnetic resonance: magic angle imaging of the Achilles tendon.
Lancet. 2001 Nov 10;358(9293):1610-1.
PMID: 11716890 [PubMed - indexed for MEDLINE]

17. Fletcher MD, Warren PJ.
Sural nerve injury associated with neglected tendo Achilles ruptures.
Br J Sports Med. 2001 Apr;35(2):131-2.
PMID: 11273977 [PubMed - indexed for MEDLINE]

18. Humble RN, Nugent LL.
Achilles' tendonitis. An overview and reconditioning model.
Clin Podiatr Med Surg. 2001 Apr;18(2):233-54. Review.
PMID: 11417153 [PubMed - indexed for MEDLINE]

19. Eriksson E.
Achilles tendon surgery and wound healing.
Knee Surg Sports Traumatol Arthrosc. 2001 Jul;9(4):193. No abstract available.
PMID: 11522072 [PubMed - indexed for MEDLINE]

20. Speed CA.
Fortnightly review: Corticosteroid injections in tendon lesions.
BMJ. 2001 Aug 18;323(7309):382-6. No abstract available.
PMID: 11509432 [PubMed - indexed for MEDLINE]

21. Van der Linden et al (Pharmacy World and Science vol 23 no 3 2001 pg 89-92)
The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture
source: http://bmj.com/cgi/content/full/324/7349/1306


2002

1. Ulreich N, Kainberger F, Huber W, Nehrer S.
[Achilles tendon and sports]
Radiologe. 2002 Oct;42(10):811-7. German.
PMID: 12402109 [PubMed - indexed for MEDLINE]

2. Doral MN, Tetik O, Atay OA, Leblebicioglu G, Oznur A.
[Achilles tendon diseases and its management]
Acta Orthop Traumatol Turc. 2002;36 Suppl 1:42-6. Review. Turkish. No abstract available.
PMID: 12510123 [PubMed - indexed for MEDLINE]

3. Hersh BL, Heath NS.
Achilles tendon rupture as a result of oral steroid therapy.
J Am Podiatr Med Assoc. 2002 Jun;92(6):355-8.
PMID: 12070236 [PubMed - indexed for MEDLINE]

4. [No authors listed]
Side effects of levofloxacin.
Prescrire Int. 2002 Aug;11(60):116-7. No abstract available.
PMID: 12199267 [PubMed - indexed for MEDLINE]

5. Hatori M, Matsuda M, Kokubun S.
Ossification of Achilles tendon--report of three cases.
Arch Orthop Trauma Surg. 2002 Sep;122(7):414-7. Epub 2002 May 03.
PMID: 12228804 [PubMed - indexed for MEDLINE]

6. Pouzaud F, Rat P, Cambourieu C, Nourry H, Warnet JM.
[Tenotoxic potential of fluoroquinolones in the choice of surgical antibiotic prophylaxis in ophthalmology]
J Fr Ophtalmol. 2002 Nov;25(9):921-6. French.
PMID: 12515937 [PubMed - indexed for MEDLINE]

7. Sobel E, Giorgini R, Hilfer J, Rostkowski T.
Ossification of a ruptured achilles tendon: a case report in a diabetic patient.
J Foot Ankle Surg. 2002 Sep-Oct;41(5):330-4.
PMID: 12400718 [PubMed - indexed for MEDLINE]

8. Lohrer H, Scholl J, Arentz S.
[Achilles tendinopathy and patellar tendinopathy. Results of radial shockwave therapy in patients with unsuccessfully treated tendinoses] Sportverletz Sportschaden. 2002 Sep;16(3):108-14. German. No abstract available.
PMID: 12382183 [PubMed - indexed for MEDLINE]

9. Eriksen HA, Pajala A, Leppilahti J, Risteli J.
Increased content of type III collagen at the rupture site of human Achilles tendon.
J Orthop Res. 2002 Nov;20(6):1352-7.
PMID: 12472252 [PubMed - indexed for MEDLINE]

10. Kannus P, Paavola M, Paakkala T, Parkkari J, Jarvinen T, Jarvinen M.
[Pathophysiology of overuse tendon injury]
Radiologe. 2002 Oct;42(10):766-70. German.
PMID: 12402104 [PubMed - indexed for MEDLINE]

11. Summers JB.
Importance of an accurate diagnosis for Achilles rupture.
Am Fam Physician. 2002 Nov 15;66(10):1836. No abstract available.
PMID: 12469956 [PubMed - indexed for MEDLINE]

12. Ulreich N, Huber W, Nehrer S, Kainberger F.
[High resolution magnetic resonance tomography and ultrasound imaging of the Achilles tendon]
Wien Med Wochenschr Suppl. 2002;(113):39-40. German.
PMID: 12621837 [PubMed - indexed for MEDLINE]

13. Dwornik L, Lomasney LM, Demos TC, Lavery LA.
Radiologic case study. Acute Achilles tendon rupture.
Orthopedics. 2002 Nov;25(11):1239, 1318-20. No abstract available.
PMID: 12452339 [PubMed - indexed for MEDLINE]

14. Wood ML, Schlessinger S.
Levaquin induced acute tubulointerstitial nephritis--two case reports.
J Miss State Med Assoc. 2002 Apr;43(4):116-7. No abstract available.
PMID: 11989200 [PubMed - indexed for MEDLINE]

15. McClelland D, Maffulli N.
Percutaneous repair of ruptured Achilles tendon.
J R Coll Surg Edinb. 2002 Aug;47(4):613-8. Review.
PMID: 12363186 [PubMed - indexed for MEDLINE]

16. Eriksson E.
Tendinosis of the patellar and achilles tendon.
Knee Surg Sports Traumatol Arthrosc. 2002 Jan;10(1):1. Epub 2001 Dec 18. No abstract available.
PMID: 11819012 [PubMed - indexed for MEDLINE]

17. Bleakney RR, Tallon C, Wong JK, Lim KP, Maffulli N.
Long-term ultrasonographic features of the Achilles tendon after rupture.
Clin J Sport Med. 2002 Sep;12(5):273-8.
PMID: 12394198 [PubMed - indexed for MEDLINE]

18. Majewski M, Widmer KH, Steinbruck K.
[Achilles tendon ruptures: 25 year's experience in sport-orthopedic treatment]
Sportverletz Sportschaden. 2002 Dec;16(4):167-73. German.
PMID: 12563559 [PubMed - indexed for MEDLINE]

19. Cook JL, Khan KM, Purdam C.
Achilles tendinopathy.
Man Ther. 2002 Aug;7(3):121-30. Review.
PMID: 12372309 [PubMed - indexed for MEDLINE]

20. Shukla DD.
Bilateral spontaneous rupture of achilles tendon secondary to limb ischemia: a case report.
J Foot Ankle Surg. 2002 Sep-Oct;41(5):328-9.
PMID: 12400717 [PubMed - indexed for MEDLINE]

21. Grechenig W, Clement H, Bratschitsch G, Fankhauser F, Peicha G.
[Ultrasound diagnosis of the Achilles tendon]
Orthopade. 2002 Mar;31(3):319-25. German.
PMID: 12017866 [PubMed - indexed for MEDLINE]

22. Mazzone MF, McCue T.
Common conditions of the achilles tendon.
Am Fam Physician. 2002 May 1;65(9):1805-10. Review.
PMID: 12018803 [PubMed - indexed for MEDLINE]

23. Schepsis AA, Jones H, Haas AL.
Achilles tendon disorders in athletes.
Am J Sports Med. 2002 Mar-Apr;30(2):287-305. Review.
PMID: 11912103 [PubMed - indexed for MEDLINE]

24. Fluoroquinolones and risk of Achilles tendon disorders: case-control study BMJ 2002;324:1306-1307 ( 1 June ) P D van der Linden, researcher a, M C J M Sturkenboom, assistant professor a, R M C Herings, associate professor b, H G M Leufkens, professor b, B H Ch Stricker, professor a.
a Pharmaco-epidemiology Unit, Department of Epidemiology & Biostatistics and Internal Medicine, Erasmus Medical Centre Rotterdam, PO Box 1738, 3000 DR Rotterdam, Netherlands, b Department of Pharmaco-epidemiology and Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands

25. Pai VS, Patel N.
Atypical coronal or sagittal Z ruptures of the achilles tendon: a report of four cases.
J Foot Ankle Surg. 2002 May-Jun;41(3):183-5.
PMID: 12075907 [PubMed - indexed for MEDLINE]

26. van der Linden PD, Sturkenboom MC, Herings RM, Leufkens HG, Stricker BH.
Fluoroquinolones and risk of Achilles tendon disorders: case-control study.
BMJ. 2002 Jun 1;324(7349):1306-7. No abstract available.
PMID: 12039823 [PubMed - indexed for MEDLINE]

27. Tiling T.
[Is an Achilles tendon rupture without degeneration possible?]
Dtsch Med Wochenschr. 2002 Jun 21;127(25-26):1401. German. No abstract available.
PMID: 12075502 [PubMed - indexed for MEDLINE]

28. Med Clin (Barc). 2003 Jan 25;120(2):78-9.
Comment on: Med Clin (Barc). 2002 Jun 8;119(1):38-9.
Levofloxacin and bilateral spontaneous Achilles tendon rupture

29. 4 cases of levaquin induced tendintis (orign spansih)
Mica magazine of Chile Issn0034-9887 versi printed
Rev. m. Chilev.130n.11Santiagonov.2002
Rev Méd Chile 2002; 130: 1277-1281
Associated aquiliana Tendinitis to the levofloxacino use:
communication of four cases
Claudius Hoops And, Claudius Flowers W, Sergio Mezzano A.
Levofloxacin associated Achilles

29. Pedros A, Emilio Gomez J, Angel Navarro L, Tomas A.
[Levofloxacin and acute confusional syndrome]
Med Clin (Barc). 2002 Jun 8;119(1):38-9. Spanish. No abstract available.
PMID: 12062009 [PubMed - indexed for MEDLINE]

30. Maffulli N, Kader D.
Tendinopathy of tendo achillis.
J Bone Joint Surg Br. 2002 Jan;84(1):1-8. Review. No abstract available.
PMID: 11837811 [PubMed - indexed for MEDLINE]

31. Sidorenko SV, Krivitskaia NS
[Use of ciprofloxacin in sequential antibiotic therapy]
Antibiot Khimioter. 2002;47(7):25-30. Review. Russian. No abstract available.
PMID: 12516193 [PubMed - indexed for MEDLINE]

32. Paavola M, Kannus P, Jarvinen TA, Khan K, Jozsa L, Jarvinen M.
Achilles tendinopathy.
J Bone Joint Surg Am. 2002 Nov;84-A(11):2062-76. Review. No abstract available.
PMID: 12429771 [PubMed - indexed for MEDLINE]

33. Roberts C, Deliss L.:
Acute rupture of tendo Achillis.
J Bone Joint Surg Br. 2002 May;84(4):620; author reply 620. No abstract available.
PMID: 12043793 [PubMed - indexed for MEDLINE]

34. Tumia N, Kader D, Arena B, Maffulli N
Achilles tendinopathy during pregnancy.
Clin J Sport Med. 2002 Jan;12(1):43-5. No abstract available.
PMID: 11854590 [PubMed - indexed for MEDLINE]

35. Paffey MD, Faraj AA.
Acute rupture of tendo Achillis.
J Bone Joint Surg Br. 2002 May;84(4):620-1; author reply 621. No abstract available.
PMID: 12043792 [PubMed - indexed for MEDLINE]

36. Chhajed PN, Plit ML, Hopkins PM, Malouf MA, Glanville AR.
Achilles tendon disease in lung transplant recipients: association with ciprofloxacin.
Eur Respir J. 2002 Mar;19(3):469-71.
PMID: 11936524 [PubMed - indexed for MEDLINE]

37. Greene BL.Physical therapist management of fluoroquinolone-induced Achilles tendinopathy.
Phys Ther. 2002 Dec;82(12):1224-31.
PMID: 12444881 [PubMed - indexed for MEDLINE]

38. Breck RW.
"Ciprofloxacin: a warning for clinicians".
Conn Med. 2002 Oct;66(10):635. No abstract available.
PMID: 12448217 [PubMed - indexed for MEDLINE]

39. Hufner T, Wohifarth K, Fink M, Thermann H, Rollnik JD.
EMG monitoring during functional non-surgical therapy of Achilles tendon rupture.
Foot Ankle Int. 2002 Jul;23(7):614-8.
PMID: 12146771 [PubMed - indexed for MEDLINE]

40. Khurana R, Torzillo PJ, Horsley M, Mahoney J.
Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease.
Respirology. 2002 Jun;7(2):161-3.
PMID: 11985741 [PubMed - indexed for MEDLINE]

41. Mert G.
Rupture of the Achilles tendon in athletes: do synthetic grass fields play a part?
J Bone Joint Surg Am. 2002 Feb;84-A(2):320-1. No abstract available.
PMID: 11861742 [PubMed - indexed for MEDLINE]

42. Lynch RM
Management of Achilles tendon ruptures.
Am J Sports Med. 2002 Nov-Dec;30(6):917; author reply 917-8. No abstract
available.
PMID: 12435663 [PubMed - indexed for MEDLINE]

43. Amendola N.
Surgical treatment of acute rupture of the tendo Achillis led to fewer
reruptures and better patient-generated ratings than did nonsurgical treatment.
J Bone Joint Surg Am. 2002 Feb;84-A(2):324. No abstract available.
PMID: 11861747 [PubMed - indexed for MEDLINE]

44. Zwar RB.
Utility of musculoskeletal ultrasound.
Aust Fam Physician. 2002 Jun;31(6):559, 561.
PMID: 12154604 [PubMed - indexed for MEDLINE]

45. Cottrell WC, Pearsall AW 4th, Hollis MJ.
Simultaneous tears of the Achilles tendon and medial head of the gastrocnemius muscle.
Orthopedics. 2002 Jun;25(6):685-7. No abstract available.
PMID: 12083581 [PubMed - indexed for MEDLINE]


2003

1. Journal of Antimicrobial Chemotherapy (2003) 51, 747–748
DOI: 10.1093/jac/dkg081
Advance Access publication 28 January 2003
Correspondence
Spontaneous Achilles tendon rupture in patients
treated with levofloxacin
L. J. Haddow, M. Chandra Sekhar, V. Hajela and
G. Gopal Rao

2. Manoj Kumar RV, Rajasekaran S.
Spontaneous tendon ruptures in alkaptonuria.
J Bone Joint Surg Br. 2003 Aug;85(6):883-6.
PMID: 12931812 [PubMed - indexed for MEDLINE]

3. Harris RD, Nindl G, Balcavage WX, Weiner W, Johnson MT.
Use of proteomics methodology to evaluate inflammatory protein expression in tendinitis.
Biomed Sci Instrum. 2003;39:493-9.
PMID: 12724941 [PubMed - indexed for MEDLINE]

4. Milgrom C, Finestone A, Zin D, Mandel D, Novack V.
Cold weather training: a risk factor for Achilles paratendinitis among
recruits.
Foot Ankle Int. 2003 May;24(5):398-401.
PMID: 12801195 [PubMed - indexed for MEDLINE]

5. Schwalm JD, Lee CH.
Acute hepatitis associated with oral levofloxacin therapy in a hemodialysis patient.
CMAJ. 2003 Apr 1;168(7):847-8.
PMID: 12668542 [PubMed - indexed for MEDLINE]

6. Oh YR, Carr-Lopez SM, Probasco JM, Crawley PG.
Levofloxacin-induced autoimmune hemolytic anemia.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1010-3.
PMID: 12841809 [PubMed - indexed for MEDLINE]

7. Bardin L.
Comments on 'Achilles tendinopathy'.
Man Ther. 2003 Aug;8(3):189; author reply 190-1. No abstract available.
PMID: 12909446 [PubMed - indexed for MEDLINE]

8. Ackermann PW, Li J, Lundeberg T, Kreicbergs A.
Neuronal plasticity in relation to nociception and healing of rat achilles tendon.
J Orthop Res. 2003 May;21(3):432-41.
PMID: 12706015 [PubMed - indexed for MEDLINE]

9. Gotoh M, Higuchi F, Suzuki R, Yamanaka K.
Progression from calcifying tendinitis to rotator cuff tear.
Skeletal Radiol. 2003 Feb;32(2):86-9. Epub 2002 Apr 05.
PMID: 12589487 [PubMed - indexed for MEDLINE]

10. Dalal RB, Zenios M.
The flexor hallucis longus tendon transfer for chronic tendo-achilles ruptures revisited. Ann R Coll Surg Engl. 2003 Jul;85(4):283. No abstract available.
PMID: 12908473 [PubMed - indexed for MEDLINE]

11. Joseph TA, Defranco MJ, Weiker GG.
Delayed repair of a pectoralis major tendon rupture with allograft: A case report.
J Shoulder Elbow Surg. 2003 Jan-Feb;12(1):101-4. No abstract available.
PMID: 12610495 [PubMed - indexed for MEDLINE]

12. [No authors listed]
Tendon abnormalities and hypersensitivity of levofloxacin.
Prescrire Int. 2003 Feb;12(63):20. No abstract available.
PMID: 12602391 [PubMed - indexed for MEDLINE]

13. Magnusson SP, Beyer N, Abrahamsen H, Aagaard P, Neergaard K, Kjaer M.
Increased cross-sectional area and reduced tensile stress of the Achilles tendon in elderly compared with young women.
J Gerontol A Biol Sci Med Sci. 2003 Feb;58(2):123-7.
PMID: 12586849 [PubMed - indexed for MEDLINE]

14. Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, Taunton JE.
Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study.
Br J Sports Med. 2003 Apr;37(2):149-53.
PMID: 12663358 [PubMed - indexed for MEDLINE]

15. DY, Song JC, Wang CC.
Anaphylactoid reaction to ciprofloxacin.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1018-23.
PMID: 12841811 [PubMed - indexed for MEDLINE]

16. Ying M, Yeung E, Li B, Li W, Lui M, Tsoi CW.
Sonographic evaluation of the size of Achilles tendon: the effect of exercise and dominance of the ankle.
Ultrasound Med Biol. 2003 May;29(5):637-42.
PMID: 12754062 [PubMed - indexed for MEDLINE]

17. Cook J, Khan K.
The treatment of resistant, painful tendinopathies results in frustration for athletes and health professionals alike.
Am J Sports Med. 2003 Mar-Apr;31(2):327-8; author reply 328. No abstract available.
PMID: 12642274 [PubMed - indexed for MEDLINE]

18. [No authors listed]
Fluoroquinolones in ambulatory ENT and respiratory tract infections: rarely appropriate.
Prescrire Int. 2003 Feb;12(63):26-7.
PMID: 12602405 [PubMed - indexed for MEDLINE]

19. Matsumoto F, Trudel G, Uhthoff HK, Backman DS.
Mechanical effects of immobilization on the Achilles' tendon.
Arch Phys Med Rehabil. 2003 May;84(5):662-7.
PMID: 12736878 [PubMed - indexed for MEDLINE]

20. Maffulli N, Kenward MG, Testa V, Capasso G, Regine R, King JB.
Clinical diagnosis of Achilles tendinopathy with tendinosis.
Clin J Sport Med. 2003 Jan;13(1):11-5.
PMID: 12544158 [PubMed - indexed for MEDLINE]

21. Forslund C.
BMP treatment for improving tendon repair. Studies on rat and rabbit Achilles tendons.
Acta Orthop Scand Suppl. 2003 Feb;74(308):I, 1-30. No abstract available.
PMID: 12640969 [PubMed - indexed for MEDLINE]

22. Cetti R, Junge J, Vyberg M.
Spontaneous rupture of the Achilles tendon is preceded by widespread and bilateral tendon damage and ipsilateral inflammation: a clinical and histopathologic study of 60 patients.
Acta Orthop Scand. 2003 Feb;74(1):78-84.
PMID: 12635798 [PubMed - indexed for MEDLINE]

23. Mulvaney S.
Calf muscle therapy for Achilles tendinosis.
Am Fam Physician. 2003 Mar 1;67(5):939; author reply 939-40. No abstract available.
PMID: 12643353 [PubMed - indexed for MEDLINE]

24. Khaliq Y, Zhanel GG.
Fluoroquinolone-associated tendinopathy: a critical review of the literature.
Clin Infect Dis. 2003 Jun 1;36(11):1404-10. Epub 2003 May 20. Review.
PMID: 12766835 [PubMed - indexed for MEDLINE]

25. Prasad S, Lee A, Clarnette R, Faull R.
Spontaneous, bilateral patellar tendon rupture in a woman with previous Achilles tendon rupture and systemic lupus erythematosus.
Rheumatology (Oxford). 2003 Jul;42(7):905-6. No abstract available.
PMID: 12826711 [PubMed - indexed for MEDLINE]

26. Gold L, Igra H.
Levofloxacin-induced tendon rupture: a case report and review of the literature.
J Am Board Fam Pract. 2003 Sep-Oct;16(5):458-60. Review. No abstract available.
PMID: 14645337 [PubMed - indexed for MEDLINE]

27. Schindler C, Pittrow D, Kirch W.
Reoccurrence of levofloxacin-induced tendinitis by phenoxymethylpenicillin therapy after 6 months: a rare complication of fluoroquinolone therapy?
Chemotherapy. 2003 May;49(1-2):90-1. No abstract available.
PMID: 12756981 [PubMed - indexed for MEDLINE]

28. de La Red G, Mejia JC, Cervera R, Llado A, Mensa J, Font J.
Bilateral Achilles tendinitis with spontaneous rupture induced by levofloxacin in a patient with systemic sclerosis.
Clin Rheumatol. 2003 Oct;22(4-5):367-8. No abstract available.
PMID: 14579169 [PubMed - indexed for MEDLINE]

29. Tomas ME, Perez Carreras M, Morillasa JD, Castellano G, Solis JA.
[Rupture of the Achilles' tendon secondary to levofloxacin]
Gastroenterol Hepatol. 2003 Jan;26(1):53-4. Spanish. No abstract available.
PMID: 12525331 [PubMed - indexed for MEDLINE]

30. Mathis AS, Chan V, Gryszkiewicz M, Adamson RT, Friedman GS.
Levofloxacin-associated Achilles tendon rupture.
Ann Pharmacother. 2003 Jul-Aug;37(7-8):1014-7.
PMID: 12841810 [PubMed - indexed for MEDLINE]

31. Aros C, Flores C, Mezzano S.[Achilles tendinitis associated to levofloxacin: report of 4 cases]
Rev Med Chil. 2002 Nov;130(11):1277-81. Spanish.
PMID: 12587511 [PubMed - indexed for MEDLINE]

32. Shah P.[Do tendon lesions occur during quinolone administration?]
Dtsch Med Wochenschr. 2003 Oct 17;128(42):2214. German. No abstract available.
PMID: 14562223 [PubMed - indexed for MEDLINE]

33. Melhus A, Apelqvist J, Larsson J, Eneroth M.
Levofloxacin-associated Achilles tendon rupture and tendinopathy.
Scand J Infect Dis. 2003;35(10):768-70.
PMID: 14606622 [PubMed - indexed for MEDLINE]

34. Cebrian P, Manjon P, Caba P.
Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to
levofloxacin.
Foot Ankle Int. 2003 Feb;24(2):122-4.
PMID: 12627618 [PubMed - indexed for MEDLINE]

35. Bernacer L, Artigues A, Serrano A.
[Levofloxacin and bilateral spontaneous Achilles tendon rupture]
Med Clin (Barc). 2003 Jan 25;120(2):78-9. Spanish. No abstract available.
PMID: 12570920 [PubMed - indexed for MEDLINE]

36. Haddow LJ, Chandra Sekhar M, Hajela V, Gopal Rao G.
Spontaneous Achilles tendon rupture in patients treated with levofloxacin.
J Antimicrob Chemother. 2003 Mar;51(3):747-8. No abstract available.
PMID: 12615887 [PubMed - indexed for MEDLINE]

37. Othmani S, Battikh R, Ben Abdallah N.
[The myo-tendinopathy caused by levofloxacin]
Therapie. 2003 Sep-Oct;58(5):463-5. French. No abstract available.
PMID: 14682197 [PubMed - indexed for MEDLINE]

38. Gutierrez E, Morales E, Garcia Rubiales MA, Valentin MO.
[Levofloxacin and Achilles tendon involvement in hemodialysis patients]
Nefrologia. 2003 Nov-Dec;23(6):558-9. Spanish. No abstract available.
PMID: 15002793 [PubMed - indexed for MEDLINE]

40. Spontaneous Achilles tendon rupture in patients treated with levofloxacin
L. J. Haddow, M. Chandra Sekhar, V. Hajela and G. Gopal Rao*
Department of Microbiology, University Hospital Lewisham, Lewisham High Street, London SE13 6LH, UK 2003 The British Society for Antimicrobial Chemotherapy

41. Clinical Infectious Diseases 2003;36:1404-1410
2003 by the Infectious Diseases Society of America. All rights reserved.
Fluoroquinolone-Associated Tendinopathy: A Critical Review of the Literature
Yasmin Khaliq1 and George G. Zhanel2

42. J Am Podiatr Med Assoc. 2003 Jul-Aug;93(4):333-5.
Fluoroquinolone therapy and Achilles tendon rupture.
Vanek D, Saxena A, Boggs JM.

43. Clin Rheumatol. 2003 Dec;22(6):500-1. Epub 2003 Oct 18.
Ciprofloxacin and Achilles' tendon rupture: a causal relationship.

44. Aten Primaria. 2003 Sep 15;32(4):256
Bilateral Achilles tendinitis as adverse reaction to levofloxacine.

45. Therapie. 2003 Sep-Oct;58(5):463-5.
The myo-tendinopathy caused by levofloxacin

46. Reumatismo. 2003 Oct-Dec;55(4):267-9.
Levofloxacin-induced bilateral rupture of the Achilles tendon: clinical and sonographic findings

47. Gastroenterol Hepatol. 2003 Jan;26(1):53-4.
Rupture of the Achilles' tendon secondary to levofloxacin

48. J Antimicrob Chemother. 2003 Mar;51(3):747-8.
Spontaneous Achilles tendon rupture in patients treated with levofloxacin.

49. Foot Ankle Int. 2003 Feb;24(2):122-4.
Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to levofloxacin.

50. Chemotherapy. 2003 May;49(1-2):90-1.
Reoccurrence of levofloxacin-induced tendinitis by phenoxymethylpenicillin therapy after 6 months: a rare complication of fluoroquinolone therapy?

51. rupture of the Achilles tendon: clinical and sonographic findings]
Reumatismo. 2003 Oct-Dec;55(4):267-9. Italian.
PMID: 14872227 [PubMed - indexed for MEDLINE]

52. Ann Pharmacother. 2003 Jul-Aug;37(7-8):1014-7.
Levofloxacin-associated Achilles tendon rupture.

53. Clin Rheumatol. 2003 Oct;22(4-5):367-8.
Bilateral Achilles tendinitis with spontaneous rupture induced by levofloxacin in a patient with systemic sclerosis.

54. Scand J Infect Dis. 2003;35(10):768-70.
Levofloxacin-associated Achilles tendon rupture and tendinopathy.

55. Levofloxacin-associated Achilles tendon rupture and tendinopathy. Scand J Infect Dis 2003;35(10):768-70 (ISSN: 0036-5548) Melhus A; Apelqvist J; Larsson J; Eneroth M Department of Medical Microbiology, Malmo University Hospital, Malmo, Sweden. asa.melhus at mikrobiol.mas.lu.se.

56. Levofloxacin and trovafloxacin inhibition of experimental fracture-healing. Clin Orthop 2003 Sep;(414):95-100 (ISSN: 0009-921X) Perry AC; Prpa B; Rouse MS; Piper KE; Hanssen AD; Steckelberg JM; Patel R Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN 55905, USA.

57. Levofloxacin-associated Achilles tendon rupture. Ann Pharmacother 2003 Jul-Aug;37(7-8):1014-7 (ISSN: 1060-0280) Mathis AS; Chan V; Gryszkiewicz M; Adamson RT; Friedman GS Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA. smathis at sbhcs.com.

58. Richardson LC, Reitman R, Wilson M.
Achilles tendon ruptures: functional outcome of surgical repair with a "pull-out" wire.
Foot Ankle Int. 2003 May;24(5):439-43.
PMID: 12801203 [PubMed - indexed for MEDLINE]

59. Ultrasonography of non-traumatic rupture of the Achilles tendon secondary to levofloxacin. Foot Ankle Int 2003 Feb;24(2):122-4 (ISSN: 1071-1007) Cebrian P; Manjon P; Caba P Departamento de Radiodiagnostico, Hospital Universitario 12 de Octubre, Madrid, Spain. pcvbb at yahoo.es.

60. J Am Board Fam Pract. 2003 Sep-Oct;16(5):458-60.
Levofloxacin-induced tendon rupture: a case report and review of the literature.


2004

1. Mehra A, Maheshwari R, Case R, Croucher C.
Bilateral simultaneous spontaneous rupture of the Achilles tendon.
Hosp Med. 2004 May;65(5):308-9. No abstract available.
PMID: 15176150 [PubMed - indexed for MEDLINE]

2. Vergara Fernandez I.
[Muscle and tendon problems as a side-effect of levofloxacine: review of a case]
Aten Primaria. 2004 Mar 15;33(4):214. Spanish. No abstract available.
PMID: 15023326 [PubMed - indexed for MEDLINE]

3. McKinley BT, Oglesby RJ.
A 57-year-old male retired colonel with acute ankle swelling.
Mil Med. 2004 Mar;169(3):254-6. No abstract available.
PMID: 15080249 [PubMed - indexed for MEDLINE]

4. Fama U, Irace S, Frati R, de Gado F, Scuderi N.
Is it a real risk to take ciprofloxacin?
Plast Reconstr Surg. 2004 Jul;114(1):267. No abstract available.
PMID: 15220615 [PubMed - indexed for MEDLINE]

5. Kahn F, Christensson B.
[A rapid development of Achilles tendon rupture following quinolone treatment]
Lakartidningen. 2004 Jan 15;101(3):190-1. Swedish. No abstract available.
PMID: 14763088 [PubMed - indexed for MEDLINE]

6. Long term outcome after Fluoroquinolones tendinopathies
13/01/2004 14:11:07 P-0077
C Guy (1); Y Murat (1); MN Beyens (1); M Ratrema (1); G Mounier (1); M Ollagnier (1); (1) Centre de Pharmacovigilance, Hôpital Bellevue - CHU St-Etienne, Sant-Etienne

7. Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature. J Orthop Sci 2004;9(2):186-90 (ISSN: 0949-2658) Kowatari K; Nakashima K; Ono A; Yoshihara M; Amano M; Toh S Department of Orthopaedic Surgery, Aomori Rosai Hospital, 1 Minamigaoka, Shirogane-machi, Hachinohe 031-8551, Japan.

8. Pharmacol Exp Ther. 2004 Jan;308(1):394-402. Epub 2003 Oct 20. In vitro discrimination of fluoroquinolones toxicity on tendon cells: involvement of oxidative stress.

9. Hosp Med. 2004 May;65(5):308-9.
Bilateral simultaneous spontaneous rupture of the Achilles tendon.
Mehra A, Maheshwari R, Case R, Croucher C.

10. Therapie. 2004 Nov-Dec;59(6):653-5.
Ofloxacin-induced achilles tendinitis in the absence of a predisposition

11. An Med Interna. 2004 Mar;21(3):154.
Achilles bilateral tendonitis and levofloxacin

12. J Orthop Sci. 2004;9(2):186-90.
Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature.

13. Scand J Infect Dis. 2004;36(4):315-6.
Recurrent tendinitis after treatment with two different fluoroquinolones.

14. Joint Bone Spine. 2004 Nov;71(6):586-7. Related Articles, Links
Rupture of multiple tendons after levofloxacin therapy.
Braun D, Petitpain N, Cosserat F, Loeuille D, Bitar S, Gillet P, Trechot P.
Pneumology Department, Maillot Hospital, 54150 Briey, France.

15. Aten Primaria. 2004 Mar 15;33(4):214.
Muscle and tendon problems as a side-effect of levofloxacine: review of a case

16. Kowatari K, Nakashima K, Ono A, Yoshihara M, Amano M, Toh S.
Levofloxacin-induced bilateral Achilles tendon rupture: a case report and review of the literature.
J Orthop Sci. 2004;9(2):186-90. Review.
PMID: 15045551 [PubMed - indexed for MEDLINE]

17. Gomez Rodriguez N, Ibanez Ruan J, Gonzalez Perez M.
[Achilles bilateral tendonitis and levofloxacin]
An Med Interna. 2004 Mar;21(3):154. Spanish. No abstract available.
PMID: 15043504 [PubMed - indexed for MEDLINE]

18. Filippucci E, Farina A, Bartolucci F, Spallacci C, Busilacchi P, Grassi W.[Levofloxacin-induced bilateral

19. Burkhardt O, Kohnlein T, Pap T, Welte T.
Recurrent tendinitis after treatment with two different fluoroquinolones.
Scand J Infect Dis. 2004;36(4):315-6.
PMID: 15198194 [PubMed - indexed for MEDLINE]


2005

1. Toxicology. 2005 May 9
Fluoroquinolones cause changes in extracellular matrix, signalling proteins, metalloproteinases and caspase-3 in cultured human tendon cells.
Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R.

2. Arch Orthop Trauma Surg. 2005 Mar;125(2):124-6. Epub 2005 Jan 12.
Missed Achilles tendon rupture due to oral levofloxacin: surgical treatment and result.

3. An Med Interna. 2005 Jan;22(1):28-30.
Partial bilateral rupture of the Achilles tendon associated to levofloxacin

4. Expert Opin Drug Saf. 2005 Mar;4(2):299-309.
Fluoroquinolones and tendon disorders.
Melhus A.

5. Toxicology. 2005 May 9
Fluoroquinolones cause changes in extracellular matrix, signalling proteins, metalloproteinases and caspase-3 in cultured human tendon cells.
Sendzik J, Shakibaei M, Schafer-Korting M, Stahlmann R.
Institute of Clinical Pharmacology and Toxicology, Department of Toxicology, Charite-Universitatsmedizin Berlin, Campus Benjamin Franklin, Garystr. 5, 14195 Berlin, Germany; Institute of Anatomy, Department of Cell and Neurobiology, Charite-Universitatsmedizin Berlin, Campus Benjamin Franklin, Konigin-Luise-Str. 15, 14195 Berlin, Germany; Musculoskeletal Research Group, Institute of Anatomy, Ludwig-Maximilian-Universitat Munich, Pettenkoferstr. 11, 80336 Munich, Germany.

Additional references:

AUSTRALIA
THE ACHILLES HEEL OF FLUOROQUINOLONES
One of the more unusual adverse reactions known to be associated with the fluoroquinolone antibiotics is the occurrence of tendinitis. This is a serious effect since it may progress to tendon rupture with many weeks of disability as a result. Over 200 cases have been reported in the literature with the majority from France. Most members of the class including ciprofloxacin, enoxacin, ofloxacin, and norfloxacin have been implicated. The Achilles tendon is most often involved.
In Australia, there have been 25 reports of tendinitis in association with fluoroquinolones. Most (22) have been with ciprofloxacin and the other three with norfloxacin. The majority of the patients involved were elderly, ranging in age from 46 to 91 (median 69) years and the sex distribution was equal. For ciprofloxacin, daily dosages ranged from 750 mg to 2250 mg although most (13) patients were taking 1000 mg daily. For norfloxacin, all three patients were taking the usual dose of 800 mg daily. Time to onset ranged from the same day that the drug was commenced (in two patients) to two months although in 13 of the 24 reports which provided the information, the reaction occurred within the first week. Almost all (23) of the reports specified the Achilles tendon as the site of the tendinitis. Tendinitis was described as bilateral in 11 cases. Only 8 patients had recovered at the time the report was submitted and the other patients were being treated with rest and/or physiotherapy. There have been no reports of tendon rupture in Australia although in one severe case, the patient required a plaster cast up to the mid thigh.
A number of risk factors have been identified with regard to this adverse reaction. These include old age, renal dysfunction, and concomitant corticosteroid therapy. Of the patients reported to ADRAC, 72% were older than 60 years. Nine of these patients were taking corticosteroids as were three of the younger patients.
Prescribers are reminded that tendinitis, especially involving the Achilles tendon, is a rare adverse effect of the fluoroquinolones. It is more likely to occur in association with the risk factors referred to above. The antibiotic should be withdrawn immediately to reduce the risk of tendon rupture.


DUTCH
Fluoroquinolones have been associated with tendon disorders, usually during the first month of treatment,1-5 but the epidemiological evidence is scanty. We did a nested case-control study among users of fluoroquinolones in a large UK general practice database to study the association with Achilles tendon disorders.

Participants, methods, and results

We obtained data from the IMS Health database (UK MediPlus), which contains data from general practice on consultations, morbidity, prescriptions, and other interventions in a source population of 1-2 million inhabitants. The base cohort consisted of all patients aged 18 years or over who had received a fluoroquinolone. We excluded people with a history of Achilles tendon disorders, cancer, AIDS, illicit drug use, or alcohol misuse. We identified potential cases by reviewing patient profiles and clinical data and excluded tendon disorders due to direct trauma. We randomly sampled a group of 10 000 control patients from the study cohort.

We defined four categories of exposure to fluoroquinolones: current use, recent use, past use, and no use. We defined current use as when the tendon disorder occurred in the period between the start of the fluoroquinolone treatment and the calculated end date plus 30 days, recent use as when the calculated end date was between 30 and 90 days before the occurrence of the disorder, and past use as when the calculated end date was more than 90 days before the occurrence of the disorder. We used unconditional logistic regression analysis to calculate adjusted relative risks and 95% confidence intervals for Achilles tendon disorders, using the no use group as the reference. We adjusted for age, sex, number of visits to the general practitioner, use of corticosteroid, calendar year, obesity, and history of musculoskeletal disorders.

The cohort included 46 776 users of fluoroquinolones between 1 July 1992 and 30 June 30 1998, of whom 704 had Achilles tendinitis and 38 had Achilles tendon rupture. Four hundred and fifty three (61%) of the cases were women, and the mean age was 56 years. Cases visited the general practitioner significantly more often than did controls (mean 20 v 17). Cases and controls were similar with respect to indications for use of fluoroquinolone. Age, number of visits to the general practitioner in the previous 18 months, gout, obesity, and use of corticosteroid were determinants of Achilles tendon disorders. The adjusted relative risk of Achilles tendon disorders with current use of fluoroquinolones was 1.9 (95% confidence interval 1.3 to 2.6). The risk for recent and past use was similar to that for no use. The relative risk with current use was 3.2 (2.1 to 4.9) among patients aged 60 and over and 0.9 (0.5 to 1.6) among patients aged under 60 (table). In patients aged 60 or over, concurrent use of corticosteroids and fluoroquinolones increased the risk to 6.2 (3.0 to 12.8).

Relative risk of Achilles tendon disorders associated with use of fluoroquinolones according to age
Current exposure to fluoroquinolones increases the risk of Achilles tendon disorders. This finding is in agreement with a smaller study, in which we found an association between tendinitis and fluoroquinolones.5 Our results indicate that this adverse effect is relatively rare, with an overall excess risk of 3.2 cases per 1000 patient years. The effect seems to be restricted to people aged 60 or over, and within this group concomitant use of corticosteroids increased the risk substantially. The proportion of Achilles tendon disorders among patients with both risk factors that is attributable to their interaction was 87%. Although the mechanism is unknown, the sudden onset of some tendinopathies, occasionally after a single dose of a fluoroquinolone, suggests a direct toxic effect on collagen fibres. Prescribers should be aware of this risk, especially in elderly people taking corticosteroids.

Acknowledgments
We acknowledge the cooperation of IMS Health United Kingdom.
Contributors: PDvdL, MCJMS, and BHChS formulated the design of the study. PDvdL carried out the analyses. PDvdL, MCJMS, and BHChS wrote the paper, and RMCH and HGML edited it. BHChS and HGML are guarantors for the paper.

Funding:
Dutch Inspectorate for Health Care.

Competing interests:
MCJMS is a consultant for Lundbeck (France) and Beaufour (UK) and has previously been a consultant for Pfizer (USA), Roche (Switzerland), and Novartis Consumerhealth (Switzerland). MCJMS is responsible for research conducted with the integrated primary care information database in the Netherlands, which is supported by project specific grants from GlaxoSmithKline, AstraZeneca, Merck Sharp & Dohme, Pharmacia & Upjohn, Bristol-Myers Squibb, Eli Lilly, Wyeth, and Yamanouchi. MCJMS has conducted research projects on use of antibiotics for Merck & Co (USA) and Bayer (Italy).

This is far from being an all inclusive list of such medical journal entries and other such main stream documentation. Starting in 1965 and ending in 2005, almost forty years worth of such reports and the treating physician as well as the patient have no prior knowledge concerning such events. This defies logic but sadly enough this is the true state of affairs. In spite of the overwhelming evidence presented at that 62 Meeting of the Anti-Infective Drugs Advisory Committee that the fluoroquinolones cause irreversible joint damage in the pediatric population the FDA has recently added the use of Ciprofloxacin in the pediatric population, treating children as young as one years of age.

Numerous studies have indicated that such use in a pediatric patient runs the risk of crippling the child for life. Yet additional clinical trials continue aided and abetted by the FDA, for other drugs in this class other than Ciprofloxacin. A disaster that is detailed within the 62nd meeting of the Anti-Infective Drugs Advisory Committee where it was so eloquently stated:

"…when we talk about the issue of arthropathy that potentially includes a number of things, ranging from simple effusion, for instance, of a knee joint, which might rapidly resolve after the conclusion of therapy, to a more permanent disability. .." (sic)

"…in September of 1997 there is now a ciprofloxacin suspension which is available, and although it continues to have the same warning statements about arthropathy in juvenile animals and the potential concern in pediatric populations, obviously, the issue of off label use will extend over to pediatric populations in this formulation…."(sic)

"…An important safety question is, what adverse events should be monitored, and Doctor Goldberger alluded to this earlier. This is some of the examples I present. One is permanent lameness, reversible lameness, joint effusion, joint pain, and even latent articular disease or damage that may occur months or years following drug exposure, and there may be others…."(sic)

"…And, data submitted to the Agency, as well as data from the scientific literature, indicate that these lesions don't appear to be reversible…"(sic)

"…Doctor Stahlmann in Berlin is working on an idea that it may be an effect between the endocrines, the magnesium and the matrix and the quinolone. And that data is just coming out now. But as to the exact mechanism, I think you're right. I don't think we have a handle, as far as I know, on the exact mechanism. If there's anybody else that does, I'd sure like to hear it…"(sic)

"… Relating your personal experience, I was wondering about the potential for a delayed effect that in fact one might have a patient who had some histologic changes that would not be manifest clinically for many years. Is that a potential?" (sic)

"… I think it is a potential…"(sic)

"… In trying to assess toxicity with a very sensitive assay, obviously you've got tissue that you can look at in your animal models. There is some human data that were collected by Doctor Urs Schaad using MRI scanning in children and I'm wondering if you can correlate some of your histopathologic findings with MR in the animal model to give us an idea of how sensitive it would be sort of as a follow-up to Doctor Klein's question is the MR something that will be able to predict long-term outcomes, even if there are no clinical symptoms during therapy…."(sic)

"… That I don't know. I'll just be perfectly frank. I don't know. But on the slides I've seen from the animals from the chronic study, the repaired articular cartilage that is there is principally fibrocartilage yet it will provide the same joint margin and it has a calcified base and when we stain it with safrain O screen there's no proteoglycans there so it's going to make it an extremely chondromalaistic area and beyond the one year I can't tell you what the results will be…"(sic)

"…Anyway, it was by a group in Vienna where they looked at the articular cartilage of postmortem specimens of articular cartilage from kids with cystic fibrosis that had been on quinolones for a period of time and they found that there was damage in the chondrocytes…."(sic)

"…There were no deaths reported in U.S. pediatric zero to 18 year old cases where a flouroquinolone was reported as the suspect drug. However, there are eight deaths in the whole cohort of suspect and concomitant flouroquinolone drug reports in the system. Five of these deaths reported ciprofloxacin as a concomitant drug and not the suspect drug. These five were U.S. cases with ages ranging from seven months to six years. The remaining three deaths were all foreign, all 18 year old patients with either ofloxacin or norfloxacin reported as the suspect drug…."(sic)

"…There are 14 reports of arthropathy or arthralgia in the pediatric zero to 18 year old flouroquinolone reports. One report of a 14 year old girl had both ofloxacin and lomefloxacin as the suspect drug so there is an extra count because of the two flouroquinolones on this one report. This particular report indicates that a pediatric orthopedic surgeon diagnosed femoral anteversion as the cause for the girl's arthralgia, therefore you see it listed twice, and not the flouroquinolones. Most of the reports indicated that either an involved knee or elbow with or without other joints was involved…."(sic)

"…One interesting case which is not included on this slide for arthralgias was a 15 year old boy who received ofloxacin IV for an emergency appendectomy and had not grown more than his 70 inches in height over the last year. The 15th percentile for height for a 15 year old boy however is 66.5 inches and the expected growth rate is about two inches per year…"(sic)

"…Three patients had their seizure after the first dose of flouroquinolone, one on ciprofloxacin and the other two on ofloxacin, one of which had received ofloxacin several months earlier…"(sic)

"…The 15 psychiatric reports are a loose grouping of reports which include events ranging from euphoria to psychosis. The ages range from five to 18 years with the median at 15 years. There were two suicide attempts, one on ofloxacin and the other on norfloxacin, three reports of hallucination, one each on ciprofloxacin, ofloxacin and norfloxacin, and one report of aggressive behavior with confusion in a patient who had a psychiatric history and was on norfloxacin. The seven cases of photosensitivity were reported with lomefloxacin with one case on ciprofloxacin and two cases on ofloxacin. …"(sic)

"…I will mention that there were 152 U.S. cases aged zero to 18 years in the U.S. AERS system suspect flouroquinolones in the WHO line listing. The country with the most pediatric reports in the WHO foreign reports is the United Kingdom with 177 reports followed by Germany with 72 and France with 71. The rest of the countries had 20 or fewer reports…."(sic)

"…And with regards to muscular-skeletal events, 21 percent of the patients had an event in ciprofloxacin…"(sic)

"…We have focused our analysis on joint disorders and pefloxacin. 79 cases were reported and consist mainly of arthralgia. I don't know the pronunciation of hydrarthrosis -- 49 persons. It involved the knee in 52 cases, the wrist in 20 cases, the elbow in 20 cases, the shoulder in 6 cases, the ankle in 5 cases, and the hip once. It is associated with a functional discomfort in all cases, and when the duration of this discomfort is known, it can persist more than one month in 61 percent of these cases. But the outcome was favorable in 58 cases without discontinuation in two cases. …"(sic)

"…There have been sequelae in three cases with knee effusions persisting one year later in one case with discomfort following 8 months later in the second case. The third case is articular. It is a 17-year-old patient who experienced arthropathy and the drug was not suspected and the treatment was continued two following months. It leads to destructive arthropathy of the knees and the hip and prothesis was performed three years later. He was treated for a cerebral abscess. The outcome was unknown in 18 cases. In 9 cases, there was no follow-up. In the 9 last cases, we had a follow-up three months later and patients were not -- were still with disabilities and after we have no evolution…." (sic)

"… It is my understanding that one of the children had a joint replacement, is that correct?"

" Pardon me?"

" One of the children with the complications had an artificial joint replacement?"

"Yes."

"…If an irreversible cartilaginous lesion can occur, it is very likely that is going to cause problems down the line and we can't even anticipate what they are like…" (sic)


Again I state that this is for your reference & review and being made in support of my oppossing opinion that such occurences are not rare. I also take exception to the statement made that there is some kind of obligation to report such events. There is not. Such reports are done strictly on a voluntary basis and no law mandates that this be done by the treating physician. The medwatch program is voluntary and less that 3% of such events are ever reported to the FDA. A full 97% of such events never make it to the FDA. When reviewing the medwatch data base for the fluoroquinolones, joint, tendon and cartilage damage are all the top three events being reported, more so than any other adr.

In addition when a physician fails to recognize such an event it is doubtful that it would be reported. The NUMBER ONE complaint of those who have suffered such an event is the fact that the treating physician DENIES that it could possibly be the result of fluoroquinolone therapy. Any number of the tens of thousands of such victims I have discussed this issue with have reported that their physician REFUSED to make such a report, REFUSED to review the citations brought to them by their patients, and instructed their patients to stay off the internet. Even when such documentation was presented to the drug reps via pharmacafe those posting such information were ridiculed and harassed. This is not a situation I find condusive to accurate reporting of such events. It is a situation that results in false and misleading information being available to both the patient and the physician, while the true state of affairs is swept under the carpet.

Result number: 115

Message Number 185946

Re: New CPT Codes for ESWT View Thread
Posted by Dr. Z on 10/27/05 at 19:59

Steve W,
When this occurred I had a very very long discussion with the APMA. I was told that the description of a local and a regional block would be included in the CPT book . I was told that a posterior tib block and sural nerve block meets this CPT description.
Actually the story I was told was different and that even though healthronics and AKMS-orth was involved it was for another reason

Result number: 116

Message Number 185931

Re: post surgery question View Thread
Posted by Dr. S . Goldstein on 10/27/05 at 16:45

sometimes with open surgery the sural nerve may ave been tuged upon moved or touched causing a temporary neuropraxia or nerve compression just from the slightest manipulation so the nerve has to repair itself. taking a b complex vitamin daily can help with this problem

Result number: 117

Message Number 185537

Re: post surgery question View Thread
Posted by Dr. Z on 10/23/05 at 19:47

Hi
At this time frame, the swelling could be causing the numbness. There is also the possibility of a problem with the sural nerve. Just too soon to tell. Just as your surgeon told you give it some time

Result number: 118

Message Number 185410

Re: New CPT Codes for ESWT View Thread
Posted by Dr. Z on 10/22/05 at 11:51

It is my understanding that the block is a regional anesthetic such is used with the ankle block ie posterior tibial and sural nerve. No MAC is needed for coverage.
Could you e-mail me at footcare at comcast.net when you have the time. I would like your opinion on something.

Result number: 119

Message Number 184844

Re: to Dr. Goldstein View Thread
Posted by Dr. Goldstein on 10/15/05 at 08:32

every patient has their own decision as to visit my website or not. They also have the right to view what I have to say and believe me or not. If I have something that has proven in My hands to help a great many people should I keep it under wraps because you do have one. If you have patients responding to your website and you read their postings most hqave tried everything else that has not worked so should we offer them no hope or leave them to hang on to hope. Almost every patient that has contacted my website is called that same day or emailed. Do you offer that servicw with promptness. I spend as long as necessary talking to them it usually is not less than 1/2 hour. Almost every out of state patient that contacts me come for cryo even when i tell them to seek the docotr who does cryo even in their own state. the usual response is this the docotr will not get on the phone, never calls me back, or has not done the volume of cases you have done. I know you think I am bragging but I'm not I am just stating pure fact. having under botched neuroma surgery mysely with disaterous complications I know exeactly what these patients are going through and I feel my compassion shows to these patients. So do not talk about professionalism as I talk that as an insult. As far as a pioneer how many other docs have done tarsal tunnel 15 of them sural nerve entrapment achilles tendonitis, calcific tendonitis plantar fibromsa sinus tarsi syndrome just to mention a few.

Result number: 120
Searching file 17

Message Number 179212

Re: Post Surgery Loss of Feeling / Movement in Foot View Thread
Posted by Dr. Z on 7/27/05 at 00:21

Ned,
Your surgeon will be able to tell if if there was any nerve that was removed. Maybe the sural nerve, however it appears that the swelling is causing all of this stuff and should improve with time.. Compression, rest, elevation are all very important at this stage. I am sure your surgeon will go into any detail about nerve sensation lost. Give this time. You just had foot surgery which causes swelling and pressure on nerves. Good luck.

Result number: 121

Message Number 178888

Re: ESWT after procdure pain/recovery timeline View Thread
Posted by Dr. Z on 7/22/05 at 20:42

Foot and Ankle

The Safety and Efficacy of High Energy Extracorporeal Shock Wave Therapy in Active, Moderately Active, and Sedentary Patients

By John P. Furia, MD
ORTHOPEDICS 2005; 28:685

July 2005

Extracorporeal shock wave therapy was investigated in patients with chronic plantar fasciitis. Fifty-three patients (60 heels) were treated with a single session of shock wave therapy. Sixteen patients (19 heels) were active, 21 (22 heels) were moderately active, and 16 (19 heels) were sedentary. Twelve weeks post-treatment, mean visual analog scores improved from 9.2 to 2.4 (P<.05), RAND-Physical Functioning score improved from 40.4 to 91.5 (P<.05), and RAND-Pain score improved from 33.3 to 90 (P<.05). Fifty heels (83.3%) were assigned an excellent or good result. Extracorporeal shock wave therapy is an effective treatment for chronic plantar fasciitis.

Plantar fasciitis is the most common cause of inferior heel pain. It is estimated that plantar fasciitis occurs in approximately two million Americans per year,1 and it is the most common foot condition seen by most foot and ankle surgeons.2 The disorder frequently occurs in athletes3-5 but also afflicts sedentary individuals, particularly middle-aged women.6-8 Men and women are affected equally.7,8 Symptoms are bilateral in .10% of cases.2 The exact etiology is unknown.

Plantar fasciitis is characterized by pain on the bottom of the heel, particularly with the first steps in the morning and when weight bearing is resumed after sitting.9-12 The pain usually persists and often becomes worse with activities of daily living. Physical examination almost always reveals tenderness over the fascia. Pain is aggravated by dorsiflexion of the toes.

Radiographs frequently reveal a heel spur on the inferior surface of the calcaneus.10,11 The heel spur may be an incidental finding as heel spurs also have been noted in 10% to 27% of asymptomatic individuals.2,13

Most physicians agree that acute plantar fasciitis often will respond to traditional nonoperative measures6,8,14-16; however, approximately 20%-30% of those patients treated with traditional measures progress to a chronic condition.17 Martin et al17 reviewed a large number of reports of nonoperative treatment of plantar fasciitis and showed a wide range of acceptable outcomes ranging from 44% to 82% of patients who obtained complete pain relief.

There is no consensus as to the best method of treatment.8,15,16,18 Traditional measures include relative rest, ice, massage, stretching of the plantar fascia and Achilles tendon, anti-inflammatory medications, taping, shoe modification, orthotics, and night splints.

Steroid injections into the painful fascia may be helpful but are not without risk. Steroid injections often are associated with recurrence of symptoms, and the effect usually is temporary.19,20 Steroid injections may cause infection, fat pad atrophy, and complete plantar fascia rupture.19,20

Surgical treatment of chronic plantar fasciitis with either open or endoscopic partial plantar fascia release is an option for those who fail to respond to nonoperative measures.8,21-23 Surgical intervention is invasive, has inherent morbidity, and can produce inconsistent results.8,22

Extracorporeal shock wave therapy is a byproduct of renal lithotripter technology. Extracorporeal shock wave therapy has been used in Europe since the 1980s to treat a litany of orthopedic conditions including lateral epicondylitis, shoulder calcific tendinitis, Achilles tendinitis, and nonunion of fractures of long bones.24-32

In 1996 Rompe et al10 reported on their favorable experience using shock wave therapy to treat chronic plantar fasciitis. Since that time many investigators have substantiated these results.5,11,33-42

Extracorporeal shock wave therapy is approved by the United States Food and Drug Administration (FDA) for the treatment of chronic plantar fasciitis and chronic lateral epicondylitis. A meta-analysis of the current published literature on the relationship between shock wave therapy and chronic plantar fasciitis revealed that the application of shock wave therapy to the enthesis of the plantar fascia is a safe and effective method to treat chronic plantar fasciitis.43 The authors suggested that shock wave therapy should be considered prior to surgical intervention.43 Several recent studies, however, have questioned the efficacy of shock wave therapy for the treatment of chronic tendinopathies.44-46

This study examined the effects of extracorporeal shock wave therapy on patients with chronic plantar fasciitis treated by the same investigator (J.P.F.) in a rural, community setting to determine if there was a difference in outcome between active, moderately active, and sedentary individuals. The hypothesis was that extracorporeal shock wave therapy would be an effective treatment for each patient.

Materials and Methods
From June 2002 to June 2003 all patients treated by the primary investigator for chronic plantar fasciitis were considered for evaluation. Inclusion criteria included patients with an established diagnosis of chronic plantar fasciitis for at least six months prior to treatment who had failed at least three forms of traditional nonoperative treatment. For this study, chronic fasciitis was defined as symptoms of moderate to severe heel pain in the involved foot at the origin of the proximal plantar fascia on the medial calcaneal tuberosity. Traditional nonoperative treatments consisted of rest, anti-inflammatory medications, heel cups, orthotics, stretching, night splints, physical therapy, and steroid injections.

Exclusion criteria included rheumatoid arthritis, generalized polyarthritis, Reiter’s syndrome, local infection, pregnancy, patients with bleeding disorders, patients with tumors, patients aged <18 years, patients with severe endocrine disease, and patients with advanced peripheral vascular disease. Patients with a history of spontaneous or steroid-induced plantar fascia rupture and patients with a history of previous plantar fascial surgery also were excluded.

For the purposes of this study "active" lifestyle was defined as one in which the patient regularly participated in some form of aerobic fitness activity approximately three hours per week. Patients were assigned an "active" designation if their work required extensive physical activity such as manual labor or heavy factory work

A "moderately active" lifestyle was defined as one in which the patient exercised <3 hours per week. Patients also were assigned a "moderately active" designation if their work required regular, moderate physical activity such as nursing or restaurant work. A "sedentary" lifestyle was defined as one in which the patient did not exercise or worked in a sedentary profession.

All patients signed an informed consent form. The details of the procedure and potential risks were discussed fully before treatment. The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 1983.

All treatments were performed on an outpatient basis. Patients were anesthetized in a pre-treatment holding room using a combined tibial and sural nerve block with 1% lidocaine. A blood pressure cuff was applied to their right arm. They were positioned in the lateral decubitus position with a pillow between their knees and with their affected foot resting on the target head. A coupling gel was applied to their heel, and the ultrasound was used to focus on the area of intended treatment. The patient's vital signs and local discomfort were monitored by a registered nurse throughout the procedure.

The extracorporeal shock wave therapy was applied using the Dornier Epos lithotripter (Dornier MedTech Inc, Kennesaw, Ga) by following the protocol used in the FDA clinical trials.33,45 The Dornier Epos uses an electromagnetic coil to generate shock waves47 and the shock waves are focused using a lens. Shock wave application was applied to the area of maximal tenderness as based on the physical examination, and guided using ultrasound.

A standard protocol was used for application of shock waves. Each patient received a single treatment using a total of 3800 shocks for a total energy flux density of 1300 mJ/mm2. Fifty shocks were given at each power level from one through six for a total of 300 shocks. The final 3500 shocks were given at power level seven (0.36 mJ/mm2), which makes this a high-energy treatment. Frequency of shock wave application was increased from 60 shocks/minute at power level one to 240 shocks/minute at power level seven.

Upon completion of the procedure the treated heel was assessed for hematoma, bruising, and swelling. The patients were discharged from the same day holding area with instructions to ice and stretch their heels. No patient received narcotics or other forms of prescription medications. No other co-interventions were used, but patients were told to continue using their orthotics if they had used them regularly prior to treatment.

The follow-up examinations were scheduled at 4 and 12 weeks post-treatment. All patients were contacted via a telephone survey. Outcome measures included visual analog scores, RAND-Physical Functioning scores, RAND-Pain scores, Roles and Maudsley scores, and a subjective assessment of overall satisfaction with the procedure.

Visual analog scores were collected pre-treatment, 4 weeks post-treatment, and 12 weeks post-treatment. On the visual analog scale 10 points indicated severe pain and zero points indicated no pain. The values of the scores pre-treatment and at 4 and 12 weeks post-treatment were compared statistically using a paired t test with a statistical significance at P<.05.

The RAND-36 -Item Health Survey scores (Physical Functioning and Pain) were collected pre-treatment, 4 weeks post-treatment, and 12 weeks post-treatment. The RAND-36-Item Health Survey score is a validated instrument for the assessment of health concepts.48 The RAND-Physical Functioning score ranges from 100, indicating perfect physical functioning, to zero, indicating severe loss of physical functioning.48 The RAND-Pain score ranges from 100, indicating absence of pain, to zero, indicating severe pain.48 The values of the scores pre-treatment and at 4 and 12 weeks post-treatment were compared statistically using a paired t test with a statistical significance at P<.05.

The Roles and Maudsley scale49 is a subjective four-point rating scale that has been used by many investigators when reporting results of shock wave therapy.5,11,36 On the scale, one point was defined as an excellent result with the patient having no symptoms. Two points was defined as a good result with the patient significantly improved from the pre-treatment condition and satisfied with their result. Three points was defined as a fair result with the patient somewhat improved from their pre-treatment condition and partially satisfied with their treatment outcome. Four points indicated a poor outcome with symptoms identical or worse than their pre-treatment condition and with dissatisfaction with the treatment result.

At 12 weeks post-treatment patients were asked if they were pleased with their overall result, and, if they had the condition again, would they elect to undergo the procedure. The results of both questions were recorded as yes or no.

Statistical analysis was performed using the paired student t test for comparison of the outcome variables. The significance level was <.05.

Results
A total of 56 patients (65 heels) were treated during the study. All but three patients were assessed by the primary investigator after treatment, and all patients were contacted by telephone three months after treatment. One patient did not return for follow-up. The other two patients were unable to return for a follow-up evaluation. Both of these patients had a bilateral procedure. Thus, after three months, 53 (34 women and 19 men) patients representing 60 heels were available for analysis. The average patient age was 47.7 years (range: 31-71 years). Seven patients underwent bilateral treatments. The average duration of the condition was 22 months (range: 9-120 months) for the entire group.

Visual Analog Scale
The mean pre-treatment visual analog score for the entire group was 9.2±0.7. Four weeks after treatment the VAS score decreased to 3.4±1.9. This difference was statistically significant (P<.05) (Figure 1).


Figure 1: The difference in mean visual analog score pre-treatment and four weeks post-treatment was statistically significant (P<.05).


Twelve weeks after treatment the VAS score decreased to 2.4±1.8. The difference between pre-treatment and 12 week post-treatment VAS scores was statistically significant (P<.05) (Figure 2).


Figure 2: The difference in mean visual analog score pre-treatment and 12 weeks post-treatment was statistically significant (P<.05).


RAND Score-Physical Functioning
The mean pre-treatment RAND-Physical Functioning score for the entire group was 40.4±1.3. Four weeks after treatment the RAND-Physical Functioning score increased to 91.5±11.5. This difference was statistically significant (P<.05).

Twelve weeks after treatment the RAND-Physical Functioning score was 91.5±10.6. The difference between pre-treatment and 12 week post-treatment RAND-Physical Functioning scores also was statistically significant (P<.05).

RAND Score-Pain
The mean pre-treatment RAND-Pain score for the entire group was 33.3±11. Four weeks after treatment the RAND-Pain score increased to 88.6±16. This difference was statistically significant (P<.05).

Twelve weeks after treatment the RAND-Pain score increased to 90±11.6. The difference between pre-treatment and 12 week post-treatment RAND-Pain scores also was statistically significant (P<.05).

Roles and Maudsley Score
Pre-treatment all patients rated the condition of the affected heel as “4” (poor) in the subjective four point Roles and Maudsley scale. Four week post-treatment, 34 (56.7%) heels were rated as “1” (excellent), 15 (25%) heels were rated as “2” (good), and 7 (11.6 %) heels were rated as “3” (fair), and 4 (6.7%) heels rated as “4” (poor or unchanged).

Twelve week post-treatment 36 (60%) heels were rated as “1” (excellent), 14 (23.3%) heels were rated as “2” (good), and 6 (10%) heels were rated as “3” (fair). There were 4 (6.7%) heels rated as “4” (poor or unchanged) (Table 1). No patient reported a worsening of symptoms compared to pre-treatment.

Table 1
Patients With Excellent, Good, Fair, and Poor Results 4 and 12 Weeks Post-Treatment*
No. (%)
--------------------------------------------------------------------------------

4 Weeks Post-Treatment 12 Weeks Post-Treatment

Excellent 34 (56.7) 36 (60)
Good 15 (25) 14 (23.3)
Fair 7 (11.6) 6 (10)
Poor 4 (6.7) 4 (6.7)

*Roles and Maudsley Scores, N=60 heels.


Patient Satisfaction
Four weeks post-treatment, 49 (82%) patients reported that they were satisfied with their procedure and all 49 patients reported that they would undergo the procedure again. Twelve weeks post-treatment the same 49 (82%) patients reported that they were satisfied with their procedure and all 49 patients reported that they would undergo the procedure again.

Subgroups
There were 16 patients who were designated as having an “active” lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.7±1.6, 90±11.3, and 87.6±11.2 respectively (Table 2). There were 21 patients who were designated as having a "moderately active" lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.3±1.8, 92.3±10.4, and 91±11 respectively (Table 2).

Table 1
Mean VAS, RAND-Physical Functioning, and RAND-Pain Scores 12 Weeks Post-treatment
Scores
--------------------------------------------------------------------------------

Visual Analog RAND-Physical Activity RAND-Pain

Active 2.7±1.6 90.0±11.3 87.6±11.2
Moderately active 2.3±1.8 92.3±10.4 91.0±11.0
Sedentary 2.2±1.5 92.5±10.5 91.7±13.4
Total group 2.4±1.6 91.5±10.6 90.0±11.6



There were 16 patients who were designated as having a "sedentary" lifestyle. Mean VAS, RAND-Physical Functioning, and RAND-Pain scores 12 weeks post-treatment were 2.2±1.5, 92.5±10.5, and 91.7±13.4 respectively (Table 2). Although the values of the VAS, RAND-Physical Functioning, and RAND-Pain scores for "active," "moderately active," and "sedentary" patients were similar, there were not enough patients in each subgroup to make statistically significant comparisons between the three subgroups.

A few minor complications were noted, all of which were temporary and that resolved spontaneously with minimal treatment. Two patients had pain for approximately one week after the treatment. The pain subsequently resolved without the use of prescription medication. One patient had pain during treatment that prolonged the procedure by approximately 15 minutes. One patient developed mild bruising at the site of the local injection. The bruising resolved without treatment 48 hours after the procedure.

Discussion
The plantar fascia is a broad, thick structure that originates from the medial calcaneal tuberosity and inserts on the plantar plates of the metatarsalphalangeal joints and proximal phalanges.50,51 The plantar fascia supports the medial longitudinal arch of the foot.50,51

Although the exact pathogenesis of plantar fasciitis remains unclear, it has been hypothesized that excessive stress on the plantar fascia can result in microtears at its origin.52 An inflammatory reaction is incited that then leads to a degenerative process.44,52 Biopsies of diseased plantar fascia reveal fibroblastic proliferation and chronic granulomatous tissue.52 The diseased fascia becomes thickened, from a normal 3.0-mm thickness to as much as 15.0-mm of thickness.52 Decreased vascularity, loss of normal elasticity, and alterations of nociceptor function may all contribute to the onset and persistence of this condition.3,4

Prior to 1996, failure of nonoperative treatment often led to surgical intervention. Some investigators have reported favorable results with plantar fasciitis surgery23; however, several recent studies have demonstrated that, despite improvement in symptoms, a prolonged recovery time and persistent pain were not uncommon.53-58 Davies et al53 reported that <50% of patients treated with chronic heel pain were completely satisfied with the results of surgery.

Several lithotripsy devices have been approved by the FDA for the treatment of various musculoskeletal conditions. Two of the devices, including the Dornier Epos used in this study, generate the shock waves using electromagnetic energy; one device uses electrohydraulic energy.12 Comparison studies of devices used for musculoskeletal lithotripsy have not been performed.

Extracorporeal shock wave therapy is an emerging technology and protocols vary from trial to trial. The different delivery modes of shock waves—single treatment versus multiple treatments, low energy shock waves (often defined as energy levels between 0.05-0.10 mJ/mm2) versus high energy shock waves, electrohydraulic versus electromagnetic methods of generating the shock waves—all can influence the outcome of therapy. For this reason, the results reported in a study are only valid for the parameters applied in that study.

In a prospective single-blinded pilot study, Rompe et al10 in 1996 reported a significant alleviation of pain and improved function in 30 patients treated with low-energy shock wave therapy for chronic plantar fasciitis. Follow-up was 24 weeks. Maier et al36 reported 75% good or excellent results in 48 heels 29 months after shock wave therapy. These investigators noted that clinical outcome was not influenced by length of follow-up.

Ogden et al39 used a very rigid success criteria to determine efficacy of shock wave therapy for patients with chronic plantar fasciitis. Patients were assigned a success or failure status according to four criteria: a minimum of 50% improvement in investigator assessment of pain, a minimum of 50% improvement in a patient’s self-assessment of pain, an improvement of a patient’s assessment of physical activity, and lack of use of pain medication between 10 and 12 weeks after treatment.39 Each patient had to meet all four outcome criteria to be considered a success. Twelve weeks after treatment 47% of treated patients met all four success criteria compared to only 30% of patients who received sham treatment.39 This difference was statistically significant. Approximately 76% of treated patients were satisfied with their outcome, even when pain relief was not complete.39

Buch et al33 reported the results of another multicenter prospective randomized double blind placebo controlled trial. These investigators followed the identical protocol used in the present study. After 12 weeks 61% of the treated patients met all success criteria compared to 40% of the placebo group.33

Chen et al16 reported on 80 patients treated with high-energy shock wave therapy for chronic plantar fasciitis. At 24 week follow-up, 86% were either symptomatic or significantly improved. Hammer et al35 reported on their experience using high-energy shock wave therapy to treat 47 patients (49 heels) with chronic plantar fasciitis. Approximately 80% of patients experienced complete or nearly complete pain relief at six months post-treatment.35

Wang et al41 demonstrated 80% satisfactory results in their cohort of patients with chronic plantar fasciitis treated with shock wave therapy. These investigators noted a positive cumulative effect from 6 to 12 weeks post-treatment.41 In a second study with longer follow-up, these same investigators noted that shockwave therapy for patients with chronic plantar fasciitis provided 94% complete or nearly complete resolution of pain.34

Rompe et al5 demonstrated similar findings. In their cohort of 45 running athletes with chronic plantar fasciitis treated with low-energy shock wave therapy, visual analog scores decreased from an average of 6.9 to 2.1 24 weeks after treatment and from 6.9 to 1.5 one year after treatment.

In another report with longer follow-up, Rompe et al11 noted that patients with chronic plantar fasciitis treated with shock wave therapy had progressive diminution of pain on manual pressure over a five-year period. The mean score for pain on manual pressure gradually decreased from 77 points (before treatment) to 19 points (at six months post-treatment) to 9 points (at five years post-treatment).11 In controls, the mean scores were 79 points before treatment, 77 points at six months, and 29 points at five years post-treatment.11

The results from this study add to the growing number of favorable reports that substantiate the efficacy of extracorporeal shock wave therapy as an effective treatment for chronic plantar fasciitis. Mean VAS, RAND-physical functioning, and RAND-pain scores were statistically improved at one and three months following treatment. The percentage of excellent or good results using the Roles and Maudsley score at 12 weeks post-treatment was 83.3%. There were no significant complications and no patient required additional shock wave treatment. Subjectively, patients were very satisfied with the procedure.

Two patient cohorts seem to have a particularly high incidence of plantar fasciitis: obese middle-aged women and young athletic men.8,36,39 This is the first report that examined the relationship between activity level and outcome after extracorporeal shock wave therapy. Although the outcome parameters among “active,” “moderately active,” and “sedentary” patients were similar, the relatively small number of patients prevented meaningful comparisons among the subgroups. Larger prospective studies are necessary to better define the role of extracorporeal shock wave therapy in these groups of patients.

Recent reports have shown that extracorporeal shock wave therapy was ineffective in the treatment of chronic plantar fasciitis. In a double-blind, randomized study from Australia, Buchbinder et al44 reported no statistically significant difference in the degree of improvement between the extracorporeal shock wave therapy treated group and a placebo group. In a German trial, Haake et al45 also reported no difference between the extracorporeal shock wave therapy treated group and a placebo group. Speed et al46 reported that a moderate dose of shock wave therapy (1500 impulses of 0.12 mJ/mm2, given monthly for three months) resulted in a 37% improvement in the extracorporeal shock wave therapy group and 24% improvement in the sham group with respect to pain.

There were some important differences between these negative studies and the present study. In the Buchbinder et al study,44 shock wave therapy was given in smaller doses, weekly, for three weeks.44 In the Haake et al study,45 shock wave therapy was applied every 2 weeks ±2 days (3 doses of 4000 impulses). In the Speed study,46 shock wave therapy was given each month for three months. In this study, shock wave therapy was given in a single, larger dose.

In the Buchbinder study,44 the total calculated dose of shock waves administered to each treated patient was different. In this study, each patient received the same dose.

In regards to inclusion criteria, patients were enrolled in the Buchbinder et al study if they were symptomatic for at least six weeks.44 Patients were enrolled in the Speed et al study46 if they were symptomatic for three months. In this study, patients were only treated with shock wave therapy if they were symptomatic for a minimum of six months. In this author’s experience, those patients with less chronic symptoms (<6 months) are likely to improve whether or not they have extracorporeal shock wave therapy.

The treatment parameters in the Speed et al46 study (1500 pulses of 0.12 mJ/mm2, given in several doses over a period of several months) are very different from the treatment parameters used in this study. The protocol in the Speed et al study used a “moderate-energy” dose of shock waves whereas a “high-energy” dose was used in this study.

We believe that the results of extracorporeal shock wave therapy are only valid for the therapeutic parameters applied. Patient selection and treatment technique (adequate number of shocks, adequate total dose) are critical. Differences in results between different trials may be related to heterogeneity of treatment parameters (total dose, interval of time between doses, number of sessions, etc), study populations (rural versus university), and perhaps machine design. Further work is needed to clarify these issues.

This study is retrospective and as such has some inherent weaknesses. This series represents a relatively large number of patients considering that patients were derived from a rural, community setting. However, when considering the number of patients in each subgroup, the absolute numbers are relatively small. The length of follow-up was only three months, however, a positive effect was already evident at this time. Other larger studies have used a similar length of follow-up.39,41,44 Finally, this study did not use a control group.

Nonetheless, this series contributes valuable information. The data from this study demonstrates that extracorporeal shock wave therapy is a safe and effective procedure that can be used to treat patients with chronic plantar fasciitis. The procedure is reliable and enjoys a high rate of patient satisfaction.

Conclusion
The results of the current study revealed beneficial effects of extracorporeal shock wave therapy in patients with chronic plantar fasciitis. Unlike surgery for plantar fasciitis, which bears a higher risk of complications, recovery from shock wave therapy generally occurs without significant morbidity. Our results show that this procedure can be an excellent treatment option. Further prospective work is underway to better define this emerging technology.

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Benton-Weil W, Borrelli AH, Wiel LS Jr, Will LS Sr. Percutaneous plantar fasciotomy: a minimally invasive procedure for recalcitrant plantar fasciitis. J Foot Ankle Surg.1998; 37:269-272.
Tomczak RL, Haverstock BD. A retrospective comparison of endoscopic plantar fasciotomy to open plantar fasciotomy with heel spur resection for chronic plantar fasciitis/heel spur syndrome. J Foot Ankle Surg.1995; 34:305-311.
Ward WG, Clippinger FW. Proximal medial longitudinal arch incision for plantar fascia release. Foot Ankle.1987; 8:152-155.
Authors
Dr Furia is from SUN Orthopedics and Sports Medicine, Lewisburg, Pa.

Reprint requests: John P. Furia, MD, SUN Orthopedics and Sports Medicine, 900 Buffalo Rd, Lewisburg, PA 17837.




· Experts discuss what to expect after ankle surgery (Jul. 2005)
· Treatment of Foot Drop Using a Dynamic, Non-Rigid Dorsiflexion Foot Lifter (Jun. 2005)
· How top surgeons treat arthritis (May. 2005)

Result number: 122

Message Number 177579

ESWT questions for Dr.'s View Thread
Posted by Jennifer on 6/30/05 at 15:20

I had ESWT 10 months ago. I had no prior nerve damage based on nerve testing 3 days before procedure, and actually had no inflammation of the fascia or surrounding tissues based on MRI - but my Dr. said it could help my chronic foot pain - that I'd be no worse for the wear if I did it. I had both feet done with high energy ossatron. I immediatly felt excruciating pain after anesthesia wore off. I was MRI'd a month after and nerves were tested using Neural Scan, showing significant bone edema and nerve damage of peroneal and sural nerve. 10 months post, and I still have inflammation of the bone tissue of calcaneous and all surrounding tissue, as well as muscle atrophy on bottom of foot. I'm having a difficult time finding information on whether this has ever occured to anyone else, and whether the ossatron is supposed to cause this. Also, are there any contraindications for very petite people and this machine - I'm 4-10 and 88 pounds - and 33 years old. The bony edema is very painful, and the nerve damage kept me off my feet for several months. I don't know that I will ever be the way I was before this procedure. Please help with any information.

Result number: 123

Message Number 176701

Drs please weigh in - is this possible? View Thread
Posted by messed up foot on 6/13/05 at 17:11

quick summary - Left peroneal tendon repair 12/04 (sural nerve is now numb), left TTS and partial plantar fasciectomy in Feb 05 (heel, toes and medial side of heel still numb). Ortho referred me to PT to evaluate why I cannot go up on toes on left foot and now right peroneals are swollen and sore. Ortho thinks that I can't do it because I was immobilized for 16 weeks over 4 months. He won't even consider the pain issue.

PT says that I have "too many toes" on the left and marked pronation on the left but I think that it is about the same as pre-op. He noted that I have pain at the sinus tarsi region. He said my strength and flexibility are about the same between left and right.(all of which I regained without PT - just a lot of hard work) I asked about PTTD he said that the surgeon should have seen the tendon when he did the TTS surgery (I have an 14cm scar)and that PTTD wouldn't hurt where I feel pain.

PT says that he thinks that I have another nerve impingement. I could cry. Also says that right foot has too much laxity. He is puzzled that I have good strength and pain in the front of the ankle when I try to do a toe raise. I can walk with only a mild limp for 3-4 miles now but my ankle rolls over at least once/day on irregular surfaces.

What nerve could this be? Have any of you heard of this? I am so frustrated that I could scream. What else can be done to fix my foot surgical or non-surgical? While not being able to toe raise seems minor, it affects using ladders, stairs and even hills.

Result number: 124

Message Number 176452

Re: tarsal tunnel + painful numbness View Thread
Posted by messed up foot on 6/10/05 at 10:29

I only take Voltaren for pain and it dulls the perpetual ache.

I have no feeling at all in the middle of my heel (had that preop) and postop no feeling on the medial (inner) side of my heel. Plus I lose all feeling in my first 3 toes whenever I wear shoes. I have nerve damage on the outside of my foot (sural nerve)from another foot surgery so numbness is my life. My surgeon pushed on the area of the pf release and asked if it hurt - nada, completely numb. He said "good, otherwise this would hurt like hell" - gotta love his sense of humor! Oddly, I have a sense of deep, almost knife-like pain in the same areas that are completely numb to the touch. Rather than improving (nerves do take time), mine is static if not a little worse.

Maybe one of the good doctors can explain this. I am sure that is all nerve related. I also find that since the pf & tts release, my arch hurts. Never did before.

Re: nerve blocks - no they do not hurt at all if the anesthesiologist give you some Versed/Fentnyl before the injection. After that combo - you feel nothing and are happy as can be! Without meds? I would imagine that it stings. I didn't think that cortison injections into the tarsal tunnel hurt at all so keep that in mind. Pain is relative.

Result number: 125

Message Number 176066

bone edema, nerve damage 8 months post ESWT View Thread
Posted by supertwin on 6/02/05 at 23:28

I have posted for two years now intermitantly, and posted directly after high energy ossaton on both heels in September. I've had numerous MRI's, and neural scans throughout my recovery, showing significant nerve damage to sural and peroneal nerves, bony edema still, and muscle atrophy, and edema in all the surounding tissues of the fascia. I stopped seeing the doctor who performed the procedure in November of 2004, and now see an anesthesiologist to control the pain, and a new podiatrist who is trying to get the nerve damage resolved, and the bony edema. I immediatly felt something had gone wrong the minute I came out from under anesthesia. I couldn't walk, and was in a wheelchair for almost two months. My new doctors don't know about this procedure, and have no experience treating damage from ESWT that I've sustained. I'd like to discuss exactly how abnormal my case is - just to know. I was very dissappointed to find out 3 weeks ago that I continue to have significant swelling of the calcanous, muscle atrophy, and inflammation of the tissues 8 months after the procedure. However, it does explain why I still have so much pain. To add, I had a clean MRI - no edema or inflammation, and fascia of normal size - and normal nerve test 3 days prior to the ossatron - and no underlying systemic cause/reason (except pronation)for heel pain. The only thing any doctor has speculated is that perhaps my petite 4-10 frame and 90 pounds couldn't handle the high energy shock wave. Please email me at wondertwin71@yahoo.com
Thank you so much

Result number: 126

Message Number 175338

Re: TTS Board and conversation about it View Thread
Posted by carynz on 5/19/05 at 20:35

my nerve damage is both sides. Yes I know where the nerves run thanks. Probably in haste to write my 2c, did not go into great detail. First thought that TTS condition was reason for all the pain. Upon further testing , I had part of the sural nerve taken to determine if in fact neuropathy was my condition rather than TTS. I have no feeling in my left foot or ankle now right up my lower calf. it has not extended to the knee level yet but my balance is affected greatly by having lack of circulation and numbness/tingling in the left foot itself. I was tested for MS as well since the symptoms are very similiar also for diabetic neuropathy but this has all proved negative. Final diagnosis last year is Chronic Demylinating Peripheal Neuropathy. Recently I was diagnosed with a type of Peroneal Atrophy, which is directly influenced by the peripheal nerve. Over the last 2 1/2 years I have also been experiencing "shock like pain" which is actually more painful than anything else.

Until I found this board, all of this was "french" to me and it was hard to find any information at all.

Cheers
Caryn

Result number: 127

Message Number 175138

Re: TTS Board and conversation about it View Thread
Posted by elliott on 5/16/05 at 16:03


Carynz,

Can I ask a few questions about your case:

1. Where exactly on your foot is your nerve pain?

2. Why did the doc take a piece of your sural nerve from your ankle?

3. Did doing so leave you with any new sensory problems?

4. The sural nerve branch goes down the outer side of the ankle, while the TTS nerve goes down the inner one. So how was doing something with the sural nerve a test for TTS (surgery)?

Thanks

Result number: 128

Message Number 175077

TTS Board and conversation about it View Thread
Posted by carynz on 5/15/05 at 11:23

hello everyone,

I have not posted in a very long time however do read the boards when time permits. As for this TTS Board and information contained in it and the heelspurs pain book pages......Had it not been for this board and the information I got from it 2 years ago, I would have never had enough ammunition to go back to the neurologist and ortho surgeon to push for further testing etc. It was this site and TTS board, Wendy and some others who gave me enough to work with so I could go further. My own doctor knew of TTS but was amazed at the info I gave him to read which turned out to be much like a good book he admitted after reading the information. I was able to take this information to a foot/ankle surgeon in Vancouver who after much agonizing and taking a piece of the sural nerve from my left ankle determined that surgery for TTS would not be my answer as he did not feel the problem would be repaired due to much nerve damage already. After this appt. I was then able to give this information to CPP who after 18 months determined that yes I suffered with chronic pain and that the condition known as TTS is in fact good enough to be granted disability benefits.
I thank people like Wendy and Scott for having this information available when I needed it most. Don't take that away from here, there may be others just like me who have nothing else to go on and may find the one thing they need to get a clear understanding and eventual diagnosis to the condition they may suffer from.

I suffer everday with chronic pain in my left ankle and now the numbness and tingling has gone up into my lower calf so for some it gets worse, others may be able to go on for a long time without any changes.

So this is my 2c to share, but don'[t take the TTS board off this site.

CarynZ

Result number: 129

Message Number 173653

lymphedema and a nerve impingement question View Thread
Posted by messed up foot on 4/24/05 at 14:28

After TTS/PF and peroneal tendon repair I now have lymphedema. How common is this and will it improve with treatment? I am lucky to have access to a lymphedema treatment clinic once they have an opening.

Also - is there a nerve that runs under (plantar) the peroneal tendon that could be impinged? The sural has been numb since the peroneal repair - but now I have a 'nerve' pain that radiates to my small toe on the from under the lateral maleolus on the plantar surface of my foot while the top of my foot remains numb. My ortho says that my nerves definitely do not like any pressure or contact (actually he said that my sural didn't even like being looked at:-)) Heel is numb despite the TTS release as well.

Just curious I guess - I'm not having anymore surgery on this foot!

Result number: 130

Message Number 170817

Ganglion cyst and plantar fasciitis View Thread
Posted by Scott R on 3/09/05 at 16:40

Hi Scott,
Thanks for taking so much time to give such good
information about plantar fasciitis (PF). I'd like to
share my story about a ganglion cyst that mimicked PF.
It was successfully removed from my ankle 11/04 by my
current podiatrist. The cyst was pressing on a nerve
bundle, mimicking not only PF and several other foot
problems (Achilles tendonitis, bursitis, nerve
entrapment, neuropathy and tarsal tunnel syndrome).
Last spring (5/04), when my former doctor, an
orthopedist specializing in feet, supposed to be one
of the best in the country, diagnosed me with PF, I
found your website and read it, believing that I truly
had PF. I did what he recommended and what you
recommended, then after several months, when the pain
didn't go away, he gave up on me. Originally I went
to him in 11/03 because of a heel fracture (developed
in 9/03, probably from running on concrete) that was
still causing me problems and I needed advice on how
to treat it. My first orthopedist was not very bright
and simply told me to wear a boot, ignoring my concern
for swelling and extreme pain between 9/03 and 11/03.

By 6/04, my heel was causing excruciating pain and I
had to use crutches to walk any distance further than
100 feet, otherwise I needed a cane. The foot
orthopedist finally referred me to another doctor who
does ESWT but since this doctor was very far from
home, I decided to find a podiatrist closer to home
that did ESWT and it's the best decision I have ever
made.
My current podiatrist listened to my symptoms and said
that although it sounds like PF, it also sounds like
something else is going on, like nerve entrapment, but
he wanted me to try orthotics, physical therapy and an
anti-inflammatory that is known for helping PF. My
former orthopedist had not prescribed any of these
even though I requested it. Three months later, I
discovered Z-Coil shoes (the only things that really
helped me to function normally and worth every penny
and more) and was able to walk without crutches for
several blocks. The Z-Coils literally changed my life
at that time because I no longer needed crutches or a
cane. The inflammation seemed to decrease, things
seemed to be getting better because I was still taking
it slow but eventually, the pain came back with
increased activity (because the cyst was still there).
This time, my podiatrist sent me for an MRI (11/04)
to a place where he knew the doctor reading the films
was an excellent radiologist. He found a 2.5 cm
ganglion cyst, which was very obvious on the films,
deep in a nerve bundle, wreaking all sort of havoc on
surrounding tissues. It had to be removed surgically.
This radiologist who read my MRI in 11/04, compared
it to two previous MRIs (9/03 and 5/03) prescribed by
my former doctors who barely looked at them, but
mainly read the accompanying reports. When he
compared, he said that the cyst looked the same on the
previous MRIs even the one from 9/03! Sure enough,
when I checked them, now that I knew what to look for,
there was a white glob that was referred to as “mild
ankle effusion” by the radiologist who read them. I
had asked each of my other doctors what the
radiologist meant in her report by “mild ankle
effusion” and they simply said it’s swelling and not
to worry about it.
It made me sick to think that the first two MRIs were
ignored by my doctors because of negligence by the
radiologist, and ignorance by the doctors and that I
went for over a year with this pain and was
undiagnosed, then misdiagnosed. This did not only
cause physical pain, it caused numerous problems at my
job, my home life, my relationships with everyone
around me and my emotional well being. No one thought
there was anything really wrong with me, that plantar
fasciitis couldn't possibly be causing me to need
crutches, that I was making it up for attention and
only to get short term disability from work. Nothing
could have been further from the truth. I had been a
very active person, I was training for a marathon and
when I fractured my heel, I took up cycling to avoid
impact. I simply would not stop because 1) I love
exercise 2) I believed my doctor when he said riding
my bike wouldn't hurt the PF, but now that I know
there was a cyst, I think the bike probably aggravated
it. But I won't get into any more details about the
issue of how the doctors helped to prolong my agony.
It's been nearly four months since I had the cyst
removed, and I am feeling more like a normal person
again, I can go grocery shopping and on other errands,
and am able to walk two miles about once a week, on
top of my commute of half a mile a day and my usual
walking at work, without too much pain. I still wear
the Z-Coils because there continues to be a lot of
swelling around both sides, rear and bottom of my heel
for which I take Indocin and also Neurontin for the
burning in my sural nerve which was pressed on by the
cyst and now by the swelling. My podiatrist is
hopeful that things will continue to improve over the
next few months and that I will be able to run again,
go on long walks, and return to a normal life and I
believe him.
I hope that sharing this story will help someone else
who has been misdiagnosed but will not give up trying
to find an understanding doctor who pays attention and
makes a correct diagnosis.
Thanks,
Julie Z

Result number: 131
Searching file 16

Message Number 164423

Re: Pf & SN? View Thread
Posted by Ed Davis, DPM on 11/20/04 at 12:35

Linda:
Severs desesae at age 12 is unlikely to have any sequelae. Sural neuritis just means that the sural nerve, the nerve o nthe outside of your foot is inflamed. That sometimes occurs when patients with PF tend to walk on the outside of their feet to avoid PF pain.
Ed

Result number: 132

Message Number 164413

Pf & SN? View Thread
Posted by Linda O on 11/20/04 at 11:08

Hi again I have been suffering from feet pain more on left than right .My DR has decided I should see a Nuroligest.His diognoses is PF and sural neuritis I have never heard of sural neuritis has anyone else?
I fell at work my left foot was caught in a plastic container my foot problems started then. My Dr thinks that severs disease at12 could play a role here I'm 48 now and have had no problem in between 12 and now.Both feet go numb and both have heel pain but my left foot has a burning on the lateral side that he can't explain or won't I am 5'8 and wiegh 190 I am over wieght but not an extream amount. He told me I had arturitis but that ius not in his paper work. I feel he is slacking on me because I filed for my 3 weeks pay with W/C.He also told me to find a sit down job not in his report would that stop him from treating me? sorry this is long.

Result number: 133

Message Number 162525

Re: Anyone had ESWT in Dallas? View Thread
Posted by vince on 10/30/04 at 13:48

Use any doc on the united list whose fee is what you can handle, they are all well trained- Don't even be concerned if it's the first time they are doing ESWT. Your only concern with the doc is his ability to give an efficient PT and Sural nerve block- the tech that will assist the doc has probably performed many 100's of treaments. The tech that assisted the doc who I went to had done over 1000 treatments for united. I actualy had more confidence in him than I did in the doc for starters. GOOD LUCK, you're making a smart choice having this done.

Result number: 134
Searching file 15

Message Number 155074

Re: hospital based ESWT or physician office? View Thread
Posted by Dr. Z on 7/10/04 at 20:17

MarkL

I just reviewed the training tape from this liberal company that you are talking about. It talks about using alot of more anesthetic then you are talking about. I do agree that very little is needed only PT with Sural block is needed. I have done thousands of these blocks for ESWT and other types of foot surgery and it appears very simple but if you aren't experienced will take practice.
I am able to teach all of our doctors this technique and they pick it up due to the special methods of training I have developed

Result number: 135

Message Number 155060

Re: hospital based ESWT or physician office? View Thread
Posted by MARK L on 7/10/04 at 16:34

Mike,
If you needed a significant amount of local than it wasn't injected properly. The PT and Sural nerve block, expertly administered should require a total of not much more than 5cc of 1% Lidoacaine. I have watched it done many time with less than 5 cc. A Podiatrist I know does it all the time with a total of 3cc of 1% plain Lidocaine and the patient feels nothing during the ESWT therapy. He just looks for the nerve and when it's found it's knocked out in a flash. If he's doing a bilateral he'll add 1 cc of .5% Marcaine to the second foot. However, I know that there are some out there who couldn't hit the nerve if it had an arrow pointing to it and a sign that said "Inject here"

As far as naming the company with the very liberal payment policy- I won't use this site for commercial purposes.

Result number: 136

Message Number 154817

Re: Has any one heard of just cutting the nerve once it branches of at the ankle? View Thread
Posted by Richard M on 7/07/04 at 22:33

Jeffery, Talk to your best foot doctor surgeon in your area, ask about a Sural nerve neurectomy. Or a possible neuroma in that area.??????? good luck

Result number: 137

Message Number 152822

Re: Ice after ESWT? View Thread
Posted by Dr. Z on 6/12/04 at 13:41

I agree that the actual protocol works well. I don't agree that the blocking of just the medial calcaneal nerve works well. According to the FDA results 75% of the patients experienced pain DURING the patient. When you block Post Tib and the sural nerve the pain level is reduced to almost nothing in most cases.
I have never had Dornier recommend any ice vs heat vs nothing. There will be difference of opinion but my advice as I stated before is based on experience, personal communication with ESWT experts and common sense.
There is probaby no difference between ice and heat with ESWT but in theory heat is what you want. If ice feels better use ice if heat feels better use heat, if you feel better take your pick.
Stating that the use of heat is not scientific is false and that is what I take exception to .
I can understand why you did jump on this topic. The patient was from your clinic. All patients should take the advice of the treating ESWT clinic and or doctor.
If you trust you doctor/clinic to perform your procedure you should trust the advice that you were given to follow after the procedure

Result number: 138

Message Number 152810

Re: Ice after ESWT? View Thread
Posted by Dr. Z on 6/12/04 at 08:30

Hi Scott,
I said it was what I use.!!!!! Do you know why the FDA study didn't use NSAID for 12 weeks.?? It was to show that it was the ESWT working and not any of other treatments such as NSAID. By the way my opinions are based on 25 years of experience of treating patients,conversations with leading ESWT researchs and common sense Do you know that ICE is an anti-inflamatory modality?. It causes vaso-constriction which reduces blood flow to an area. That is the science behind ice. Heat causes vaso-dilation of blood vessels and causes increase blood flow.
What is your anesthetic protocol at your clinic? If you are blocking more then just the medial calcaneal nerve and or using IV sedation then you have just changed the FDA protocol that was used. It is my opinion and by now the entire ESWT profession ( personal conversation) that most
are using a complete Posterior Tib and sural nerve block and some times
IV sedation. This is not the original protocol . In about 75% of the FDA cases patients reported pain. With the PT/Sural block protocl in our group 95% undergo have no pain when undergoing ESWT treatment . I am willing to bet that your Doctors are using both a posterior Tib and sural nerve block and probaby IV sedation.
Soott what is going on ? Only I did was give my opinion when asked

Result number: 139

Message Number 152502

Re: sclerosing injections for nerve damage View Thread
Posted by Dr. Z on 6/09/04 at 08:23

Hi

If this is a sural nerve problem then I would go with the local alchol,sclerosing injections. It could take up to seven injections for relief. Another treatment that can be used is cryotherapy. This is a procedure that freeezes the nerve. Both are used for sensory nerve problems such as yours

Result number: 140

Message Number 152472

sclerosing injections for nerve damage View Thread
Posted by lee on 6/08/04 at 20:23

Nine montha ago I had surgery to remove the fractured lateral process of the talus and other damage to my right ankle. The surgery caused sural nerve damage which still causes me a lot of pain. I have used capsasin cream to reduce superficial pins-and-needles tingling with good success. My doctor has given me a series of injections into the scar that has helped to flatten it and reduce scar tissue. But the worst pain has not resolved. I have sensations that I'm being stuck hard with a needle that come out-of-the-blue anywhere from about six inches above my ankle all along the area behind the lateral malleolus down the side of my foot to my smallest toes. There is a spot of extreme tenderness behind the lateral malleolus.

At my doctor's visit today he brought up the possiblility of doing a series of sclerosing injections into the sural nerve to deaden the nerve and, along with it, the pain. He wanted me to research this treatment (he knows I love to do that!) and let him know what I want to do. I've found a lot of information about using this treatment for neuromas but nothing about using it for post surgical nerve damage.

Could you give me your opinion on this treatment for my specific problem? I'm so ready to be painfree and won't even consider a surgical alternative.

Result number: 141

Message Number 151148

Re: PF relaese surgery and sciatica pain View Thread
Posted by Ed Davis, DPM on 5/24/04 at 17:51

Kristie:
The sciatic nerve ends on the outside of the heel with its sural branch but sensation and nerve supply is brought to the heel by branches of the posterior tibial nerve which is the nerve on the inside of the heel and ankle.
Ed

Result number: 142

Message Number 151019

Re: To Robert J View Thread
Posted by MARK L on 5/22/04 at 07:37

Your heel should not be painful and swollen from the injections- the block given should be a Posterior Tibial or Medial Cancaneal with a very shallow injection to the sural nerve on the lateral side. These blocks, properly administered, can be effective with as little as 5cc for both sites. This puts no anesthetic into the heel or treatment area. Moreover, the location of your pain and the fact that the thickness of your plantar fascia is under 4mm leaves me wondering if you really have traction degeneration of the plantar fascia at the medial tubercle and hence the less than desirable results from ESWT.

Result number: 143
Searching file 14

Message Number 143734

Re: Dornier with full IV View Thread
Posted by Mark L on 2/06/04 at 07:07

There was one study that suggested that a local block where the anesthetic is injected into the treatment area may attenuate the effect of the therapy. This, however, was with LOW ENERGY ESWT. With the DORNIER EPOS HIGH ENERGY ESWT and using a properly applied PT block and a Sural nerve block there would be a very minimul amount of novacaine, if any at all, in the treatment area. Part of the driving force behind using the Ossatron, in my opinion,is so ASC's can bill for the IV sedation and fatten their pockets as well as the pockets of their "gas passers" Why add the risks of IV sedation to a very safe procedure. Here's the reason-$$$$$$$$$$$$$$$$$$

Result number: 144

Message Number 143393

True Facts View Thread
Posted by Mark L on 2/01/04 at 13:52

I am very distressed at the misinformation about high energy ESWT I ahve seen posted here.

Fact: YThe Dornier Epos U has a wider range of flux density energy than the Ossatron 0.03 - 0.98 mj/mm2 vs. 0.09 - 0.34 mj/mm2. Healthtronics is using Enron type math in order to claim that the Ossatron has a wider rtange of energy

Fact: The energy level shock to shock of the Dornuier is more consistant that the Ossatron

Fact: The information that Healthtronics disememinated in order to entice investors is being questioned.

Fact: The application of ESWT treatment with the Dornier usually has a very low level of patient discomfort. I have personally observed quite a number of ESWT treatments with the Epos where the patient actually fell asleep with nothing more than a PT and Sural block with as little as a total of 6cc. of 1% Lidocaine.

Fact: I have spoken with several podiatrist who have done 15+ treatments each with the Epos and who state that they have experienced 95%+ patient satisfaction 6 months post treatment.

Result number: 145

Message Number 143392

True Facts View Thread
Posted by Mark L on 2/01/04 at 13:49

I am very distressed at the misinformation about high energy ESWT I ahve seen posted here.

Fact: YThe Dornier Epos U has a wider range of flux density energy than the Ossatron 0.03 - 0.98 mj/mm2 vs. 0.09 - 0.34 mj/mm2. Healthtronics is using Enron type math in order to claim that the Ossatron has a wider rtange of energy

Fact: The energy level shock to shock of the Dornuier is more consistant that the Ossatron

Fact: The information that Healthtronics disememinated in order to entice investors is being questioned.

Fact: The application of ESWT treatment with the Dornier usually has a very low level of patient discomfort. I have personally observed quite a number of ESWT treatments with the Epos where the patient actually fell asleep with nothing more than a PT and Sural block with as little as a total of 6cc. of 1% Lidocaine.

Fact: I have spoken with several podiatrist who have done 15+ treatments each with the Epos and who state that they have experienced 95%+ patient satisfaction 6 months post treatment

Result number: 146

Message Number 143354

Total regional field blocks View Thread
Posted by Dr. Z on 1/31/04 at 21:07

What happen was at that time we were not giving a full sural block on the outside of the foot. There was never any sural nerve block given during the FDA study There was never a LOCAL GIVEN to Brian period . He was given a posterior tib nerve block with partial sural nerve block
You have to realize that we were one if not the first to use the dornier epos in the country outside of the FDA study.
If you follow the FDA study they only used a medial plantar nerve block and not a full posterior tibial nerve block. In the FDA study the pain during the treatment was very high.
I had to deveolp a new anesthetic protocol to prevent most if not ALL patients from feeling pain.

Today most if not all of all patients have pain free treatment due to a regional field blocks.

Result number: 147
Searching file 13

Message Number 137621

nerve problem following surgery View Thread
Posted by lee on 11/15/03 at 20:26

A little over four weeks ago I had surgery to repair damage from an old fracture of my talas. Following the surgery I was put into a hard cast. I noticed that my baby toe and the lateral top edge of my foot was numb. After a couple of weeks a pins-and-needles tingling started in that lateral area which gradually became more and more intense. My doctor thought it could be sural nerve impingement that might be inflamatory and wanted me to try nsaids to see if it would help. When it didn't he decided to remove the cast. This seemed to help at first but the painful tingling is now worse with really unpleasant electric shock sensations thrown in. All the doc can say is that it could go away or could last forever. He wasn't forthcoming with any more information than that.

What I'd like to know is if its too soon following surgery to be so alarmed? What specifically can be done to help make it better? Is it best to get on it sooner rather than later? I like to have as much information as possible so I will have something to take to my doctor so we might formulate a plan.

I have quite a history of foot problems so this new development is really scaring me. I really appreciate the help!

Result number: 148

Message Number 130437

Re: Sural Nerve Entrapment? View Thread
Posted by Dr. Z on 9/18/03 at 11:58

It could also be the peroneal brevis tendon causing this. Could the doctor reproduce the sural nerve pain on examination? It this is a sural nerve entrapement local steriod injection may help this. Must first be sure that this is in fact a sural nerve problem

Result number: 149

Message Number 130418

Sural Nerve Entrapment? View Thread
Posted by Sniff Y on 9/18/03 at 08:36

Hi. I'm a 32 year-old male. I ruptured the Achilles tendon in my right leg about 6 months ago. The surgery seemed to go well, and the tendon itself is healing nicely. However, my rehab is being badly hampered by pain that radiates through the outside of my heel as I walk. I find the I can reproduce the pain by rubbing the outside of my Achilles tendon, about halfway up towards the calf.
From consultations with doctors, and my own research, I believe that I may have sural nerve entrapment.

My questions are: (1) does that sound like a plausible theory? and (2) are there non-surgical ways of alleviating the pain, or even gettgin rid of the entrspment altogether.

For obvious reasons, surgery is my last preferred course of action.

Thanks.

Result number: 150
Searching file 12

Message Number 122181

Re: post op recovery Haglunds View Thread
Posted by Dr. Z on 6/17/03 at 21:20

Hi

The type of tendon and bone surgery that have gone thru can take up to one year to get better. Sometimes a nerve can be trapped or damaged. Not sure where the incision was made but it is possible with this type of surgery. In most cases this areas does in fact take up to one year to get better. There is alot of swelling after this surgery. I would discuss your concerns with your doctor. Ask him if the sural nerve could be trapped

Result number: 151
Searching file 11

Message Number 119977

Re: European experience View Thread
Posted by Dr. Z on 5/26/03 at 19:57

I have found that the posterior tibial nerve in addition to a sural nerve works very well with high energy ESWT. I would think that it would work even better with low energy if needed. Marcaine 0.5% plain mixed with 1% lidocaine plain is a very good combination that gives profound anesthesia

Result number: 152

Message Number 117763

Another one for Dr. Z -- new treatments for neuropathy View Thread
Posted by Sharon W on 5/03/03 at 16:59

I was interested to see this quote: "...PATIENTS WITH EARLY DIABETIC PERIPHERAL NEUROPATHY... APPEAR TO BE THE GROUP OF PATIENTS MOST RESPONSIVE TO THERAPY." In fact, one of the most promising new treatments doesn't work on patients with advanced disease, but it DOES work on milder cases.

This is another very encouraging link, detailing new treatments being developed for neuropathy:

http://www.medscape.com/viewarticle/438361

Sharon

------------------------------------

New Developments in the Treatment of Neuropathy

Disclosures
Aaron I. Vinik, MD, PhD

"A Prophecy Fulfilled?"

"Last year, I reported on the highlights of the diabetic neuropathy reports presented at the 61st Scientific Sessions of the American Diabetes Association.[1] I pointed out that the new buzzwords in neuropathy were "oxidative and nitrative stress," and that evidence had accrued that there was overproduction of reactive oxygen species (ROS) that were potentially harmful to nerve function. I also showed that the ROS could bind to nitric oxide (NO) -- an important vasodilator -- and convert it to peroxynitrite, culminating in depletion of NO and formation of yet another "toxic compound" (peroxynitrite) that could further cause nerve damage."

"The prediction was that if we could find the ways and means of abrogating this process, we might be able to affect disease progression, or even slow it down sufficiently to allow the body to repair itself. At this year's meeting, this prophecy appeared to be fulfilled in part."

"Pursuing the notion that oxidative stress at the mitochondrial level might be important, Irina Obrosova, PhD, University of Michigan, Ann Arbor, and colleagues[3] examined the consequence of oxidative stress via poly ADP ribosylation, ie, transfer of NAD to nuclear protein by the enzyme poly ADP ribose synthetase (PARS). Inhibitors of this enzyme have been shown to improve nerve function in rats. In this study, the investigators showed that creation of transgenic animals deficient in PARS restored endothelial function, repleted the stores of the potent endogenous antioxidant GSH, and protected the animals from galactose-induced nerve damage."

"The Role of Protein Kinase C (PKC) Beta"

"PKC beta is one type of the group of enzymes found in tissues that are targeted by diabetes complications, such as the nerve, kidney, and eye. Current theories of the pathogenesis of diabetic neuropathy suggest that activation of PKC beta may be key in the process that leads to microvascular dysfunction, impairment of endoneurial blood flow, and, ultimately, damage of nerves. While hyperglycemia may be the major stimulus to de novo synthesis of diacylglycerol (DAG), which in turn stimulates the activation of PKC beta, other factors, such as oxidative stress, accumulation of advanced glycation end products, and, possibly, other metabolites that are deranged in diabetes (eg, free fatty acids), may contribute."

"Identifying Treatable Patients"

"Vera Bril, MD, University Health Network, Toronto, Ontario, Canada, and colleagues[4] reported that PATIENTS WITH EARLY DIABETIC PERIPHERAL NEUROPATHY, identified by vibration detection threshold (VDT) and electrophysiology testing, APPEAR TO BE THE GROUP OF PATIENTS MOST RESPONSIVE TO THERAPY. The investigators concluded that detectable sural nerve conduction, or sural nerve action potential (SNAP), identified an earlier degree of diabetic peripheral neuropathy and a greater likelihood of responding to therapy. In addition, the duration of neuropathy was identified as the only factor that might contribute to the difference in ability to detect SNAP (P = .0043; odds ratio = 0.896). These findings should prove useful in the evaluation of novel agents, such as LY333531, for the treatment of diabetic neuropathy."

"PKC Beta Inhibition in the Treatment of Diabetic Neuropathy"

"LY333531 is a specific inhibitor of PKC beta (Figure 2) currently undergoing phase 3 clinical trials. Several studies of this investigational agent in the treatment of neuropathy were presented at the ADA meeting."

"In a 1-year, double-blind, placebo-controlled, parallel trial,[4] LY333531 treatment was found to improve diabetic peripheral neuropathy, as assessed by neurologic examination, objective measures of nerve function, and physician assessment. A total of 205 type 1 or 2 diabetes patients with diabetic peripheral neuropathy received either 32 mg of LY333531, 64 mg of LY333531, or placebo. Treatment with the 32-mg dose of LY333531 produced overall improvement in neurologic examination (P = .076 vs placebo), most notably in the lower limbs (P = .049 vs placebo) -- sites most affected by diabetic peripheral neuropathy -- and reflexes (P = .033 vs placebo). Similar improvements in 2 composite scores, which include components of the neurologic exam and electrophysiologic and quantitative sensory tests, were seen in the 32-mg LY333531 group (P = .046 and 0.72 for the 2 composite scores vs placebo). Investigator global assessment of patient improvement corroborated these findings."

"...The most common side effect was diarrhea, but in general the drug was well tolerated. There were no effects on glycemic control or hepatic, renal, or bone marrow function."
:)

Result number: 153

Message Number 114958

Re: Our very own HS.com Iron Woman, WOW ! View Thread
Posted by rekha on 3/31/03 at 00:07

Yes, I opted for local....because that way I would save $600 for an anesthesiologist...( without anesthesia it cost me $3000). When they started the ossatron, I could feel intense pain in my outer ankle resonating all the way up my foot so the pod injected more block into my sural nerve....it took many shots to get foot numb...maybe that is why my outer ankle is so sore....

Previously I had it done on orby...no anesthesia...but it with low intensity shockwaves...not as intense as the ossatron.... when I woke up the next morning after ossatron...my heel was soooo sore....this threw me completely off...bcuz with orby...foot pain was no different after the 3 times I got it done....

I dont know If I qualify for an Iron woman...but I guess 5 years of PF has given me more tolerance for pain...

Result number: 154

Message Number 114928

Re: 2 days post-eswt/ pretty sore View Thread
Posted by rekha s on 3/30/03 at 13:40

ok, I do think that the anesthesia did cause soreness for some reason...the outer ankle is very sore....they had to administer more block in the sural nerve cause I could feel intense pain while under the ossatron for 6 min.

Any other patients who have had pain post ossatron please post any experiences....or any advice...I will see my dr this tues.

I am trying to walk a little today...but not much....

Result number: 155

Message Number 113062

Re: ESWT Treatment Any noticable difference View Thread
Posted by Dr. Z on 3/15/03 at 07:58

The posterior tibial block should do the trick. In addition I use a sural nerve block. We go from medial to lateral so we need the sural block.
If you go from the the plantar it could be painful for the patient due to the sound blastpath going up into the dorum. Even with low energy may have to go the top of the foot and place a line of anesethesia from dorsum to plantar.

Result number: 156
Searching file 10

Message Number 104410

Re: two injections, two different nerves View Thread
Posted by Dr. Z on 12/31/02 at 15:04

It wasn't the sural nerve that caused the pain.

Result number: 157

Message Number 104408

Re: two injections, two different nerves View Thread
Posted by Dr. A on 12/31/02 at 14:54

I have found that blocking the outside of the ankle will prevent vibrations from irritating the Sural nerve which may be uncomfortable during the procedure. This is the reason for two injections and I encourage others to try this approach. Brian, you may have experienced pain due to the fact that this outside nerve was not blocked.

Result number: 158

Message Number 103307

Re: Would like to schedule ESWT..&Ques. for Eve & Dr.Z too View Thread
Posted by Eve M. on 12/16/02 at 14:25

Hi folks,

I've just gotten back from my appointment. I thought I would give a blow-by-blow description, for those who are curious.

I got the Dornier treatment, not the Ossatron; I'd been confused about this. Apparently, with the Ossatron I would have needed to be in a hospital with more serious anesthetic, not in what was essentially rented office space with local blocks. I was very happy about this turn of events... The Dornier machine gets toted around the New England area by a guy from Superior Shockwave Treatment, which owns the machine. He hits Bowe (sp?), New Hampshire on a weekly basis, I think.

Dr. Zinsmeister gave me a heel block (two shots to the inner ankle), but the middle portion of the bottom of my foot persisted in having feeling. So he added a "PT" block (not sure what nerve that is), which worked.

We started positioning my foot on the Dornier treatment head. When we tried out the shocks, I found that the outer portion of my ankle was hurting. The assistant said this was the shocks exiting my foot; we tried a wet towel to absorb the shockwaves but it didn't work, so the doctor had to add a shot for my sural nerve. (Four shots total -- I was getting nervous by this time, and my foot looked like a pin cushion, but after that there was no more pain.)

The positioning took a little time; apparently I have a thick fascia due to my persistent problems, and a thin-diameter heel bone -- no doubt a contributor to my problems!

I had a total of 3800 shocks, at four per second (240 per minute), on a high-voltage setting (setting 7 on the machine). The doctor and the assistant mentioned that the treatments that had gotten some bad press in the Wall Street Journal were low-voltage, and therefore destined to fail.

The anesthetic and setup took about 20 minutes, and the shockwave treatment took 15-20 minutes. Overall, the whole thing was easy to do and kind of cool to observe. My foot is now a bit swollen and very warm from all the anesthetic, and the doctor said I probably won't get full feeling back for 12-24 hours.

Thanks to all for your earlier advice! Hope this is interesting to some. -Eve

Result number: 159
Searching file 9

Message Number 94542

Re: For Sharon: I have it! View Thread
Posted by June on 9/05/02 at 16:47

Hi Sharon,
The little bird was here and I have a copy of the test. As far as the wording, all I see, is negative-negative..good thing, bad thing, who the heck knows?? I will relay them, and as far as Drs. agreeing, or not, that is an understatement, I will also give you a rudown on that. Also, I am having a horrible time dealing with a 'disability".My God, how does one ever get used to the idea of 'paying' someone to do something you actually like, or even 'love' to do. Any in most cases, it would be something you could sooo much better yourself. Tonight I must hire someone to open and unload boxes, unbelievable, well so much for profit! That's MY job, and I liked it that way! Who would have ever imagined 1 foot could make this much difference in ones life.I had a LOT of life style changes with my lung disease, but the foot???? Ok here it goes. Hope I am giving the correct info you asked about.
Peronea 3.6
Tibial-med.plantar3.8
Tibial-lat.plantar 4.0
Sural 3.0
Superficial Peroneal 6.9

None of that means anything to me, just looks like really bad professional ice skating scores! Any imput? Anyone?
Drs. & dx
a few years ago Neurologist said it's from the back, he did an upper and lower nerve conduction with the elec and needles and blood work, MRI..MANY nerve blocks. No help..he sent me to Hershey Med Centr. Head of the ortho dept did MRI on the foot,and blood work, dx.. deterioated fat pads,I asked him to lypo some from my butt and put it in the foot, goodness I have plenty to spare.. not even a remote possibility, fat does not replace like that, it would turn into little rocks in the heel, gave me an over priced gel heel insert, and elevil to calm the nerves in the foot. Back to the original Neuro, he took me off the Elevil, said it wouldn't help, and it. wouldn't have been a high enough dose anyway. More nerve blocks, Hydrocone, Duragesic Patch, no help. Gave up for a short time. oh, I didn't mention, I tried all of the antiinflamitories, was allegeric to all, Celebrex, Vviox,Ultram.I have stomack ulcers, reflux, and many med. allergies.After a short time I was back to the Neuro, the pain was unberable for walkig, or standing . Got another MRI on my 'back', I tried Neurontin,Topamax,Oxycontin ,Kadien/Morphine,lots of nlood work I got an electric scooter, nothig helped, so I pitched a fit to the Neuro, he sent me to the Orthopedic surgeon, I chose one with a specialty in sports med. I forgot somewhere in there I went to the GP, he had me doing calf streatches..ouch! One more possibly helpful bit of info. When my lungs act up I am on 50 mg. of Prednisone a day,it's a very nasty drug, and has caused a big weight gain, but helps the foot a bit, 'sometimes', while taking it for my lungs.I use a strong inhaled steroid 2x every day. There it is, except for giving birth, you have it all!! Anyone at all have any thoughts.Pleeease.
Thankfully,
June

Result number: 160

Message Number 90726

Re: Pain in the Peroneal Tendon, Heel and Upper Leg View Thread
Posted by Dr. John Cozzarelli on 7/27/02 at 04:48

HI Gina:

It ould be a sural nerve entrapement or it could be a peroneal tendonitis. Are your shoes worn on the oter sole? Did they examine your walking shoes? I would start with the bascics.

Dr. John Cozzarelli

Result number: 161
Searching file 8

Message Number 89185

Re: TTS symptoms -vs- PN symptoms View Thread
Posted by Dennis B. on 7/05/02 at 15:32

My original diagnosis just over 3 years ago was for TTS and PN. Had the TTS release on the foot that was the worse of the two. No help. to make a very, very long story short, it ended up being the PN that was the problem, Vasculitic Neuropathy diagnosed via a sural nerve biopsy, but now doc thinks CIDP (see earlier post). But latest and greatest is doc, neuro, says I don't really show the "classic" signs of either, lumbar puncture for CIDP was ok. Neuro wants me to go to Mayo but says wait is too long so going to a teaching hospital here in my state, Univ. Of Nebr. Med. Center, but sounds like Sep before can get in. Bottom line on your case, not a doc of course, could be PN over-riding the TTS symptoms. AS to whether or not TTS and PN could be alike, don't know. Good luck to you and keep plugging away at your condition, you are the one that has to live with it, or get it corrected. DENNIS

Result number: 162

Message Number 88771

Re: Dont kick yourself/ narcotics arent the bad guy, Pain is View Thread
Posted by Dennis B. on 6/29/02 at 14:11

Diagnosed with TTS, Spinal Stenosis and Vasculitic Neuropathy. Vasculitis induced Neuropathy. Do a search of Vasculitic Neuropathy and/or Vasculitis and it will tell you the very grim facts of the disease. Dx was via a sural nerve biopsy in Feb. of this year. Spinal tap on Wed. to look for CIDP, also details available via a search. Both are autoimmune diseases where in the blood cells, Leukocytes and "t" cells sense a foreign matter and destroy the myelin sheath leading to the nerves. In layman's terms the blood is wacko and destroying the nerves, danger is that it may attack ANY major organ at any time. Fatality is a definite possibility. Have talked to others that have it and CAN lead to open sores on the body wherein protein and enzymes ooze out through the open sores. sounds like fun doesn't it? Anyway, that's the lowdown. Good luck to you. DENNIS. P.S. not trying to scare anyone, only trying to educate all of you as to what was initially dx as TTS for me that actually ended up being something much worse, for me the dx was made too late. TALK TO YOUR DR. ABOUT THIS!!!!!!

Result number: 163

Message Number 87055

Re: Stinging pain on ankle bone View Thread
Posted by Dr. John Cozzarelli on 6/11/02 at 05:48

Alexandra:

Again it sounds like your describing the sural nerve or describing sinus tarsi syndrome. Try icing it and Ibuprofen. If no relief see a Doc. Good luck!

Dr. John Cozzarelli

Result number: 164

Message Number 86906

Re: Stinging pain on ankle bone View Thread
Posted by Dr. John Cozzarelli on 6/10/02 at 05:51

Hi Alexandra:

Id the pain on the inside(medial) of the ankle or the outside(lateral)? If it is on the inside this may be the beginning of tarsal tunnel syndrome. If on the outside could be the Sural nerve. You could have it checked out with an NCV (Nerve Conduction Velocity) test.

Dr. John Cozzarelli

Result number: 165

Message Number 86521

Re: Severe Pain View Thread
Posted by Dr. Mitchell Kahn on 6/06/02 at 11:25

Dear Lis,

I would think that if you asked the doctor to give you a posterior tibial blocka nd sural nerve block that he would be able to accomodate you. there is no reason to suffer while getting the treatments. While Valium will help the local is superior. The anesthetic blocks will enable you to get a complete treatment and get relief more quickly than if you are only getting a amller number of shocks. speak with your podiatrist before your next treatment. Good luck.

Result number: 166

Message Number 85208

Re: Good news/bad news View Thread
Posted by Dennis B. on 5/25/02 at 15:54

Nope, never went to see a Dr. Yu, you are thinking of someone else. As to seeing a neurologist, definitely helpful as he was the one that ordered the sural nerve biopsy which led to the diagnosis of vasculitis. After the diagnosis he turned me over to my pcp who said that it was unlikely that meds would reverse what was already done and that the only hope was to deter the progression. Meds offered were long term usage of Prednisone and/or cyclophosphamide. He explained the possible side effects of both and thus far I have opted to decline using them. Prednisone is the lesser of the 2 evils. If you do a search of them on the internet you will see that LONG TERM usage of either can be pretty ugly. Good luck to you with your TTS, DENNIS

Result number: 167

Message Number 82320

Re: Question for Dennis B. about PN View Thread
Posted by Dennis B. on 5/03/02 at 13:25

After many blood tests and emg's and ncv's on the arms and legs, my neurologist recommended a sural nerve biopsy. That was performed on Feb 18th and the pathologist at the teaching hospital where the actual biopsy was performed, diagnosed vasculitic neuropathy. That is Peripheral Neuropathy caused by vasculitis. It is an autoimmune disorder wherein the T-cells and the Leuko(something or another)cells are attacking the nerves and cutting off the blood flow to them, thereby damaging/destroying them. As to treatment, long term use of Prednisone or Cyclophosphamide were offered and I declined due to the very nasty side effects of them. Since that biopsy, I have developed a tendency to drop things, run into things while walking and have tremors, hence the dr. is concerned that i may also have ALS. The "jury" is still out on that one. Generally the sural nerve biopsy is a last resort kind of thing, there are also muscle biopsy's available, as I recall reading elsewhere. You may wish to check out www.neuropathy.org. to seek answers on your condition. You sign up to access the bulletin board but if you are concerned about them contacting you, you can give them a false name and address. The only time I have been contacted by them is via a quarterly news letter sent regular mail. Good luck to you and please advise if you have any other questions, I will give you my e-mail address if you so desire. DENNIS

Result number: 168
Searching file 7

Message Number 76947

Re: OK, You TTS Guru's-Got My Third Opinion Today View Thread
Posted by Donna SL on 3/20/02 at 02:37

Yeeow Mike,

When my TTS was at it's very worse my feet, and ankles were not numb to touch like that anywhere as far I remember. Even when I was first diagnosed I went to a neurologist, and he tested them with pin pricks all over I felt it. He also did a bunch of other test with tuning forks, and other things I can't remember. I've had plenty of acupuncture, almost 10 monthts worth. I'm greatful, because it helped me so much, but I wasn't thrilled when my doctor stuck them in any part of the sole of the foot, arch, web spaces between the toes, side, and tops of ankles, top of foot, etc., because I sure did feel it. It wasn't bad in the legs, and back, but my feet were always more sensitive. Once they were in I was ok, but I either felt them, or they hurt in those areas during the insertion. He used the tiniest gauge needle too, and didn't stick them in that far.

This does sound like something else is going on, or you just have a higher pain tolerance then me. Do you have diabetes, or been diagnosed with any small fiber neuropathy? Has your back been tested? I've heard of stories where diabetics have walked around with a small nail, or tack in their foot through their shoe, and didn't even feel it.

I noticed you mentioned in a prior post that you've seen a neurologist, and physiatrist for ncv test. Did they do a full neurological work-up too? Have all forms of polyneuropathy, and other neurological problems been been completely ruled out? Have they done ncv/emg's to see if you have any nerve compressions in the lower lumbar spine? An MRI may, or may not show anything, but did you have one for the spine, plus other imaging studies? Have you gotten second, and third, opinions from other neurologist, orthopedic surgeons, physiatrist, etc. Has your vascular system been checked for any blockages, etc.? Has your auto-immune system been investigated? Also, Dennis B. who post on this board was diagnosed with vasculitic neuropathy, from a sural nerve biopsy. Even if the sural nerve was slow on the NCV, some suspician should be raised that there is something else going on besides just TTS. Did the sural nerve show any slowing on the NCV test? Any slowing of that nerve could possibly suggest some form of polyneuropathy, especially if most of the other major nerves in the foot showed slowing too. I know I had asked some of the above before, but I'm just curious if you've done most of these already.

You also mentioned previously (unless there is another Mike S) that you were weak all the way up to your thighs, and one of your feet is very sluggish, and half the control is gone. In my opinion I don't think you would experience these symptoms just from TTS. How long has this been going on?

That podiatrist seems like he did a good deed, and hopefully you'll find some more answers to what's going on before considering any TTS surgery.

Donna

Result number: 169

Message Number 76180

Re: Update View Thread
Posted by Dennis B. on 3/11/02 at 14:05

I have no copy of the ncv tests. the sural nerve biopsy was sort of a last resort as the neurologist was unable to diagnose the underlying cause. Most people that have had the nerve biopsy have not gotten results that indicate the cause, this time I was one of the lucky ones. Side effect of the biopsy is numbness, that I am told probably will not go away. It starts from the middle of the heel and goes around the outside of the foot to and including the small toe,in my case only the lower 1/2 of the toe. Thought it would help since I wouldn't feel pain in that area, but not true. Pain is in arms, left one worse than right. Oddly enough the right lower leg worse than the left one. Go figure. Have been dropping things alot. Have to concentrate when holding something. Wore my dinner a couple of weeks ago, but the dogs thought that was great!! I sincerely appreciate all of the thoughts and prayers from you folks. I'll stick around and keep you posted. Thanks again.

Result number: 170

Message Number 76124

Re: Update View Thread
Posted by Donna SL on 3/10/02 at 17:00

Dennis,

I am very sorry to hear about your diagnosis.

Do you have a copy of your original ncv test that was done prior to your surgery? I'm just curious if the sural nerve was tested at the time, along with the other nerves in the the foot, and ankle, and if any abnormalities showed up on that nerve too?

I agree with Wendy, please keep coming to the board for support, etc.

Donna

Result number: 171

Message Number 76062

Update View Thread
Posted by Dennis B. on 3/09/02 at 16:39

I've posted on here several times and the last time Wendyn made an interesting comment about how my diagnosis of TTS turned into something else. Originally was told TTS in both feet, release performed on 1 of them Feb. 07 of last year. Was also told of spinal stenosis but found out it was mild and not a probale cause. Additionally was told of Peripheral Neuropathy. Many months and doctor visits later, had a sural nerve biopsy performed on Feb.18th of this year. Results in this week, is vasculitis, specifically vasculitic neuropathy. Damage ireeversible. To impede further damage have a choice between 2 drugs which may cause damage to organs. Dr. said I can't name an organ that wouldn't be a candidate for a side effect. Just to let you all and specifically Wendyn know what has happened. Will still be around in the background of this board daily so as to see if anyone may have similar symptoms to mine and alert them accordingly so that they can mention it to their Dr. Thank you all for everything that you have done to me in the past and with that, I will "ride off into the sunset" and hope that I don't have to alert anyone to a similar condition.

Result number: 172

Message Number 73512

Re: Tingling during dorsiflexion View Thread
Posted by Dr. Zuckerman on 2/12/02 at 18:07

This could be the sural nerve. Very very rare to have an entrapement with this nerve. I would have a podiatrist take a look at this . Early treatment is the key to avoid a chronic problem

Result number: 173

Message Number 73065

some thoughts View Thread
Posted by elliott on 2/08/02 at 14:41


Your description seems to eliminate the sural nerve. Sounds more like the lateral plantar nerve. At the ball, it seems to cross over the center; maybe that's the medial plantar nerve, or else some complicated crossover effect of the lateral plantar nerve as the nerve bundles branch there.

The fact that you still have problems at the ankle probably implies there is a global TTS problem. (If you had a more distal entrapment, maybe surgery would still have a shot.) The great thing about a vein wrap is it gives one last chance at relief. The bad thing about it is it gives one last chance at relief. Hard to consider yet another release after your foot has been rewired with a vein around your nerve; not even sure it's possible.

Hard for me to give advice when the likes of Myerson and Schon have already done so. Suggest, in addition to that syringe, you get Dr. S to order some Formula 5 (if you haven't tried it yet) from that same pharmacy. It too can help for burning. Then play tactical games with these two drugs in their application. For example, if you have burning in the sole and apply a drug only to the tarsal tunnel area behind the ankle and it DOES give you some relief, that would seem to show that the source (or at least one) of your pain is the ankle.

You could try Dr. Dellon, a big-name TTS surgeon located on the floor below Drs. S & M. He has a different testing device which may zone in the source. Still think surgery is unlikely.

Nothing else to say. The implant is your decision. I'm real sorry for your plight.
---

Result number: 174

Message Number 73050

Re: Cann't stop this buring on the bottom of my foot. Anyone have some suggestions. View Thread
Posted by Henry C on 2/08/02 at 13:34

If I stay completly off my feet, I do not have any burning. Usally when I first wake up in the morning, I experience no pain at all on the bottom of my foot. It is only when I have been on my feet for a little while that I begin to feel the burning. It's usally worse when I'm standing still and gets worse as the day goes on. Even with a desk job, my foot is unbearable by the evening. When I get home I usally just lay on the couch.

If I could draw a line down the center of the bottom of my foot. the pain in the heel and in the middle of my foot is always on the outside half. It is only on the front of my foot where the toes connect that I experience the burning all across the bottom of the foot. It does not affect any of my toes. It seems to be mostly on the sole of my foot, but is also on the outside edge of my foot. Dr. Schon gave me a sural nerve block and that did not help at all.

The pain behind my ankle was medial. It felt like someone was sticking a screw driver into my foot and twisting it. As for nervy pain, that was eliminated with the releases. I did have what they call shooters that extended from my ankle up my leg. I don't believe I had any of this burning before the first release.

As for shoes, my foot seems to feel the best when I where flat boat shoes. I know these are supposed to be bad for people with TTS, but right now they seem the best for my feet.

Glad you responded Elloit, I read this message board every day and consider you one of the TTS guru's. You seem to be very knowledgable in this area. Five years ago when I was first diagnosed with this, there were not any message boards like this.

Any other information that I can provide?

Result number: 175

Message Number 72596

do you know what nerve it is? View Thread
Posted by elliott on 2/04/02 at 21:41


Outside is not regular tarsal tunnel. Was it sural? Superficial peroneal or one of its branches (which one)? Doc better know or you have the wrong doc. What kind of doc is he and what is his background? Sorry for your problems.

--

Result number: 176

Message Number 72193

Re: Mike and Dennis View Thread
Posted by Dennis B. on 2/01/02 at 13:55

Yes, I had a poor outcome from the surgery. At the time that the neurologist diagnosed the TTS he also indicated that I had the Peripheral Neuropathy, however we "focused" on the TTS. As mentioned earlier, the PN has now spread to the hands and arms as well as up the legs. So, I really feel that the PN is the over-riding condition in my case, and am probably not in a position to judge the TTS release as to the degree of success. As a side note, I am scheduled for a sural nerve biopsy on the 18th of this month at a teaching hospital here in Nebraska. It is to be performed on the foot that did not have the TTS release. I try not to comment on this board because I don't want to create any confusion between the two conditions since I can't define the differences myself. However, I am a daily reader of the board and find all of the inputs valuable to me.

Result number: 177

Message Number 71962

Re: DORNIER PLANTAR TREATMENTS View Thread
Posted by DR Zuckerman on 1/30/02 at 15:01

I have found that using no anesthesia or posterior/sural nerve block does just fine. The dornier machine can be both a multiple low energy ESWT or one high energy. treatment From all the research I have done I can't find any literature stating that you need extremely high ESWT energy. We treat at .6mj/mm. . The dornier is .5mj/mm at F2 I am not sure of the ossatron treatment in mj/mm but my guess is over one joules. Can anyone confirm this for me.

So with the dornier you have the option it appears to have one of two kinds of ESWT treatments. One treatment sessions or three treatments sessions

Pretty neat.We are moving forward

Result number: 178

Message Number 71961

Re: DORNIER PLANTAR TREATMENTS View Thread
Posted by DR Zuckerman on 1/30/02 at 15:01

I have found that using no anesthesia or posterior/sural nerve block does just fine. The dornier machine can be both a multiple low energy ESWT or one high energy. treatment From all the research I have done I can't find any literature stating that you need extremely high ESWT energy. We treat at .6mj/mm. . The dornier is .5mj/mm at F2 I am not sure of the ossatron treatment in mj/mm but my guess is over one joules. Can anyone confirm this for me.

So with the dornier you have the option it appears to have one of two kinds of ESWT treatments. One treatment sessions or three treatments sessions

Pretty neat.We are moving forward

Result number: 179
Searching file 6

Message Number 64788

Reply to Matt L (Scott R please also read) View Thread
Posted by elliott on 11/14/01 at 15:02

Hope this goes through. (Scott R, I get the feeling you think everything is OK here; wanted to let you know I tried to respond to a post earlier today on another of these boards and it became a new threadstarting post instead. In addition, when you click on Message Boards, you can't access the sites by clicking on the site's name at left, only the index to the right. I think many are refraining from posting until the problems are sorted out. Thanks.)

You've seemed pretty well-informed, so if I suggest things you already thought of or eliminated, bear with me. Can you describe your pain more precisely? Is it for sure nervy? Anything radiating into the toes?

If it's just the lateral plantar nerve (LPN), the pain on the lateral side should be more forward, not at the outer ankle, since the LPN just doesn't run there. Of course, there are other major nerves on that side (sural, peroneal). First suggestion is to get a(nother?) nerve conduction test. If it's clearly one or the other nerve, it might show elevated readings for that nerve only.

Result number: 180

Message Number 62361

Re: 1month post op open plantar fascia release-now cuboid syndrome?? View Thread
Posted by tim on 10/06/01 at 05:56

Cuboid Syndrome has never been proven to actualy exist. The cuboid articlulates with several other bones and due to its shape and anatomical attachments it is very,very stable. The planatarfascia is not a major stabiliser of the cuboid it is more likely that you may have sustained another injury possibly to the peroneal tendons, sural nerve or many other structures present.

Result number: 181
Searching file 5

Message Number 59159

Re: Hamstrings, sciatic nerve, patience, yoga - Glenn View Thread
Posted by Julie on 9/05/01 at 19:31


Glenn: thoughts on your last paragraph first. I agree with your diagnosis of the hamstrings, and yes, I do think that lengthening them is part of the PF-treatment picture. I've thought for a while that it is better and more effective to stretch them individually, and not at the same time as the gastro/soleus/achilles; and thanks to this discussion I now think it is also safer.

My theory about your tingling/burning was that the stretching of the sciatic nerve along its full length was setting up some kind of response in the soles of your feet. The sciatic nerve has several branches: it divides about 2/3 of the way down the thigh into the tibial nerve and the common peroneal nerve. The latter divides into the deep peroneal and superficial peroneal branches. Other branches and sub-branches of the sciatic nerve are the sural, medial calcanean, medial plantar and lateral plantar nerves. The last three, and the deep peroneal, terminate in the foot. So, if there is adverse neural tension anywhere along that nerve complex, which there probably is if the whole muscle complex of hamstrings/gastro/soleus/achilles is tight, I would not be surprised if there was tingling and burning at the termini when the whole complex was being stretched at once. But, when you don't dorsiflex the foot, you're not only taking the gastro/soleus/achilles out of the equation, you're taking those lower branches of the SN out of it too.

I'm enjoying these speculations during a sleepless night (my husband has a painful earache which is keeping us both awake, so I'm trying to do something useful with the time). It's interesting to me to think about it, because it fits in well with my discovery that it's more effective to stretch the hamstrings and calf muscles individually than to work on them together. If we can also avoid nerve irritation by isolating the stretches for those two muscle groups, that's another good reason to do so.

I particularly meant 'the long haul', but the other is true too. I guess we are both about the same age - I know you have grandchildren (I don't, but I'm old enough to). One of the things I appreciate about you is your patience for the long haul, which is always implicit in your posts. You're prepared to work towards goals, but you're also willing for things to take the time they take, and to enjoy the journey. I remember clearly when my own feeling about PF shifted: after the first few weeks of disbelief and sadness, I got the measure of it, knew it was going to take time and that I had to work at it, and kind of buckled down to it as just one more of life's challenges, knowing it was going to take however long it was going to take. There was something both satifying and liberating in that - not just in the eventual results, but in feeling like that. Does that sound strange to you? I don't think so.

Since you found heelspurs.com you've made a truly important contribution to people's thinking here: I mean about the value of determining goals, working systematically towards them, and measuring progress. I hope people take it on board, because if they do it is certain to affect their progress towards healing. I hope too that you find frequent occasions to reiterate it, because people come and go, and there are always new ones.

If you get interested in yoga, you don't have to wait till you're on your feet. There's a great deal you can do sitting down, on your own. There are all the exercises for the joints that I've mentioned, and a great variety of exercises for the spine, neck and shoulders, as well as breathing, relaxation and meditation exercises. Perhaps you'd like to have a look at my 'Office Yoga' - I hate sounding as though I'm 'selling' my book, but you might like it. The UK/US edition is out of print now, but there are used copies available from abe books, and an Indian edition published by Motilal Banarsidass that turns up on obscure websites.

I feel sure that you would enjoy yoga.

Now I'm going to see if my husband is asleep so I can go to sleep too. Good night: nice talking to you.

Julie

Result number: 182

Message Number 57342

Re: plantar fasciotomy post op pain - question for doc and other fasciotomy patients View Thread
Posted by Ed Davis, DPM on 8/20/01 at 19:50

I am not sure why you would have a needle mark in one of your toes if the surgery you had was a plantar fascial release.

The anesthesiologist generally will start the IV in your arm and provide you with sedation while the surgeon numbs your foot (usually but not always). It is unlikely but not impossible that the numbing of your foot caused the problem.

A more likely scenario is that the lateral plantar nerve was injured during the surgery. If it was just bruised, it will recover. If nicked or cut, recovery is less likely. Is the toe next to the little toe numb, particularly on the side facing the little toe? Is the numb spot just on the outer edge of your foot or on the outer portion of the sole (bottom) of your foot. If just the outer edge, not the sole, is numb and just the outer portion of the little toe is numb, then the sural nerve as opposed to the lateral plantar nerve would be involved. The sural nerve would be somewhat more likely to be injured by local anesthesia or even by an ankle tourniquet (use to stop bleeding) in surgery.
Ed

Result number: 183

Message Number 57034

Re: Haglunds surgery View Thread
Posted by Dr. Zuckerman on 8/17/01 at 18:45

Should start to feel better. Some time a nerve called the sural nerve healed into the incision .Need to find this out. Also need physical therapy to the foot and ankle working again

Result number: 184

Message Number 56227

RE: NCV View Thread
Posted by elliott on 8/10/01 at 17:20

Yes, NCV on both feet before first surgery. The numbers on the right foot to be operated on were very high (it was rare to see such high numbers), and numbers for left foot, which had just started to bother me, were certainly lower but much higher than normal (upper 6's, I believe; I can check if you like). A week or two after that first test, left foot broke out in tingling and nerve irritation I still have to this day. Other nerves such as sural normal. For awhile I did have a feeling of sensory loss in deep peroneal on lateral side of knee, but this is minimal or gone, and to unfortunately comlicate things, I now have right sciatica due to a bulging disc. But all in all, limited to abnormal medial and lateral plantar nerves. Regarding PTTD, an MRI pre-op first (right) foot only showed posterior tibial tenosynovitis, although no visible weakness in foot (e.g. through pushing medially against surgeon's hand or through single heel rise test) was felt or observed. In addition to TTS release, surgeon performed posterior tibial tenosynovectomy (this after telling me that if I didn't do it now, I might need it later, and this after promising me it wouldn't weakne my foot and I could go back to running). New big-name otho big in TTS looked at post-op MRI which did not show anything obvious, and he is not sure what it is, but has not ruled out scar tissue nor neurological disorder. I am sure I have further torn scar tissue since then as well. My foot often feels like it's near collapse after taking a step, mostly right under the ankle, but also higher up and also forward medially. I didn't have this before surgery.

Result number: 185

Message Number 56212

Re: what's your view on the flip-side issue of NCV? View Thread
Posted by Ed Davis, DPM on 8/10/01 at hrmin

Did you have both NCVs on both feet before the first surgery? What type of symptoms did you experience both before and after surgery?

It would be suspicious if both feet had same distal latencies pre-operatively. How about testing of other nerves, eg. sural nerve? I would be curious of other nerves in your feet are showing increased latencies or if the post. tib. nerves are selectively prolonged. If multiple nerves in addition to the post. tib. nerve are showing similar findings, then suspect neuropathy vs. TTS. If selective post. tib. nerve increased latencies then TTS is more probable.

What do you mean by your right foot being near collapse? I will wait for your answer but jump forward a bit---do you have diagnosis of posterior tibial deficiency? (A swollen posterior tibial tendon-tendon that hold the arch up--can place pressure on the post tibial nerve.
Ed

Result number: 186

Message Number 54378

Re: severe pain 2 yrs after trauma View Thread
Posted by Dr. Zuckerman on 7/26/01 at 14:33

The sural nerve runs right around that area. That nerve can be removed and or injections with alcohol sclerotic agents. Now for the limitation of movement that can be a tough one at this stage

Result number: 187
Searching file 4

Message Number 48064

Re: TTS pain laterally View Thread
Posted by Donna SL on 5/17/01 at 08:49

Matt,

Did your doc check out your peroneal nerves/tendon? Problems there can cause lateral pain. Also, the lateral recurrent calcaneal nerve which I think is a branch from the Sural nerve could cause lateral pain if it was entrapped.

Result number: 188

Message Number 46102

Re: types of anesthesia View Thread
Posted by Dr. Zuckerman on 4/28/01 at 21:51

Wow,

Great summary:

MAC is what is used in most foot surgery. MAC then local infiltration and or field block I believe that this is what is used for Ossatron

In addition a field block/ ankle block is what also can be used for the ossatron and is what I have used for some time for the orbasone. This is what i used in your specific case.

The field block consists of using 1% lidocaine plain around the posterior tibial nerve and in some cases the sural nerve. I believe that some doctors will use 2% lidocaine plain. This may give the doctor more lack of movement in the extremity.

I have also used demeral/visteral IM with field block for orbasone and for in-office foot surgery.

Result number: 189

Message Number 45122

Re: Nerve entrapment and ESWT View Thread
Posted by Donna SL on 4/19/01 at 18:40

Hi Dr Reid,

I just posted a lot of information in the treatment section on the board on ART yesterday. Look through the whole thread, because I kept adding info. "Look under ART is Miraculous". I think this is an incredible treatment to try. I wish I had known about it sooner.

If you could tell anything from the results of the NCV test below, I would appreciate it.

I had normal H-reflexes that rules out S1 radiculopathy. The normal sural sensory studies, and the normal medial plantar motor studies rules out most forms of polyneuropathy.

The results for the MS of the lateral plantar nerves were 6.8 for the left, 7.8 for the right, and the norm is less than (6.3).

The results for the MS of the Inferior calcaneal nerves were 5.8 for the left, and 7.1 for the right, and the norms are less than (5.1).

Amp testing was normal except for left ICN.

In the Summary is basically says study of motor fibers demonstrates slowing suggestive of demyelination bilaterally in the Lateral planter nerves. Evoked muscle amplitudes both normal. The inferior calcaneal nerves also showed slowing on the motor fiber test bilaterally. Also evoked muscle amplitude on the left ICN is dereased suggesting motor axon injury.

Also it said mixed sensory potentials could not be obtained for either the medial or lateral plantar nerves, on either side, and this could either represent a conduction block, or may be due to technical factors. (I'm
not quoting the report exactly as written. There's around 5 pages). Can nerves heal? Do you think there are any chances that with conservative treatment like ART, and any other forms of PT for this area, that this could get better? I also have an appointment around a week from now with a neurologist.

Are the above results considered advanced? Does cortizone work at this level?, and would ESWT not? Have you seen many people require surgery for this? Have you prescribed any other forms of PT for this area?

The only suggestions I've been given by the physiatrist whe did the testing was to stick with the ART, and swim or walk in the pool, which I'm going to do later tonight. I was using a Nordick track, but was told to stop, but that the recumbent bike was OK.

I know from my symptoms that this has been going on for quite a while. It wasn't properly diagnosed for way over a year by my treating pod. He just kept trying different orthotics which didn't help. I had PT, but not in that area. He was out of town when I was tested, but has contacted me, and wants to see me when he gets back. The second pod who I sought a second opinion from, and diagnosed me with this condition, suggested cortisone, or surgery.

Is this the same as tarsal tunnel syndrome? I don't have any tingling in my ankle area. Most of the pain is in the arches and the heels, and increases with activity.

Sorry for the long post.

Donna

Result number: 190

Message Number 44849

Re: One year one month post-ESWT: Pain free View Thread
Posted by Dr. Zuckerman on 4/17/01 at 15:10

Hi,

I was using a local anesthetic (posterior tibial nerve block, sural nerve block, and some local infiltration into the medial tubercle treatment area.

The amount of pulses were 3000. This is pretty standard for me.

Yesterday did a patient without any local at all. 18kv 3000 pulses. He is doing well today has pain taking motrin , but working as a salesmen.

Result number: 191

Message Number 44662

DR. Z. Re: Plantar Fascia or Achilles ? Check for nerve entrapment View Thread
Posted by Donna SL on 4/15/01 at 10:11

Hi Dr. Z,

I know you don't have a crystal ball, but do think think that I may need surgery to "un-entrap" the nerves? I have it in both feet. They also tested for polyneuropathy, and ruled out that out, but I'm still going to see a neurologist. A physiatrist did the testing himself. Also I had normal H-reflexes that rules out S1 radiculopathy. The sural nerves, and the medial plantar nerves were normal on testing.

The results for the lateral plantar nerves were 6.8 for the left, 7.8 for the right, and the norm is less than (6.3).

The results for the Inferior calcaneal nerves were 5.8 for the left, and 7.1 for the right, and the norms are less than (5.1).

The pod didn't try any cortisone shots yet, because he wanted to make sure I wasn't having any more test like an emg, etc, because he said this would affect the results. He still insists on doing a diagnostic shot first. As far as Plantar fasciitis he said he thinks I might have, or had PF, too but wasn't sure, except for a positive bone scan last May.

In the Nerve Conduction test report it says suggestion of nerve demyelination in both feet in the above nerves. (motor conduction studies) Also says some motor axom injury on the left. It also said mixed sensory potentials could not be obtained for either the medial or lateral plantar nerves, on either side, and this could either represent a conduction block, or may be due to technical factors. (I'm not quoting the report exactly as written. There's around 5 pages). Can nerves heal? Do you think there are any chances that with conservative treatment like ART, and any other forms of PT for this area, that this could get better?

Have you treated anyone conservatively with this condition, that resolved without surgery? What treatments have you done? Also,is this the same as tarsal tunnel syndrome? The pod kept talking about tarsal tunnel surgery.

I was starting to see some improvement with the ART, but the test seemed to inflame the nerves again this week, but they are calming down some what. The physiatrist said I should give the ART a chance, before I get a cortizone shot. Do you think I should get a shot sooner?

Sorry about all these questions at once, but I am so surprised, and concerned about this diagnosis.

Donna

Result number: 192

Message Number 41477

Re: Overweight and subway View Thread
Posted by Celia on 3/14/01 at 14:31

My feet burn on occasion and when that happens, I ice. Especially at night when I'm ready for bed. That's the last thing I do. In the mornings, I also feel the tear along the side of my feet. I've been checked to see how my nerves are doing because they think that it's the sural nerve that passes by the side of your knee and down to the side of your ankle and feet. I'm now being treated with cortizone, but they apply it on two patches and the patches have these little metal things that alligator clips clip on to and then they run this little electric machine through those clips. It kills! No relief just yet. Anyway, blah, blah, blah. I'm ready to head south of the border for vitamin B-12 shots!!!

Result number: 193
Searching file 2

Message Number 27266

Re: weird nerve thing going on...Help Dr's or anyone! View Thread
Posted by Dr. Biehler on 9/05/00 at 14:35

Wendyn gave a good answer. The S2 nerve (very low back) is the nerve that effects this part of the body. It is called the sural nerve by the time it reaches the ankle. It sounds like what you are getting are symptoms of nerve compression somewhere along the nerve.This is called neuropraxia and it can even be in the back effecting the ankle. Dr. BiehlerResult number: 194

Message Number 26071
Re: heel pain View Thread
Posted by Dr. Biehler on 8/22/00 at 21:45

I have never read about it in books but I diagnose it by following the path of the sural nerve and the discription of the pain or parathesas. I find that after a posterior tendon rupture or chronic flat foot with tibia vera, there comes a time when the outer edge of the foot starts to hurt. In these patients their ankle bone seems to be resting on their heel bone, In every case the pain went a way after I posted the medial side of their foot. What this does is to take enough pressure off the nerve for it to function normal again. I start with 1/8" felt. Sometimes that is all that is needed. Dr. BiehlerResult number: 195

Message Number 26024
Re: heel pain View Thread
Posted by Dr. Biehler on 8/22/00 at 12:36

Pain on the outside of the heel can be caused by standing too long if the heel bone is in varus or there is a bony build up on the out side of the heel bone. Both of these situations cause the bodies weight to be spred over an area not wide enough to disperse the weight. On the other hand, if you are extremly flat footed, it could be a sural nerve entrapment between the ankle and the heel. Dr. BiehlerResult number: 196

Message Number 22481
Re: What is different and what is the same with the ossatron-orbasone. (long) View Thread
Posted by Dr. Zuckerman on 6/27/00 at 09:58

It is simple!!!

I have no idea what you are talking about anesthesia. The patients are getting a sural nerve block, Posterior tibial nerve block. There is no local block better for this. The next step would be iv sedation or im sedation. It you won't or can't give me the joules at the focal point and mpa at the focal point, its ok. i would like to know but if you don't know that ok. Don't worry about. it
posted to the eswt board . . . keyword: Result number: 197
Searching file 1

Message Number 15608

Re: shots: to wendy, laurie and tts or atypical pf to Alan to Wendy
Posted by Laurie R on 2/08/00 at 00:00

Hi Wendy,I am still trying to figuare this out maybe you can help me,ok you say that many people have said you have TTS but they are not sure? I have been also told maybe I have TTS as well as PF my question is why can't any of these doctors diagose us properly? We all have had x-rays we all had EMG ,what is next,We all have the symptoms of it but the doctors have not come out right and say this is what you have.I get so tired of trying to figuare all this out.I do think the nerve I have entraped in my foot is called the Medail Sural Cutaneas (spelling)sorry.Thats what I was told.My Podiatrist did say next visit that he wants to try the shots.I still have to think about it because of what happened last week with the Neurologist when he put the needles in my foot talk about pain...Laurie R thanks WendyResult number: 198

Message Number 15372
Re: Duane E and orthotripsy
Posted by Dr.David Zuckerman on 2/01/00 at 00:00

I will try to answer your questions. You need to block the foot including the Posterior nerve, Sural nerve and the posterior calcaneal nerve. In addition local infiltration the focal point which is the medial tubercle where the medial band of the plantar facsia inserts. I am using 18 kv with 3000 shock wave at the initial session without any pain from the patient. Down the road I feel the key is increase power and increas shocks. I need to have more experience with this. I spoke with John W today and we both agree about power.
I believe that the failures are due to alot of things but I hate to type and my fingers are getting tire. This should be a start for you
The machine as you know is called the Orbasone the manufacture is MIP
they are from Germany, Norland medical is the United States company that is marketing the Orbasone is Norland Medical. John W told it's a
good machine but he feels that Norland medical is misleading the FDA
It could be I really don't understand of the FDA process.I do know it does cost alot of money, so John W has a right to be pissed off.
Anyway we need to have orthotripsy in the United States . I see this procedure in the future being performed in a surgical center with IV
MAC anesthesia so that even that they patient's experience will be
better. So far the way I block the foot No pain at 18kv 3000 shocks.
I just had a patient come in today that i perform EWST last week> Some subjective pain when he clears the snow for one hour. No pain
on deep palpation. It was a great feeling to see this. I own John W
a thank you. He was the first person that I talked to at Healthronic's
He directed my to Canada.
PS.I didn't proof read this I am sitting at a lap top and my hands are tired. Sorry if there area spelling, grammitical mistakes.Result number: 199
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