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wendyn FAQ on TTS

Posted by Scott R on 8/06/00 at 07:53 (030389)

Wendyn wants me to place the following on the website to help those with TTS. She mentioned that Dr. Z and Nancy could review and edit it. Nancy might also like to try to edit a section of my 'book' to see what kind of improvements can be made.

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TTS
Exactly what is it?

Tarsal Tunnel Syndrome (TTS) is also known as Posterior Tibial Nerve Neuralgia. TTS is a compression syndrome of the tibial nerve within the Tarsal Tunnel. In other words, it's a collection of symptoms that occur because the nerve in this area is being irritated.

What is the Tarsal Tunnel?

This tunnel is found along the inner leg behind the medial malleolus (bump on the inside of the ankle). The posterior tibial nerve, a major artery, veins, and tendons travel in a bundle along this pathway, through the Tarsal Tunnel. In the tunnel, the nerve splits into three different paths. One nerve (calcaneal) continues to the heel, the other two (medial and lateral plantar nerves) continue on to the bottom of the foot. The Tarsal Tunnel is made up of bone on the inside and the flexor retinaculum (a tough band) on the outside.

What's happening in the tunnel and why does it hurt so much?

Inflammation or swelling can occur within this tunnel for a number of reasons. The flexor retinaculum (that tough band on the outside) doesn't stretch much, so increased pressure will eventually cause compression on the nerve within the tunnel. As pressure increases on the nerves, the blood flow decreases. Nerves respond with altered sensations like tingling and numbness. Fluid collects in the foot when standing and walking and this makes the condition worse. As small muscles lose their nerve supply they can create a crampy feeling.

What are some of the symptoms?

- Painful/tingling in and around ankles - sometimes toes
- Swelling of the feet
- Painful burning, tingling or numb sensations in the lower legs
- The pain worsens and spreads after standing for long periods
- Pain is worse with activity and is relieved by rest
- Weakness
- Electric shock sensations
- Pain radiating up into the leg, arch, heel, and toes
- Pain can occur and persist at rest
- Typically the heels are spared (conflicting information on this)
- Hot/cold sensations in the feet
- Feeling as though the feet don't have enough padding
- Pain while driving
- Throbbing
- Pain along the Posterior Tibial nerve path
- Burning sensation on the bottom of foot, radiating up
- Parasthesia (pins and needles)
- Dysaesthesia (abnormal pain)
- Hyperaesthesia (increased sensation)
- Tinel's sign

What is Tinel's sign?


This is a tingling electric shock sensation that occurs when you tap over an affected nerve. Your doctor may tap over the TT area to see if it elicits these shocks. The sensation usually travels into the foot but can also travel up the inner leg as well.

I don't have all the symptoms listed - does that mean I don't have TTS?


This is a list of symptoms that can occur with TTS, patients don't necessarily have all of them. Only your doctor can determine whether or not you actually have this condition.


How is Tarsal Tunnel Syndrome diagnosed?

Often a doctor will arrive at a diagnosis based on the patient's symptoms, and after ruling out other possibilities. There are many foot conditions that may have symptoms similar to those experienced with TTS. Your doctor will want to rule out things like plantar faciitis, stress fractures, or tendonitis. Sometimes these other foot problems can exist with TTS.

Some systemic conditions can cause foot pain. Your doctor may order blood work including tests for low vitamin B12 (this can cause peripheral neuropathy), diabetes, thyroid, lupus, and rheumatoid arthritis. Along with a complete exam and history, the doctor may order x-rays and/or a bone scan or nerve conduction testing. Sometimes an MRI is done to get a better look at what is happening in the tunnel, and to check for possible masses causing compression.


What is Nerve Conduction Testing? Does it hurt?

A neurologist often (but not always) administers nerve conduction tests. During this test, electrodes are placed at various spots along the nerves in the legs and feet. Both sensory and motor nerves are tested at various locations. Electrical impulses are sent through the nerve and the speed and intensity at which they travel is measured. If there is compression in the tunnel, this can be confirmed and pin pointed with this test. Many doctors do not feel that this test is necessarily a reliable way to rule out TTS. It seems to be very possible to have TTS without a positive nerve conduction test. Some doctors feel that this test is unnecessary and often not helpful with diagnosis.

Whether or not it hurts seems to depend on a number of factors. There is a component to the test that isn't always done - it involves inserting needles under the skin. The universal opinion is that this causes substantial pain. Ask your doctor if this part of the test will be required.

For the electrodes themselves, the degree of pain experienced seems to depend on the type of machine used (there are different kinds), the skill of the technician, as well as the stress and pain threshold level of the patient. Try to relax as much as possible during the test, and discuss any concerns you have with the technician or your doctor.

(Writer's note: I've had this test twice on both my hands and feet - and I would describe it as mildly uncomfortable - not painful but I did not have the needles either).


What causes TTS?

It can be difficult to determine the exact cause of Tarsal Tunnel Syndrome, however it is important to try to determine the source of the problem. Treatment and the potential outcome of the treatment may depend on the cause. Anything that creates pressure in the Tarsal Tunnel can cause TTS. This would include benign tumors or cysts, bone spurs, inflammation of the tendon sheath, nerve ganglions, or swelling from a broken or sprained ankle. Systemic conditions that may cause peripheral neuropathy (defined later) also make damage or irritation of the nerve more likely. These systemic conditions would include alcoholism, diabetes, rheumatoid arthritis, or thyroid disorders. Varicose veins (that may or may not be visible) can also cause compression of the nerve.

TTS can be due to repetitive stress injury and it's more common in athletes, active people, or individuals that stand a lot. The more active someone is, the more prone the tendons are to swell and the nerve is to stretch. This increases the risk. It can also follow sudden activity in a previously inactive person.

People with flat feet may have increased pressure in the TT region and this can cause nerve compression. The short Achilles' tendons that go with flat feet can cause more stress on the foot and the TT area.

Lower back problems can cause symptoms - specifically problems with the L4, L5 and S1 regions.

My doctor wrote down 'Peripheral Neuropathy' what's that?

Don't let this scare you too much. Peripheral means outer or surrounding, and neuropathy is basically a problem with the nerves. So, peripheral neuropathy is a problem with the outer nerves (like in the hands and feet). There are many different types of neuropathies, with carpal tunnel syndrome and tarsal tunnel syndrome being just two. Neuropathies can be caused by many different things including nutritional imbalances, drugs, or infection. In the case of TTS or CTS, it's caused by compression of the nerve. It is important for your doctor to determine what's causing your symptoms. He/she will need to determine what is causing your neuropathy in order to know the best way to treat it.

How can it be treated?

Treatment options will depend on the cause of TTS, Systemic problems like arthritis, lupus, alcoholism or low thyroid need to be controlled. Your doctor will need to ensure that the symptoms are not being caused by lower back problems. Generally TTS treatment options will include the following:

- Rest
This is the first and most important step, especially if an underlying structural problem, or overuse is causing the symptoms. Recovery can take a long time, and it may be necessary to really restrict activity for a while.

- Anti Inflammatory Medication

Doctors may prescribe one of many anti-inflammatories. Sometimes it may be necessary to try different kinds in an effort to find one that is most effective with the least side effects.


- Orthotics

Custom made orthotics can be helpful if the cause is an underlying structural problem. Orthotics are usually made by a podiatrist, physiotherapist or pedorthotist. Some medical insurance providers will cover prescription orthotics. Casts are made many different ways - and orthotics can be made from several different types of materials. Some orthotics are three quarter length, some go the length of the shoe. Itt can take several adjustments or recasting to ensure a proper fit. (Personal note: I've talked to many TTS sufferers (including myself) who were using custom made orthotics when they developed TTS. Ensure your orthotics are properly made and fitted. The rigid plastic kind seem to be the most likely to cause problems.)


- Cortisone injections

Doctors may administer a cortisone injection into the TT area. This can be used to control pain and swelling and to help confirm a diagnosis of TTS. Injections should be used judiciously, there is some risk of rupture of the Posterior Tibial Tendon.

- Acupuncture

Acupuncture administered by a licensed professional can be helpful in controlling pain syndromes and in stimulating the body's natural ability to heal. Risks are minimal providing the practitioner is properly trained and certified.


Re: wendyn FAQ on TTS

john h on 8/06/00 at 19:45 (024780)

having had a tts release and all the testing that goes with it my doctor never mentioned an MRI. i really doubt that an mri would show tts unless you had a bone pressing into the area. such things a vericose veins would probably not show up on an mri and they can press on nerves in the tarsal tunnel area. even with a diagnosis of tts there is no guarantee that is what is causing your pain if your pain is where the fascia attaches to the heel. my doctor (foot and ankle board certifed orthopedic surgeon) said the tts surgery is really a hit or miss deal. no way to know for sure.

Re: wendyn FAQ on TTS

Dr. Zuckerman on 8/06/00 at 20:07 (024782)

The only thing that an mri may rule out is that you have a tear or injury to the posterior tibial tendon. It will also rule out any ligament damage to the ankle and any joint surface damage to the ankle. Tarsal tunnel can be just another part of the initial problem such as a tear of any of the collateral ligament that could happen with ankle injury or a tear of the deltoid ligament . I would get an mri before i would do any type of tarsal tunnel surgery.

Re: wendyn FAQ on TTS

wendyn on 8/06/00 at 22:23 (024789)

Thanks for your feedback folks. This is by no means a finished product - I still want to add a fair bit about the surgery etc.

With the MRI - I don't think it's a standard test to rule out or confirm TTS - but as Dr Z said, it can be used to find out just what else is going on (this is why I'm having one done). I will go back through my notes though and clarify the comments about the MRI and why it may or may not be done. I can't recall off the top of my head where I saw it mentioned or how often.

Keep the comments coming...

I spent a lot of time researching TTS and found that most places carry just a tiny little bit of info. It's hard to get the whole picture - so I'd like to condense it all for other people going through this.


Re: wendyn FAQ on TTS

alan k on 8/06/00 at 22:27 (024790)

thanks for doing this wendy.

I know how much work it is.

alan k


Re: wendyn FAQ on TTS

JudyS on 8/06/00 at 23:15 (024796)

Wendy - I haven't been following this thread closely but I thought I might let you know that my husband developed TTS after his Plantar release surgery........and he did have an MRI which confirmed the TTS. Eventually orthotics took care of the TTS.

Re: wendyn FAQ on TTS -- TO SCOTT

Nancy S. on 8/07/00 at 18:25 (024851)

Scott, I'm just back from 3 days away for a change of scene at my sister's house.
How come when I'm home for the weekend, hardly anyone posts, and after this weekend I come home and find a million. I'm overwhelmed.
But I think Wendy's contribution is important, and I will see if I can do any editing on the webtv contraption (after a day or two of coming down to earth here.). Any editing would probably entail consistency, punctuation, etc. -- nothing major -- Wendy writes very well. I would rely on others more knowledgeable about TTS, such as Alan, for content challenges.
I would be most happy to put my editorial hand to any part of the PF Book that you would like reviewed. Do you have any particular section in mind? Do you I need a printout?
--Nancy



Re: wendyn FAQ on TTS

Nancy S. on 8/08/00 at 02:17 (024870)

Judy, exactly what kind of orthotics cured John S.'s TTS? It seems to be believed that hard, rigid orthotics can actually be a cause of TTS (not to mention that a number of us feel they can exacerbate PF), so do you know what kind?
--Nancy

Re: wendyn FAQ on TTS

JudyS on 8/08/00 at 11:39 (024896)

Hi Nancy - welcome home! The orthotic my John has, believe it or not, is a 1/2 length, HARD plastic thing in an off-white color. I can't believe anyone could tolerate that! But you know, just like a man, he only wears the one on the formerly affected foot! He refuses to wear both because, of course, both feet didn't hurt! Now, you may quote me here, they will!

Re: wendyn FAQ on TTS

alan k on 8/06/00 at 10:13 (030387)

It is my understanding that an MRI cannot adequately access the causes of tarsal tunnel syndrome. That might be made more clear in the wording about MRI, pending confirmation from others.

alan k


Re: wendyn FAQ on TTS

john h on 8/06/00 at 19:45 (024780)

having had a tts release and all the testing that goes with it my doctor never mentioned an MRI. i really doubt that an mri would show tts unless you had a bone pressing into the area. such things a vericose veins would probably not show up on an mri and they can press on nerves in the tarsal tunnel area. even with a diagnosis of tts there is no guarantee that is what is causing your pain if your pain is where the fascia attaches to the heel. my doctor (foot and ankle board certifed orthopedic surgeon) said the tts surgery is really a hit or miss deal. no way to know for sure.

Re: wendyn FAQ on TTS

Dr. Zuckerman on 8/06/00 at 20:07 (024782)

The only thing that an mri may rule out is that you have a tear or injury to the posterior tibial tendon. It will also rule out any ligament damage to the ankle and any joint surface damage to the ankle. Tarsal tunnel can be just another part of the initial problem such as a tear of any of the collateral ligament that could happen with ankle injury or a tear of the deltoid ligament . I would get an mri before i would do any type of tarsal tunnel surgery.

Re: wendyn FAQ on TTS

wendyn on 8/06/00 at 22:23 (024789)

Thanks for your feedback folks. This is by no means a finished product - I still want to add a fair bit about the surgery etc.

With the MRI - I don't think it's a standard test to rule out or confirm TTS - but as Dr Z said, it can be used to find out just what else is going on (this is why I'm having one done). I will go back through my notes though and clarify the comments about the MRI and why it may or may not be done. I can't recall off the top of my head where I saw it mentioned or how often.

Keep the comments coming...

I spent a lot of time researching TTS and found that most places carry just a tiny little bit of info. It's hard to get the whole picture - so I'd like to condense it all for other people going through this.


Re: wendyn FAQ on TTS

alan k on 8/06/00 at 22:27 (024790)

thanks for doing this wendy.

I know how much work it is.

alan k


Re: wendyn FAQ on TTS

JudyS on 8/06/00 at 23:15 (024796)

Wendy - I haven't been following this thread closely but I thought I might let you know that my husband developed TTS after his Plantar release surgery........and he did have an MRI which confirmed the TTS. Eventually orthotics took care of the TTS.

Re: wendyn FAQ on TTS -- TO SCOTT

Nancy S. on 8/07/00 at 18:25 (024851)

Scott, I'm just back from 3 days away for a change of scene at my sister's house.
How come when I'm home for the weekend, hardly anyone posts, and after this weekend I come home and find a million. I'm overwhelmed.
But I think Wendy's contribution is important, and I will see if I can do any editing on the webtv contraption (after a day or two of coming down to earth here.). Any editing would probably entail consistency, punctuation, etc. -- nothing major -- Wendy writes very well. I would rely on others more knowledgeable about TTS, such as Alan, for content challenges.
I would be most happy to put my editorial hand to any part of the PF Book that you would like reviewed. Do you have any particular section in mind? Do you I need a printout?
--Nancy



Re: wendyn FAQ on TTS

Nancy S. on 8/08/00 at 02:17 (024870)

Judy, exactly what kind of orthotics cured John S.'s TTS? It seems to be believed that hard, rigid orthotics can actually be a cause of TTS (not to mention that a number of us feel they can exacerbate PF), so do you know what kind?
--Nancy

Re: wendyn FAQ on TTS

JudyS on 8/08/00 at 11:39 (024896)

Hi Nancy - welcome home! The orthotic my John has, believe it or not, is a 1/2 length, HARD plastic thing in an off-white color. I can't believe anyone could tolerate that! But you know, just like a man, he only wears the one on the formerly affected foot! He refuses to wear both because, of course, both feet didn't hurt! Now, you may quote me here, they will!

Re: wendyn FAQ on TTS

alan k on 8/06/00 at 10:13 (030387)

It is my understanding that an MRI cannot adequately access the causes of tarsal tunnel syndrome. That might be made more clear in the wording about MRI, pending confirmation from others.

alan k