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Cortisone injections for TTS?

Posted by Helene M on 11/19/00 at 15:53 (033079)

Dear Drs., I'm a 9 year PF sufferer who was recently diagnosed with bilateral TTS based on results of nerve conduction study. My pod's first plan of action would be cortisone injections in the tarsal tunnel plus wearing my orthotics (which really don't work for me-cause burning arches). If first plan fails, TTS surgery is next. I have not noticed anything mentioned on the TTS message board about cortisone injections for TTS. Also, I requested an MRI to determine if something is pressing on the nerve but he said it is not necessary. He feels I have nerve compression due to my 'anatomy' (high-arched feet). Can TTS be proven only by NCS & not MRI? This seems contrary to what I've read on this board about the necessity of having an MRI before surgery to determine if the nerve is really being compressed. I surely don't want to have needless injections or surgery. I'd value your opinion. Thanks.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/19/00 at 16:08 (033081)

In my office i have two three year trained foot and ankle surgeons that will do the tts release for my patients as a last resort. In the last three years I have had them do about five cases. Rests were good because they really know the relationship between TTS, the foot , the ankle and all related structures including the lower back

Anyway.

The reasons for the mri is for a few reasons. You need to evaluate and determine what the condition of the ankle joint is. what the condition of the lateal collateral ligments is . What the condition of the subtalar joint is . what is the condition of the Sinus tarsus is.

And last but not least what is the condition of the Tarsal Tunnel.

Lets look at it this way the mri will help to give a full picture of what is causing your pain. MRI studies have really improved in the last year or two. The quality of the films and the detail can realy help the surgeon determine what other problems are there and if they need to be address.at the time of the TTS surgery.

In my office very rarely is the pain due to just TTS. You can have posterior tibial dysfunction. Sinus Tarsus Syndrome. Lateral and medial ankle instability. So you need an MRI of the entire foot and ankle. And last but not least let's take a look at the plantar fascis and the related insertional structures GET THE MRI . After the MRI I would consider doing a steriod injection. I said consider but first get an MRI. I

Re: Cortisone injections for TTS?

Dr. Biehler on 11/19/00 at 16:13 (033083)

An approch to initial TTS can be a shot of cortisone to see if the anti-inflamtory attack is all that is needed to give the problem a chance to resolve on its own. If you have had PF for 9 years I think this places you in a seperate catagory than the person who first and only presents with TTS. If the nerve conduction test pin pointed your problem to the tarsal tunnel, because of your PF history, I would think you would want an MRI to try and see what is going on in there. Remember there are a lot of people with high arches that do not have TTS. Dr. B.

Re: Cortisone injections for TTS?

wendyn on 11/19/00 at 17:40 (033090)

I think both the doctors gave you fantastic answers for your questions.

From my own experience as a patient - there is no way that I would let anyone operate without having that MRI done first. TTS release stats are for the most part - lousy. My surgeon told me less than 50/50 - but it really depends on what's causing the TTS. How can the doctor know what he's going in to fix if he doesn't know what's going on in there in the first place?

ANY time someone is considering surgery of any kind - a second opinion is always a good idea. I would definately think you should seek one - especially an opnion from an orthepedic surgeon (just for a different perspective).

As a side note - my TTS symptoms have been significantly alleiviated by getting out of my orthotics and into Birkenstocks.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/19/00 at 20:41 (033098)

If you can keep the foot and ankle in a neutral positon you can help the stretching of the posterior tibial nerve. The nerve goes thru the flexor retinanicum (spelling) and if this shealth is pulled you will have symtoms of TTS. So get an mri and find out what other structures are causing the tts. It is true that the tunnel will be free of tumors etc but the cause is usually someother tendon failure that is causing the tunnel to function in an abnormal motion. It is important to understand the biomechanical foot and ankle mechanics that effect the Tarsal Tunnel . Dr. Biehler is much better at foot and ankle biomechanics so maybe he could explain this in more detail

Re: Cortisone injections for TTS?

alan k on 11/20/00 at 09:05 (033147)

Last year I had two shots in my tarsal tunnel, to no effect, including even no reduction of pain due to the licocaine numbing the nerve transmission. That diagnostic negative turned me off from surgery forever, and so I am glad in a way to have recieved the shots. I do feel that the shots changed something down there, just a feeling of slight instability or something. That could be my imagination.

Before the shots my podiatrist was adamant about surgery and told me tts release was %99 effective, a bold-faced lie. I am glad I got the shots just to get him off my back, as before then I could only bargain him down, after I sought out my own info, down to admitting %66.

Of I course I am not suggesting anything about your doctor, but do realize that some doctors do not have your best interest in mind and are only interested in cutting you up, getting money, and practicing their surgery skills. A resident Pod may perform tts release often while interning at a big hospital, but later in private practice they very rarely get the chance to practice it. It is probably a fun operation to perform, and they miss it.

alan k

Re: Cortisone injections for TTS?

Helene M on 11/20/00 at 10:43 (033150)

Thank you Drs. Z & B, wendyn & alank for your invaluable advice! As a regular reader of this board & a long-term sufferer, I already suspected what my doc was advising was not the best thing to do. I think it's time to move on to the next dr. I'd consider getting an orthopedist's opinion although I don't think they are experts on foot/ankle biomechanics. Can anyone recommend a good orthopedist or podiatrist in NYC/LI area? By the way, my TTS 'symptom' is burning arches. No tingling or numbness like many of you have.

Re: Cortisone injections for TTS?

alan k on 11/20/00 at 18:24 (033185)

of course you should seek second opinions but don't throw out the first one either, just get as many facts as you can first before surgery because there are risks in following the path of only one doctor if you don't know them well enough to trust them.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/20/00 at 20:38 (033196)

I found it to be a very boring operation with alot of pain after the operation. In my residency program we did more hand releases then TTS releses. The only thing i learn was don't do TTS unless you have no other choice.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/19/00 at 16:08 (033081)

In my office i have two three year trained foot and ankle surgeons that will do the tts release for my patients as a last resort. In the last three years I have had them do about five cases. Rests were good because they really know the relationship between TTS, the foot , the ankle and all related structures including the lower back

Anyway.

The reasons for the mri is for a few reasons. You need to evaluate and determine what the condition of the ankle joint is. what the condition of the lateal collateral ligments is . What the condition of the subtalar joint is . what is the condition of the Sinus tarsus is.

And last but not least what is the condition of the Tarsal Tunnel.

Lets look at it this way the mri will help to give a full picture of what is causing your pain. MRI studies have really improved in the last year or two. The quality of the films and the detail can realy help the surgeon determine what other problems are there and if they need to be address.at the time of the TTS surgery.

In my office very rarely is the pain due to just TTS. You can have posterior tibial dysfunction. Sinus Tarsus Syndrome. Lateral and medial ankle instability. So you need an MRI of the entire foot and ankle. And last but not least let's take a look at the plantar fascis and the related insertional structures GET THE MRI . After the MRI I would consider doing a steriod injection. I said consider but first get an MRI. I

Re: Cortisone injections for TTS?

Dr. Biehler on 11/19/00 at 16:13 (033083)

An approch to initial TTS can be a shot of cortisone to see if the anti-inflamtory attack is all that is needed to give the problem a chance to resolve on its own. If you have had PF for 9 years I think this places you in a seperate catagory than the person who first and only presents with TTS. If the nerve conduction test pin pointed your problem to the tarsal tunnel, because of your PF history, I would think you would want an MRI to try and see what is going on in there. Remember there are a lot of people with high arches that do not have TTS. Dr. B.

Re: Cortisone injections for TTS?

wendyn on 11/19/00 at 17:40 (033090)

I think both the doctors gave you fantastic answers for your questions.

From my own experience as a patient - there is no way that I would let anyone operate without having that MRI done first. TTS release stats are for the most part - lousy. My surgeon told me less than 50/50 - but it really depends on what's causing the TTS. How can the doctor know what he's going in to fix if he doesn't know what's going on in there in the first place?

ANY time someone is considering surgery of any kind - a second opinion is always a good idea. I would definately think you should seek one - especially an opnion from an orthepedic surgeon (just for a different perspective).

As a side note - my TTS symptoms have been significantly alleiviated by getting out of my orthotics and into Birkenstocks.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/19/00 at 20:41 (033098)

If you can keep the foot and ankle in a neutral positon you can help the stretching of the posterior tibial nerve. The nerve goes thru the flexor retinanicum (spelling) and if this shealth is pulled you will have symtoms of TTS. So get an mri and find out what other structures are causing the tts. It is true that the tunnel will be free of tumors etc but the cause is usually someother tendon failure that is causing the tunnel to function in an abnormal motion. It is important to understand the biomechanical foot and ankle mechanics that effect the Tarsal Tunnel . Dr. Biehler is much better at foot and ankle biomechanics so maybe he could explain this in more detail

Re: Cortisone injections for TTS?

alan k on 11/20/00 at 09:05 (033147)

Last year I had two shots in my tarsal tunnel, to no effect, including even no reduction of pain due to the licocaine numbing the nerve transmission. That diagnostic negative turned me off from surgery forever, and so I am glad in a way to have recieved the shots. I do feel that the shots changed something down there, just a feeling of slight instability or something. That could be my imagination.

Before the shots my podiatrist was adamant about surgery and told me tts release was %99 effective, a bold-faced lie. I am glad I got the shots just to get him off my back, as before then I could only bargain him down, after I sought out my own info, down to admitting %66.

Of I course I am not suggesting anything about your doctor, but do realize that some doctors do not have your best interest in mind and are only interested in cutting you up, getting money, and practicing their surgery skills. A resident Pod may perform tts release often while interning at a big hospital, but later in private practice they very rarely get the chance to practice it. It is probably a fun operation to perform, and they miss it.

alan k

Re: Cortisone injections for TTS?

Helene M on 11/20/00 at 10:43 (033150)

Thank you Drs. Z & B, wendyn & alank for your invaluable advice! As a regular reader of this board & a long-term sufferer, I already suspected what my doc was advising was not the best thing to do. I think it's time to move on to the next dr. I'd consider getting an orthopedist's opinion although I don't think they are experts on foot/ankle biomechanics. Can anyone recommend a good orthopedist or podiatrist in NYC/LI area? By the way, my TTS 'symptom' is burning arches. No tingling or numbness like many of you have.

Re: Cortisone injections for TTS?

alan k on 11/20/00 at 18:24 (033185)

of course you should seek second opinions but don't throw out the first one either, just get as many facts as you can first before surgery because there are risks in following the path of only one doctor if you don't know them well enough to trust them.

Re: Cortisone injections for TTS?

Dr. Zuckerman on 11/20/00 at 20:38 (033196)

I found it to be a very boring operation with alot of pain after the operation. In my residency program we did more hand releases then TTS releses. The only thing i learn was don't do TTS unless you have no other choice.