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Possible TTS/interesting case...any suggestions would be appreciated.

Posted by Ryan G. on 7/19/01 at hrmin (053689)

Hello...I'm a Physical Therapist in Ohio. I have a patient with a diagnosis of plantar fascitis however, palpation of the plantar fascia from origin to insertion is relatively asymptomatic. I feel he is experiencing TTS like symptoms with (+) Tinell's sign at his right posterior medial malleolus which reproduces his heel pain. Very light palpation just distal of the flexor retinaculum, rubbing perpendicular to the medial and lateral plantar nerves is also symptomatic. There is no real significant edema but nerves feel somewhat inflammed for lack of a better description. Heel pain is generally exacerbated by prolonged weight bearing (works 12 hour shifts). Other info...severe rear foot varus (11deg) with about 6-7 deg forefoot varus deformaty. Left foot is somewhat less and is asymptomatic most of the time and Tinnell's sign is negative. Both feet are hypermobile no doubt to the biomechanical effects over time.

I've only had one other true TTS in which the patient recieved considerable relief from OTC orthotics, ultrasound and intophoresis with dexamethasone and eventual return to activity. At any rate, the complicating factors in this case is that my patient had a kidney transplant 10 years ago and is limited on medications he is able to take and I think it is out of my scope of practice to determine if using dexamethasone via iontophoresis (or if injected) is contraindacted or not due to the PMH.

Any suggestions would be appreciated.

Thanks much,

Ryan

rsgpt@hotmail.com

Re: Possible TTS/interesting case...any suggestions would be appreciated.

Dr. Ed Davis on 7/19/01 at hrmin (053733)

It sounds like your patient may have tarsal tunnel syndrome. There are some 'variations on a theme' since the posterior tibial nerve can divide into the medial and lateral plantar nerve once in the foot (after passing through the porta pedis) or within the laciniate ligament. Compression neuropathy can occur to the main nerve, the posterior tibial nerve or to either of the branches. Another scenario is compression of the medial calcaneal branch off the posterior tibial nerve.

I think it is definitely worthwile to try those physical therapy modalities which decrease fibrosis--ultrasound, phonophoresis, iontophoresis. Most therapists in my area request a prescription for dexamethasone phosphate from the patient's physician and then proceed to perform iontophoresis. I would probably avoid deep tissue massage since the nerve is already traumatized by compression. Electrotherapy, particularly high fequency interferential therapy can provide symptomatic relief.

Consider referral of the patient to a physiatrist for EMG/NCV evaluation though.

Many will tell you that conservative therapy for tarsal tunnel has a low success rate. That is only partially true. If the tarsal tunnel syndrome is caused by nerve compression due to fibrosis (scar tissue) then conservative therapy can work very well. If, on the other hand, a space occupying lesion in the laciniate ligament (growths, cysts, varicose veins..) are what is putting pressure on the nerve, then conservative treatment will have little effect.
Ed

Re: Possible TTS/interesting case...any suggestions would be appreciated.

jason p on 7/19/01 at 19:06 (053764)

emg testing to rule out tts

Re: Possible TTS/interesting case...any suggestions would be appreciated.

eileenc on 7/20/01 at 08:16 (053801)

Hello fellow Buckeye! I had an unsuccessful tarsal tunnel release 4 years ago. The swelling/pain has now gone into the arch. I am looking for someone who knows something about this. Are you anywhere near Akron, Ohio?
I found the drug Neurontin and dunking my foot into ice water to be very helpful.

Re: Possible TTS/interesting case...any suggestions would be appreciated.

Jeff on 7/20/01 at hrmin (053869)

Go bucks. I'm in the Buckeye epicenter (well actually 40 minutes east of Columbus in Granville). Tell me more. Neurontin and ice water is no way to live.
Jeff

Re: Possible TTS/interesting case...any suggestions would be appreciated.

wendyn on 7/20/01 at 23:42 (053874)

Jeff you're right - do have an alternative for this patient? Someone with a failed TT release doesn't have a lot of options.

Re: Possible TTS/interesting case...any suggestions would be appreciated.

eileenc on 7/21/01 at 09:35 (053902)

How right you are,absolutely no way to live! Started with minimal ankle sprain (no bruise and minimal swelling) Which started to go bad 2 months after it had healed.A year later several perplexed doctors told me to go to a pain clinic.By now I was limping causing back pain so the Dr. manipulated my left sacroiliac and injured that too. Three days later I had a 1 - inch incision cut just below my ankle (right, medial) and scar tissue was removed to release the nerves,blood vessels,etc. It was to have been done by laser but the Dr. 'panicked' when he saw how much scar tissue was there and he took out a knife. Almost 4 years later my foot now has swelling below the incision into my arch and going back to my heel. I also deal with the back pain which is caused by the sacroiliac and a disc which bulged out after the manipulation.The podiatric surgeon who did the procedure committed suicide about a year later so I have not seen any foot doctor since. Can not wear anything but the most slipper-like of shoes. The ice-water may be the reason my ankle muscles are beginning to painfully tighten up.

Re: Possible TTS/interesting case...any suggestions would be appreciated.

Dr. Ed Davis on 7/19/01 at hrmin (053733)

It sounds like your patient may have tarsal tunnel syndrome. There are some 'variations on a theme' since the posterior tibial nerve can divide into the medial and lateral plantar nerve once in the foot (after passing through the porta pedis) or within the laciniate ligament. Compression neuropathy can occur to the main nerve, the posterior tibial nerve or to either of the branches. Another scenario is compression of the medial calcaneal branch off the posterior tibial nerve.

I think it is definitely worthwile to try those physical therapy modalities which decrease fibrosis--ultrasound, phonophoresis, iontophoresis. Most therapists in my area request a prescription for dexamethasone phosphate from the patient's physician and then proceed to perform iontophoresis. I would probably avoid deep tissue massage since the nerve is already traumatized by compression. Electrotherapy, particularly high fequency interferential therapy can provide symptomatic relief.

Consider referral of the patient to a physiatrist for EMG/NCV evaluation though.

Many will tell you that conservative therapy for tarsal tunnel has a low success rate. That is only partially true. If the tarsal tunnel syndrome is caused by nerve compression due to fibrosis (scar tissue) then conservative therapy can work very well. If, on the other hand, a space occupying lesion in the laciniate ligament (growths, cysts, varicose veins..) are what is putting pressure on the nerve, then conservative treatment will have little effect.
Ed

Re: Possible TTS/interesting case...any suggestions would be appreciated.

jason p on 7/19/01 at 19:06 (053764)

emg testing to rule out tts

Re: Possible TTS/interesting case...any suggestions would be appreciated.

eileenc on 7/20/01 at 08:16 (053801)

Hello fellow Buckeye! I had an unsuccessful tarsal tunnel release 4 years ago. The swelling/pain has now gone into the arch. I am looking for someone who knows something about this. Are you anywhere near Akron, Ohio?
I found the drug Neurontin and dunking my foot into ice water to be very helpful.

Re: Possible TTS/interesting case...any suggestions would be appreciated.

Jeff on 7/20/01 at hrmin (053869)

Go bucks. I'm in the Buckeye epicenter (well actually 40 minutes east of Columbus in Granville). Tell me more. Neurontin and ice water is no way to live.
Jeff

Re: Possible TTS/interesting case...any suggestions would be appreciated.

wendyn on 7/20/01 at 23:42 (053874)

Jeff you're right - do have an alternative for this patient? Someone with a failed TT release doesn't have a lot of options.

Re: Possible TTS/interesting case...any suggestions would be appreciated.

eileenc on 7/21/01 at 09:35 (053902)

How right you are,absolutely no way to live! Started with minimal ankle sprain (no bruise and minimal swelling) Which started to go bad 2 months after it had healed.A year later several perplexed doctors told me to go to a pain clinic.By now I was limping causing back pain so the Dr. manipulated my left sacroiliac and injured that too. Three days later I had a 1 - inch incision cut just below my ankle (right, medial) and scar tissue was removed to release the nerves,blood vessels,etc. It was to have been done by laser but the Dr. 'panicked' when he saw how much scar tissue was there and he took out a knife. Almost 4 years later my foot now has swelling below the incision into my arch and going back to my heel. I also deal with the back pain which is caused by the sacroiliac and a disc which bulged out after the manipulation.The podiatric surgeon who did the procedure committed suicide about a year later so I have not seen any foot doctor since. Can not wear anything but the most slipper-like of shoes. The ice-water may be the reason my ankle muscles are beginning to painfully tighten up.