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I need advice.

Posted by susanm on 8/09/01 at 21:11 (056105)

After 18 months of sometimes excruciating pain (burning and soreness) in the balls of both my feet, a podiatrist diagnosed tarsal tunnel syndrome. Yesterday I had a nerve conduction study and the results are normal.

Today my feet are hot from inflammation and I am completely confused. Any comments?

Also has anyone tried a chiropractor? What about acupuncture? What about magnets? As you can see, I am at the thin end of the wedge. I even turned down a promotion because my doctor says recupertion from the surgery is long, and we are talking both feet.

I'd appreciate any feedback.

Thanks!

Re: I need advice.

Bellel on 8/09/01 at 22:20 (056113)

I don't know if this will help or not. In June I was diagnosed with TTS, and since I didn't want to rush into surgery, my Dr. put me in a 'boot for 6 weeks. No pain while I was wearing it. Still had pain after 6 wks so he suggested orthotics, which I am now wearing. I am still having some pain, but much better. Finally started accupuncture, have had 5 treatments, and my accupuncturist says it will take 10. I am feeling much better with only occasional pain. Don't know if the orthotics did it or the Acc. I would suggest trying all options before surgery, since I heard it is a long recovery. Guess I am chicken, but I had orthoscopic knee surgery 2 years ago, and am still suffering from that.
Good luck

Re: I need advice.

wendyn on 8/09/01 at 22:56 (056120)

Hi Susanm and welcome.

The heat from inflammation seems to be common, it's due to the nerve irritation and increased blood flow. Elevating and/or icing can sometime help bring it down. Easy for me to say to you in a post, the heat and pain drive me flippin crazy sometimes.

The nerve conduction test may have aggravated your feet causing increased symptoms today. If it did, I wouldn't think it should last long. (I've never heard of it happening but I'd have to think it would be possible).

Most of us with TTS have had normal nerve conduction tests - take it as a good thing that there isn't anything else going on. Have you had blood tests done as well?

Surgery for most is considered a last resort. Success rates seem to range from anywhere from 50% to 90%. The better results are found when there is an actual mass sitting in the tunnel - rather than no known cause.

Don't rush into surgery - please read here and educate yourself lots. There's a link at the top of the main TTS page to some FAQ. Many of us have had good results with conservative treatment.

Re: I'd bet it's not even TTS

elliott on 8/10/01 at 08:38 (056138)

You're not the first to come on here describing pain in an atypical location and say you've been diagnosed with TTS. TTS is defined as entrapment of the posterior tibial nerve or its branches at the medial malleolus, that is, in the area just behind and below the medial side of the ankle (which is more or less the tarsal tunnel). You would typically feel stiffness, pain or nervy sensations at the medial ankle (or at least that something doesn't feel right there) and often medial arch pain, with nervy sensations possibly radiating from ankle into the heel, calf, and/or toes. That doesn't sound like anything you've described. It is possible to have a more distal entrapment of one of the nerve branches or their branches. There are a couple of branches of the medial plantar nerve running through the ball, as well as those of the lateral plantar nerve on the lateral side of your ball (do you have any tingling in any toes by any chance? you didn't say so), but I'd say the chances that you had a distal entrapment in the same location in both feet simultaneously is ridiculously small, and, assuming you have no other symptoms than those described (at ball), I'd say the chances your podiatrist doesn't know much about TTS is much greater. Sorry to be so blunt. But I really, truly feel the pain of those going through TTS or getting unnecessary surgery for it, and bluntness gets the point across.

The enhanced feeling from the nerve conduction test is temporary and should subside within a week ot two at most, so don't worry about that.

Burning in the balls of both feet can be due to many things, e.g. neuromas (much more common than TTS and often due to tight shoes) or other feet defects, ill-fitting shoes, tight muscles, even a back ailment. Did you switch to new shoes? If you haven't done so already, for starters I would switch shoes to something feeling more comfortable (not dress shoes, but those with a nice wide cushioned platform for ball, with plenty of room for your toes). Some other suggestions are rest, ice, NSAIDS, orthotics. Hopefully some of the podiatrists here (who seem both informed and gracious to offer advice) can enlighten you further. All those treatments you mentioned are worth a try, but I'd consider going to another doc (different podiatrist and/or foot/ankle ortho) for another opinion.

Re: I need advice.

Dr. Zuckerman on 8/10/01 at 08:38 (056139)

Hi,

Burning in your feet can be caused from a number of things
1. neuroma
2. Decrease fat padding
3. Diabetes
4. Distal plantar fasciitis, bursitis
5 Hammer toes or contracted toes

What have your treatments been and tell us more about the pain and buring. When where and how

Re: you're not chicken, you're smart

elliott on 8/10/01 at 08:49 (056142)

Actually, if the surgery really, truly is successful, the recovery is not really that long: assuming no other complications or circumstances, one usually feels at least some immediate relief and should be walking normally three weeks post-op, although some of the nervy symptoms or their surgical aftermath might take up to a year or longer to diminish with continued improvement for that long, but that's something anyone should be willing to deal with since they're getting better. The problem is not that it's a long recovery, but that the chances for success are smaller and one can end up even worse than before the surgery.

Re: I need advice.

Darlene K on 8/10/01 at hrmin (056189)

I have just been told I have Tarsal Tunnel along with Plantars F. and A heel spur the size of a baby carrott all in the same foot. HELP I have no idea what T>T> is even about any help would be appricated. Thanks Darlene

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056193)

Wendyn had mentioned 'normal' NCV for patients with TTS. A number of individuals have mechanical irrtiation to the posterior tibial nerve causing TTS like symptoms. That is why rest and biomechanical control often provides relief for such individuals. That is probably not 'true' TTS
and thus does not require surgery.

True TTS usually leads to measurable changes on NCV. There are differences in technique among testers so the sensitivity of the test can vary.

I generally do not move forward with surgical treatment unless there is a positive NCV test for TTS or a high resolution MRI demonstrating constriction or impingement of the posterior tibial nerve. My philosophy is to treat conservatively but agressively if the aforementioned criteria are absent. If there is a positive NCV or MRI, then I would be willing to try conservative treatment but would encourage surgery.
Ed

Re: Nerve Conduction Velocity Tests for TTS--ps

Ed Davis, DPM on 8/10/01 at hrmin (056195)

ps. I am a bit surprised by the number of posts by people diagnosed with TTS as 'true' TTs is not that common. I am also surprised by the number of posts of individuals who have been diagnosed with both TTS and PF or individuals who have had surgery for both entities simultaneously. My concern is that individuals with PF who are contemplating surgery may be under-treated biomechanically, leading to 'pseudo-TTS' and a lot of unecessary surgery. I may stir up a hornets nest here but if I have one fault it is my 'die hard' honesty.
Ed

Re: I need advice.

Ed Davis, DPM on 8/10/01 at hrmin (056196)

I am glad that you recovered without surgery. I wonder if you had true TTS--see my posts here.
Ed

Re: Nerve Conduction Velocity Tests for TTS--pps

Ed Davis, DPM on 8/10/01 at hrmin (056197)

There is concern about the success rate of TTS surgery as well as the recovery. Again, I believe that if we separated those cases that met my criteria for surgery from those that don't, I believe that you would see a higher success rate and easier recovery.
Ed

Re: what's your view on the flip-side issue of NCV?

elliott on 8/10/01 at 14:25 (056202)

That is, how accurate is a positive reading in avoiding false negatives? If it depends on how high the numbers are, then please elaborate.

I've been tested three times (not counting QST, which I won't get into here), once before bilateral TTS surgery and twice after, all by the same respected neuroelectrodiagnostician (what a mouthful, but that's what he calls himself; he's also a certified neurologist). The last time I was tested (Feb 01, 7 months after left foot surgery and 1 year and 6 mos. after right foot surgery), the latencies for both motors in both feet all were 7.0 and over (that's high!), and had even risen from before surgery. (After successful surgery they're supposed to gradually decline to normal or near-normal levels). While I know I have nerve irritation in my left foot, the right foot does not have any very obvious nerve irritation but is weak and near collapse (two years post-op), perhaps along the line of the nerve, although there are other mysterious problems as well, some still from pre-op and others post-op. It would be nice to know if this is or includes a nerve problem, or is it some other post-op problem such as a scar tissue mess or poor technique. There could even be another surgery riding on the answer to this puzzle. Thanks in advance for any insight you may have.

Re: Nerve Conduction Velocity Tests for TTS

wendyn on 8/10/01 at 14:29 (056203)

Dr Ed - you bring up issues that confuse a lot of us.

Is it true - that TTS stands for a syndrome - which is, essentially a collection of symptoms (not necessarily a 'cause')?

Is it fair to say that you can have 'TTS' from different causes?

While it's true that I've had normal nerve conduction tests - I've had 3 podiatrists, 2 sports med doctors,1 orthepedic surgeon,1 neurologist,1 physiatrist, 2 physio therapists tell me I have TTS. So - no, not according to the test, yes according to half a dozen or more doctors.

This, I believe, is one of the huge problems when dealing with TTS - the difference in opinions on how it's diagnosed and what exactly it means.

Re: and then let's distinguish between...

elliott on 8/10/01 at 14:58 (056206)

...neuralgia, neuroma, neuropraxia, neuropathy, neuritis, etc., etc. (anyone know the distinctions by heart?).

I think most orthos use NCV as supporting evidence, and don't automatically reject when physical examination and patient description is compatible with TTS. Sure, there are several causes, but most can be classified by ailment (diabetes, rheumatoid arthritis, gout, all of which can clog up the nerves), group (e.g. runners--unclear, with overpronation and tugging of nerve high up on the list) or event (e.g. trauma such as ankle fracture which entraps nerve). If one has, say, a positive Tinel's sign and complains of nervy symptoms at medial malleolus, I think they'll be taken seriously. But Ed is making a good point, that even many pods rush to label whatever the foot pain is wherever it is as TTS because they are not familiar with it, and that those with a whole host of degenerative problems should be treated with the utmost caution, as it may very well not be TTS, not be obviously limited to TTS with source and cause of pain elsewhere, or have low probability of surgical success.

Re: Nerve Conduction Velocity Tests for TTS--ps

Dr. Zuckerman on 8/10/01 at 15:28 (056211)

It is also very unusal for TTS without some kind of injury to the area such as an inversion sprain.

Re: what's your view on the flip-side issue of NCV?

Ed Davis, DPM on 8/10/01 at hrmin (056212)

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

Re: High resolution MRI for diagnosis

Matt L on 8/10/01 at 15:44 (056213)

I heard about this recently and check with a surgeon at Johns Hopkins which recently got the technology (MRI Neurography?). He led me to believe that it was not a good tool for tts or smaller nerves in the foot. Do you think differently? If so, what technology is utilized and where can it be found.

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056215)

The term 'syndrome' is used because the result of nerve compression can cause a range of symptoms consistent with a damaged nerve. It really is a very specific process though involving compression of the posterior tibial nerve so use of the term syndrome is misleading--syndrome here refers to the end effects as opposed to the actual pathology.

Keep in mind that the accuracy of NCV testing varies from technician to technician. Assume for a moment that the sensitivity of the test is poor, those with positive tests would be likely to have TTS but a lot would be missed. I have to admit that I am a bit lucky to have an excellent tester in my area, Dr. Saeed Mohammed of Tacoma, WA. A number of things in the canal in which the post. tib. nerve runs can place pressure on the nerve, including varicose veins--this is why a high resolution MRI can be very helpful. If the MRI shows impingement of the nerve then the NCV is probably not necessary.

Finally, if NCV and MRI are both negative, it is possible to still have TTS if there is overwhelming clinical evidence supporting it--may be your case. On the other hand, if you are being treated for TTS and not getting results (I don't know your history), I would be tempted to look further.
Ed

Re: me to but after reading all of that above I am more then lost

Tammie on 8/10/01 at 16:30 (056223)

This is all quite interesting um if you understand all of this medical talk, which leads me to believe that allot of our dr.s talk this way and we the lay person cannot retain all of what is said , or understand most except maybe a few words to work with! I liked allot of your explanations that were given and read and copied many but this above is like french to me, and gee I have trouble spelling and typing english. I think I feel more confused reading thease posts then I did before> Which let me tell u was pretty darn confused then! So where do you go and what do you do if your dr. says u have this tts and feels the testing is not necc>? And what if they think it is scar tissue from former surgery? My gosh this gets deep, What happened to easy solutions?And simple words for common people? I am a lost lamb being led to slaughter I feel!

Re: RE: NCV

elliott on 8/10/01 at 17:20 (056227)

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.

Re: Nerve Conduction Velocity Tests for TTS

elliott on 8/10/01 at 17:22 (056228)

I had an MRI on left foot pre-op which showed nothing, and then big-name TTS surgeon observed during surgery just about the largest vein he'd ever seen in his career. So does an MRI pick up a vein or not?

Re: RE: NCV

Ed Davis, DPM on 8/10/01 at hrmin (056238)

There are two areas to look at. The neurologic workup suggests TTS and I suspect that it is a correct diagnosis and that the surgery for it failed.
The second area, tibialis posterior dysfunction brings further questions.
We divide PTTD into 3 stages. The first stage involves primarily tenosynovitis, that is, inflammation and swelling of the tendon. I call this the 'warning phase' because it tells us that the tendon is in trouble.
The tibialis posterior tendon is the primary invertor (rolls the foot out) of the foot. It attaches primarily to the navicular bone (bone at the top of the arch) and also to other bones in the tarsus. The reason to consider a synovectomy would be for symptomatic relief of tendon pain but also, in your case, to prevent the swollen tendon from pressing on the posterior tibial nerve. The synovial tissue surrounding the tendon does have a role in providing nutrition to the tendon.

Stage I PTTD tends to go on to Stage 2 (degeneration with intrasubstance tear) if strain is not removed from the post. tibial tendon. There are a number of specialized orthotic designs out there for this purpose. A larger factor than the synovectomy in leading to what sounds like a progression to Stage 3 (atrophy and tendon tear) is the degree of orthotic or biomechanical control provided--it is critical.

Do not run and minimize activity on the right foot if it feels 'like it is going to collapse.' If your doc cannot tell you what is going on, see someone who does. I will try to come up with some names if I know what city you live in.
Ed

Re: High resolution MRI for diagnosis

Ed Davis, DPM on 8/10/01 at hrmin (056241)

We do not expect any MRI to have sufficiently high resolution to be able to look at the small nerves of the foot. What we are using the MRI for is to find other structures (eg. varicosities, growths, cysts) that exist in proximity to the nerve and are compressing the nerve.

A number of MRIs can help but the best resolution I have seen is from a unit using a flexible coil that is wrapped around the foot or ankle. Cascade MRI in the Northgate area of Seattle is the closest one to my area.
Ed

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056242)

Varicose veins within the tarsal tunnel may be responsible for up to 25% of TTS cases. The MRI which I use would almost certainly pick up a varicose vein in the tarsal tunnel. A number of MRI units out there may have insufficient resolution to do so.

I use Cascade MRI in the Northgate section of Seattle because they have a flexible coil scanner that is wrapped around the ankle and provides very good resolution. Patients appreciate it because they don't get the claustrophobia that occurs with the large units. I have been using them since about 1996 so it really isn't new technology.
Ed

Re: me to but after reading all of that above I am more then lost

Ed Davis, DPM on 8/10/01 at hrmin (056243)

Tammie:

People on this forum enter with varying levels of background knowledge. The doctors will do their best to answer things in a way that makes sense to you.

Keep in mind that there are individuals who have done a lot of research before posing questions here. They will tend to ask questions based on their knowledge level. If you enter into their dialogue strings, you may find it more advanced than you desire. Consider starting a new question on your own, an original post in which the answer will come directly to you.

It is important that you feel comfortable with the doctor you have chosen, not like 'a lost lamb led to slaughter.' We expect doctors to be good communicators, not just good technicians. If you are not communicating well with your doctor, consider a switch, even if he or she is considered a 'good' doctor.
Ed

Re: Nerve Conduction Velocity Tests for TTS

wendyn on 8/10/01 at 21:26 (056257)

Thanks Dr Ed - I look forward to continuing this conversation in a few weeks - I'm going on vacation!!!
Talk to you then!

Re: Ok then I will repost my ?

Tammie on 8/10/01 at 21:46 (056260)

This is my Docs plan what do u think of it? He feels tts is a issue had the pf surgery back in april side incision, lots of pain in area of incision and a hard lump wich sends me into a orbit if touched.Lots of tingling and foot pain inside ankle area to bottom heel arch area to toes, sometimes like a bruise area feeling worsens as the day progresses stiffness in am and throughout day, Night time I feel as tho I have a demon loose in my foot, wont allow me to sleep without something that( just recently the last week ) My dr. gave me to help. His plan is this, gave one shot of cortisone last wed. send me to pt for 3 tms a week (using ultrosound & that ion?? spelling sorry?) try to calm the nerve down he says , may use ice or heat or both, gave me Mobic which havve been on a bit over a week now,(had celebrex, relefen,vioxx) No change, states he will give another cortisone this wed. and continue the plan and will give me up to 4 shots of cortisone, if no changes or no improvment will talk about the surgery . I was closed minded to it did not even want to hear the word. I was the same for the pf and spur removal but we did this similar plan and I ended up with none of thease things working and had the surgery. So what next and how long before I should have some changes if they are going to occur, oh yes orthodics were in this to and I have them as he did them for the pf and he has checked them and seemed to think they are fine , so did the pt lady she liked them to. But then she is the one who stretched me to and had me stretch in barefeet toe stretches wall stretches ankle rotations that I could have commited a crime right then and left me in so much pain that I called my dr. which I do NOT do. My dr. is ok it is me, I have a problem with not being calm and nervous as a bat, I cant remember and I get upset as soon as I hear the shot word, I do usually take hubby with me, to be my ears. I do not like to hear when he says I cant return to work either, I have been off since april 17 I want to go back but I want to be able to walk and to sleep at night to! So now here it is all on the line in my words, what do U think of the plan?In case you wonder my job it is a nurses aide , in geriatrics. Oh Thank u if u decide to read this and try to answer! I have seen a ortho dr. and 2 other pods during the pf thing. My dr. is a D.P.M.FACFS but is a very busy dr. as he has 3 offices and there is one other dr. with him, so his load is large I am sure! We may wait hours for a appointment sometimes! Thanks again

Re: I'd bet it's not even TTS

susanm on 8/10/01 at 21:59 (056261)

elliot,
Thank you for your response. You have addressed some issues that have really concerned me.

First, I have never thought my symptoms were classic TTS. The pain is specific to the balls of both feet with sort of sparking pains in my toes. Sometimes my feet cramp. Sometimes my ankles burn. Sometimes I have buzzing sensations in my feet. They are both warm to the touch. I frequently awaken at night because of these pains. A co-worker tells me I walk as if I dread putting my feet down.

I see my foot doc on Monday afternoon and I plan to pursue a custom orthotic. He talked surgery at the last appointment; however, I have decided against that for all of the reasons that have been brought up in response to my plea for advice.

About shoes...I have not worn fashionable shoes for two years. I can't. Right now I am wearning Birkenstocks with the cushioned footbeds. They seem to work better than anything else I have tried, and believe me, I have spent a boat load of money on shoes I can't wear. I saw a chiropractor last week who could find nothing amiss except for something with my left shoulder. I'm thinking about acupuncture too.

Please continue with any suggestions at all.

Re: Ok then I will repost my ?

Ed Davis, DPM on 8/10/01 at hrmin (056269)

It sounds like you may have painful scar tissue about the incision. Consider a shot of triamcinolone acetonide plus Wydase (an enzyme) to get rid of the scar tissue (pass this message on to your doc).
Ed

Re: Ok Thank u wrote it down to ask him about

Tammie on 8/11/01 at 08:38 (056299)

I will ask him not that i like any more shots, but he would give me the cortisone or whatever anyways no doubt! And I am looking for a answer so not objectable to a trial of anything to help. Did I mention that thease other symptoms of the nervy stuff have been there even before the surgery for the pf stuff? Not that this will not take care of the problem, as maybe it will I am hopeful, but what if it does not, does his plan of treatment sound resonable?Should I ask for more tests? He might be open to trying this shot,but what if he is not?He did not seem to concerned with this lump area as he had said scar tissue to,but seemed more worried about when he squeezed my ankle and then the heel area that the lovely jolts and tingling was worse? I am just wondering as more knowledge has to be to my advantage! And really thank u for answering I do appreciate it, I just am trying to help by helping myself find answers, I cannot keep sitting here on hold forever,I am driving my poor family nuts! They wish me to return to workto if not as a empoyee then as aresident so that I can drive them nuts with whining about being bored and missing my job not to mention keeping hubby awake with my constant trying to get comfortable and up and down as i cannot sleep, but son will leave for college this week so will have another bed as sometimes the couch is in use with kids friends. So U see I am a not so good patient, or patient person.Always looking for a way to heal this quicker and trying anything offered! Thank u again!

Re: Nerve Conduction Velocity Tests for TTS--ps

Carol C on 8/11/01 at 11:03 (056314)

Can you advise me of the diagnostic value of a cortisone injection in
the evaluation of TTS? I am in the evaluation stages for TTS and
don't like the thought of an injection although my orhtopaedic surgeon
would like to proceed with the injection prior to consideration of
surgical options.

Re: RE: varicose veins

elliott on 8/11/01 at 22:28 (056385)

My ortho told me that as a matter of course, varicose veins are not removed during TTS surgery because doing so could cause more harm than good, e.g., disrupting the soundness of area, complications with redirected blood flow, etc. Do you agree? Also, if one is already post-op and still has serious TTS troubles possibly due to those varicose veins, is it then in order to have them removed?

Re: more details

elliott on 8/11/01 at 22:53 (056386)

I live in Baltimore and have been to the best and the brightest here. If you you have an email address, I'll converse further in private. If you know names of podiatrists or others who are especially good with things like orthotic and biomechanical devices and other nonsurgical treatments regarding TTS, heel pain, and PTTD, I'm especially interested. I certainly don't feel like getting a tendon transfer (stage 2?) or a bone fusion (stage 3?) unless I'm sure of the diagnosis and have no choice.

Thanks for the rundown on PTTD, even though I've seen it before. I haven't run in over 10 months; doubt I ever will again. Don't even walk much either. My pain feels just like what I'd imagine serious PTTD to be (again, I didn't have this pre-op). Months and months of rest and inactivity didn't make it any better. Sometimes after a few blocks of walking, my foot loosens up and feels better (although then my heel hurts; my heel pain has not been definitively diagnosed either, but I had that pre-surgery and it's still there; the numbness and burning is not, though, which is why I asked about NCV false positives). Also, after cycling (the last aerobic thing left on earth I can still do) a long distance, my foot feels better for a few hours. That sounds more like scar tissue. I know some tissue extending from that area has been torn further. Any thoughts on scar tissue, both regarding surgery to remove it or other ways to get rid of it? Thanks.

Re: Nerve Conduction Velocity Tests for TTS--ps

Ed Davis, DPM on 8/12/01 at hrmin (056460)

Carol:
Most shots like the one you are referring to include 'cortisone' and a local anesthetic such as lidocaine. Numbing nerves can often be helpful in order to narrow down the area of pathology. The post. tibial nerve gives sensation to most of the bottom of the foot so injecting an aneshtetic to that nerve would temporarily relieve pain from most painful conditions on the bottom of the foot--not bvery specific. Nevertheless, about 30 to 40% of TTS is helped by such shots so go for it.
Ed

Re: more details

Ed Davis, DPM on 8/12/01 at hrmin (056462)

Wow--you live in the city where the best tarsal tunnel surgeon lives: A. Lee Dellon, MD! If I needed surgery I would get on a plane from Seattle to Baltimore to see him. If you are considering a re-do of the TTS surgery--he is the man. I own a CD-ROM of TTS surgery that he has produced and have the podiatric surgical residents I train in Tacoma watch it several times a year.

The posterior tibial tendon dysfunction is a different ballgame and not in Dr. Dellon's armamentarium. The tendon transfer surgery you mention can be successful but conservative therapy is very successful BUT get going on the right orthotic ASAP--the tendon needs to be protected.

My email is: eddavisdpm@hotmail.com
I will be back in the office tommorrow and look up some names. Will be in Chicago from Wed thru Sunday.

There are two basic orthotics in use for Tib. post. tendon deficiency:

1) Ritchie Brace -- has a foot plate as well as a portion that
attaches above the ankle joint.

2) Mueller TPD -- looks more like a conventional foot orthotic.

I prefer the Mueller TPD as it is more comfortable. The Ritchie brace, in theory, could be used for more severe cases than the Mueller TPD
Ed

Re: RE: varicose veins

Ed Davis, DPM on 8/12/01 at hrmin (056513)

Varicose veins are diseased, abnormally enlarged veins. If they exist within the tarsal tunnel they will place pressure on the posterior tibial nerve and must be ligated (tied off). There are a number of papers which implicate varicosities within the tarsal tunnel in 25 to 40% of TTS cases.

Is it possible that he misunderstood your question? Did ask him specifically about varicosities within the tarsal tunnel as opposed to ankle/leg varicosities in general?
Ed

Re: Tammie...Sounds like we have some things in common..

CindyF on 8/13/01 at 15:49 (056604)

Tammie...I have been reading your post on here for some time...
It sounds to me like you might have something simular to what I have been going through...
Back in 1996...I had a surgery on my left heel...what I thought at the time was going to be a heel spur removed...but ended up being a nerve tumor...
Well..anyway...I developed lot's of scar tissue in the area....and I was seeing podiatrist after podiatrist...and all I seemed to get offered was the orthotics...which I bought 2 pair...and the injections...
I had limped on my foot so long...I started having more and more pain...
So I went to see an Orthopedic Dr....and he informed me I had formed scar tissue on my outer ankle also...from not walking straight...so..he first went in and did orthoscopic surgery to remove the scar tissue off the outer ankle...that was in April....I was off of work all this time...
I recently had surgery for Tarsal Tunnel on July 26th...with a second incision on top for more trapped nerves which was all caused by the origional surgery back in 1996....leaving lots of scar tissure throughout my foot...
You see....I had an infection that took a while to heel the wound...
Anyway...here I am...almost 3 weeks after the surgery...and I can tell a difference...even though I haven't bee allowed to walk yet..
I know it is going to be a hard road.....and a long one...but you need to go into this with the knowledge that this didn't happen over night...and it won't fix it's self over night either...
You seem in alot of your post that you don't treally trust your Doctor's oppinion...and that you are looking for something to find fault in your Doctor...
Maybe it is just how I read it...not sure...
I just wanted to say....you are not alone in all this....there are people here who try to post what we are going through in simple words...
I am a nurse...but I don't use all the medical terminology...
I guess what I am trying to say is....read further into these post....
There is alot of helpful information being offered here...
I didn't know one thing about TTS a little over a month ago...but before my surgery...I found this site...and beleive it or not...I have found that the people who have gone through the surgery and have posted how they were doing as time went by....has really helped me....and informed me before I got to that step....
Now...I hope by what I am going through....will help someone else also...
Just remember....PATIENTS is the key....
I would love to go back to work....but I was informed by the Ortho that it could be a year before I go back...
but...I would gladly wait a year if it meant me healing properly and being able to walk normal in the long run...

Re: Tammie...Sounds like we have some things in common../Cindy

Tammie on 8/13/01 at hrmin (056626)

Cindy,
Thanks for taking time to write me I do thank u! You have a lot of points that are true.I guess I might be more relaxed with all of this if I understood more I do not like when I feel like I am out of control with my self so to speak. I am a relitivly healthy person who never goes to a Dr. And Honestly except a gyn I dotn think I have been to a dr. in over 10 yrs.So then this happened and well I do not really like to go tot dr.s lol poor guy he proably is a great dr. I just am not happy about this whole thing, what was supposed to be 2 weeks or so and most of 8 turned into almost 4 months for something that everyone assured me was minor surgery on my foot.Now I have so many people questioning me on why I am still off and telling me I am abuser of the system and what kind of quack did I get, and on and on,I worry as I do not know what is right treatment and what I should expect next, I was upset as I took allot of flack for choosing a pod man to do the surgery,as most felt they are not qualified, I was most comfortable with him, he seemed honest and he did seem caring, and well He gave me the first dreaded cortisone shot when I was begging no, because I was afraid he promised me he would go easy he held my hand and let me collect myself and then said he would quit anytime I wanted! He kept his word. So there the trust began! He tryed many more treatments then the ortho guy did also.You see I work in a geriatric home and there are nurses and house docs and we have a pod to, well all have own thougths on things and trying to tell me what I was doing wrong,not to be mean they thought they were helping but no it was setting in some doubt, then I come here and most are against the surgery and what did I do well listened to my dr. whos said he thought it was best, he did not push me tho I will say he was for it along with the hubby who wanted this to all stop, I felt out of control and unable to make any decisions.I sometimes feel as tho they see me and hear me but dont understand me, I dont mean to doubt,as I want to trust him and believe what he says, but when u dont understand what is happening to you and your body and why or for how long or are u sure this is the right dx you do doubt! I want to be informed of what is going on and how we are going to fix it and get me back to work, I am sure by now u know I am impatient to go back to the work I love, and the need to return before my insurance runs out as I do have a son in college and a senior in hs and a daughter, not to mention a hubby who has his own medical problems and who knows if and when he will be able to continue working I have till Oct. to get well enough to get back without a financial problem.I guess this is also weighing on my mind.This pod I am seeing has all along had a feeling that nerves were involved he stated from the start, but he was hoping it was nothing that would or could not be relieved with conservitive treatment and felt the first surgery of pf release and the spur taken care of would be all that was needed or hoped. Now he is starting from start again with the dx he is giving of tts and we are working with the first shot and a new inflam and ultram and pt which I am feeling and seeing no improvement and am of course wondering and worring what is next. Time is a frame in my mind for me always I am impatient. I do feel better after seeing him and he reasures me I guess that I am not completely nuts and that yes he knows I have real pain and we just have to try things . But when people start questioning me it gets me going again! I am not oposed to any treatment he has ever offered , except I am a bit nervous about the cortisone shots. I read so much that it makes me wonder just how man I should get. I did have 3 all before may, and now I had 1 two weeks ago, I feel he will hit it again this wed. morning, after last expierance I am really scared I mean really I would rather get beat with a belt then do it again, but if he assures me that is waht i need I will do it as I do want to get better. Now I hope I have not bored u to tears as not my intent, I do feel awful of any bad mouth I might have given my pod, as really when I had a bad expierance with new pt and they did not follow his script he was wonderful and he took care of it and took care of me in the most compassionate way. So tho he is a very busy man he did come thru in my so called hour of need and at that time I thought I would rather die then live with the pain. So back on course and things are calmed down and now it is just the wondering and the waiting for something anything to feel as tho we progressed. Just a little tunnel of hope would make me feel better, I fear another surgery which could be in the cards, as look how long it has taken for the first to get better, and yes I would say it was better as I could not even walk on foot now I can put weight on hole foot! So in any case thanks for the support and encouragement, I know I whine on but must admit I always feel better to tell someone and get it out as here at home I cant as that shows I am weak and I have never ever been weak lol. I do repeat that NEVER lol.Thanks Cindy!

Re: Nerve Conduction Velocity Tests for TTS--ps

Carol C on 8/13/01 at hrmin (056662)

As rediculous as it may seem...I have a great fear of the injection in my foot. At this time, I am on one week into a four week trial of VIOXX.
No results as of yet. Is there anything anything I can do to allay my
fear of the injection into the foot or is is going to be as painful as
I think and I just need to bite the bullet and take the injection and
deal with it? Am I the only one with this fear of this injection in
the foot?

Re: more details

kim on 8/18/01 at 08:23 (057074)

Ed Davis DPM when you mention A. lEE dELLON IN BALTIMORE DO YOU MEAN AT JOHN HOPKINS OR THE UNIVERSITY OF MARYLAND. GIVE ME MORE SPECIFIC DIRECTIONS AS TO HOW TO FIND THIS DOCTOR. I LIVE IN CHAMBERSBURG PENNSYLVANIA. MAYBE YOU COULD GIVE ME THE NAME OF A GOOD DOCTOR IN THIS AREA AS WELL AS DIRECTIONS TO DR. dELLON

Re: more details

Dr.Zuckerman on 8/18/01 at 10:57 (057085)

He is at John Hopkins Uninversity. His web site is http://www.dellon.com

Re: RE: varicose veins

ken G on 8/28/01 at hrmin (058254)

I have had a surgery-epf and morton's neuroma still more
pain in arch pulls on step i take and balls of the foot
really hurts when tip toes it fells like the toes are
going through the floor.My emg/ncv said compatible with
tarsal tunnel-posterior tibial nerve irriatation and mri
said venous engorgement in tarsal tunnel.

Can you access this and make good recommendations about
my condition?
wwww.kpgbus1@hotmail.com

Re: I need advice.

Bellel on 8/09/01 at 22:20 (056113)

I don't know if this will help or not. In June I was diagnosed with TTS, and since I didn't want to rush into surgery, my Dr. put me in a 'boot for 6 weeks. No pain while I was wearing it. Still had pain after 6 wks so he suggested orthotics, which I am now wearing. I am still having some pain, but much better. Finally started accupuncture, have had 5 treatments, and my accupuncturist says it will take 10. I am feeling much better with only occasional pain. Don't know if the orthotics did it or the Acc. I would suggest trying all options before surgery, since I heard it is a long recovery. Guess I am chicken, but I had orthoscopic knee surgery 2 years ago, and am still suffering from that.
Good luck

Re: I need advice.

wendyn on 8/09/01 at 22:56 (056120)

Hi Susanm and welcome.

The heat from inflammation seems to be common, it's due to the nerve irritation and increased blood flow. Elevating and/or icing can sometime help bring it down. Easy for me to say to you in a post, the heat and pain drive me flippin crazy sometimes.

The nerve conduction test may have aggravated your feet causing increased symptoms today. If it did, I wouldn't think it should last long. (I've never heard of it happening but I'd have to think it would be possible).

Most of us with TTS have had normal nerve conduction tests - take it as a good thing that there isn't anything else going on. Have you had blood tests done as well?

Surgery for most is considered a last resort. Success rates seem to range from anywhere from 50% to 90%. The better results are found when there is an actual mass sitting in the tunnel - rather than no known cause.

Don't rush into surgery - please read here and educate yourself lots. There's a link at the top of the main TTS page to some FAQ. Many of us have had good results with conservative treatment.

Re: I'd bet it's not even TTS

elliott on 8/10/01 at 08:38 (056138)

You're not the first to come on here describing pain in an atypical location and say you've been diagnosed with TTS. TTS is defined as entrapment of the posterior tibial nerve or its branches at the medial malleolus, that is, in the area just behind and below the medial side of the ankle (which is more or less the tarsal tunnel). You would typically feel stiffness, pain or nervy sensations at the medial ankle (or at least that something doesn't feel right there) and often medial arch pain, with nervy sensations possibly radiating from ankle into the heel, calf, and/or toes. That doesn't sound like anything you've described. It is possible to have a more distal entrapment of one of the nerve branches or their branches. There are a couple of branches of the medial plantar nerve running through the ball, as well as those of the lateral plantar nerve on the lateral side of your ball (do you have any tingling in any toes by any chance? you didn't say so), but I'd say the chances that you had a distal entrapment in the same location in both feet simultaneously is ridiculously small, and, assuming you have no other symptoms than those described (at ball), I'd say the chances your podiatrist doesn't know much about TTS is much greater. Sorry to be so blunt. But I really, truly feel the pain of those going through TTS or getting unnecessary surgery for it, and bluntness gets the point across.

The enhanced feeling from the nerve conduction test is temporary and should subside within a week ot two at most, so don't worry about that.

Burning in the balls of both feet can be due to many things, e.g. neuromas (much more common than TTS and often due to tight shoes) or other feet defects, ill-fitting shoes, tight muscles, even a back ailment. Did you switch to new shoes? If you haven't done so already, for starters I would switch shoes to something feeling more comfortable (not dress shoes, but those with a nice wide cushioned platform for ball, with plenty of room for your toes). Some other suggestions are rest, ice, NSAIDS, orthotics. Hopefully some of the podiatrists here (who seem both informed and gracious to offer advice) can enlighten you further. All those treatments you mentioned are worth a try, but I'd consider going to another doc (different podiatrist and/or foot/ankle ortho) for another opinion.

Re: I need advice.

Dr. Zuckerman on 8/10/01 at 08:38 (056139)

Hi,

Burning in your feet can be caused from a number of things
1. neuroma
2. Decrease fat padding
3. Diabetes
4. Distal plantar fasciitis, bursitis
5 Hammer toes or contracted toes

What have your treatments been and tell us more about the pain and buring. When where and how

Re: you're not chicken, you're smart

elliott on 8/10/01 at 08:49 (056142)

Actually, if the surgery really, truly is successful, the recovery is not really that long: assuming no other complications or circumstances, one usually feels at least some immediate relief and should be walking normally three weeks post-op, although some of the nervy symptoms or their surgical aftermath might take up to a year or longer to diminish with continued improvement for that long, but that's something anyone should be willing to deal with since they're getting better. The problem is not that it's a long recovery, but that the chances for success are smaller and one can end up even worse than before the surgery.

Re: I need advice.

Darlene K on 8/10/01 at hrmin (056189)

I have just been told I have Tarsal Tunnel along with Plantars F. and A heel spur the size of a baby carrott all in the same foot. HELP I have no idea what T>T> is even about any help would be appricated. Thanks Darlene

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056193)

Wendyn had mentioned 'normal' NCV for patients with TTS. A number of individuals have mechanical irrtiation to the posterior tibial nerve causing TTS like symptoms. That is why rest and biomechanical control often provides relief for such individuals. That is probably not 'true' TTS
and thus does not require surgery.

True TTS usually leads to measurable changes on NCV. There are differences in technique among testers so the sensitivity of the test can vary.

I generally do not move forward with surgical treatment unless there is a positive NCV test for TTS or a high resolution MRI demonstrating constriction or impingement of the posterior tibial nerve. My philosophy is to treat conservatively but agressively if the aforementioned criteria are absent. If there is a positive NCV or MRI, then I would be willing to try conservative treatment but would encourage surgery.
Ed

Re: Nerve Conduction Velocity Tests for TTS--ps

Ed Davis, DPM on 8/10/01 at hrmin (056195)

ps. I am a bit surprised by the number of posts by people diagnosed with TTS as 'true' TTs is not that common. I am also surprised by the number of posts of individuals who have been diagnosed with both TTS and PF or individuals who have had surgery for both entities simultaneously. My concern is that individuals with PF who are contemplating surgery may be under-treated biomechanically, leading to 'pseudo-TTS' and a lot of unecessary surgery. I may stir up a hornets nest here but if I have one fault it is my 'die hard' honesty.
Ed

Re: I need advice.

Ed Davis, DPM on 8/10/01 at hrmin (056196)

I am glad that you recovered without surgery. I wonder if you had true TTS--see my posts here.
Ed

Re: Nerve Conduction Velocity Tests for TTS--pps

Ed Davis, DPM on 8/10/01 at hrmin (056197)

There is concern about the success rate of TTS surgery as well as the recovery. Again, I believe that if we separated those cases that met my criteria for surgery from those that don't, I believe that you would see a higher success rate and easier recovery.
Ed

Re: what's your view on the flip-side issue of NCV?

elliott on 8/10/01 at 14:25 (056202)

That is, how accurate is a positive reading in avoiding false negatives? If it depends on how high the numbers are, then please elaborate.

I've been tested three times (not counting QST, which I won't get into here), once before bilateral TTS surgery and twice after, all by the same respected neuroelectrodiagnostician (what a mouthful, but that's what he calls himself; he's also a certified neurologist). The last time I was tested (Feb 01, 7 months after left foot surgery and 1 year and 6 mos. after right foot surgery), the latencies for both motors in both feet all were 7.0 and over (that's high!), and had even risen from before surgery. (After successful surgery they're supposed to gradually decline to normal or near-normal levels). While I know I have nerve irritation in my left foot, the right foot does not have any very obvious nerve irritation but is weak and near collapse (two years post-op), perhaps along the line of the nerve, although there are other mysterious problems as well, some still from pre-op and others post-op. It would be nice to know if this is or includes a nerve problem, or is it some other post-op problem such as a scar tissue mess or poor technique. There could even be another surgery riding on the answer to this puzzle. Thanks in advance for any insight you may have.

Re: Nerve Conduction Velocity Tests for TTS

wendyn on 8/10/01 at 14:29 (056203)

Dr Ed - you bring up issues that confuse a lot of us.

Is it true - that TTS stands for a syndrome - which is, essentially a collection of symptoms (not necessarily a 'cause')?

Is it fair to say that you can have 'TTS' from different causes?

While it's true that I've had normal nerve conduction tests - I've had 3 podiatrists, 2 sports med doctors,1 orthepedic surgeon,1 neurologist,1 physiatrist, 2 physio therapists tell me I have TTS. So - no, not according to the test, yes according to half a dozen or more doctors.

This, I believe, is one of the huge problems when dealing with TTS - the difference in opinions on how it's diagnosed and what exactly it means.

Re: and then let's distinguish between...

elliott on 8/10/01 at 14:58 (056206)

...neuralgia, neuroma, neuropraxia, neuropathy, neuritis, etc., etc. (anyone know the distinctions by heart?).

I think most orthos use NCV as supporting evidence, and don't automatically reject when physical examination and patient description is compatible with TTS. Sure, there are several causes, but most can be classified by ailment (diabetes, rheumatoid arthritis, gout, all of which can clog up the nerves), group (e.g. runners--unclear, with overpronation and tugging of nerve high up on the list) or event (e.g. trauma such as ankle fracture which entraps nerve). If one has, say, a positive Tinel's sign and complains of nervy symptoms at medial malleolus, I think they'll be taken seriously. But Ed is making a good point, that even many pods rush to label whatever the foot pain is wherever it is as TTS because they are not familiar with it, and that those with a whole host of degenerative problems should be treated with the utmost caution, as it may very well not be TTS, not be obviously limited to TTS with source and cause of pain elsewhere, or have low probability of surgical success.

Re: Nerve Conduction Velocity Tests for TTS--ps

Dr. Zuckerman on 8/10/01 at 15:28 (056211)

It is also very unusal for TTS without some kind of injury to the area such as an inversion sprain.

Re: what's your view on the flip-side issue of NCV?

Ed Davis, DPM on 8/10/01 at hrmin (056212)

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

Re: High resolution MRI for diagnosis

Matt L on 8/10/01 at 15:44 (056213)

I heard about this recently and check with a surgeon at Johns Hopkins which recently got the technology (MRI Neurography?). He led me to believe that it was not a good tool for tts or smaller nerves in the foot. Do you think differently? If so, what technology is utilized and where can it be found.

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056215)

The term 'syndrome' is used because the result of nerve compression can cause a range of symptoms consistent with a damaged nerve. It really is a very specific process though involving compression of the posterior tibial nerve so use of the term syndrome is misleading--syndrome here refers to the end effects as opposed to the actual pathology.

Keep in mind that the accuracy of NCV testing varies from technician to technician. Assume for a moment that the sensitivity of the test is poor, those with positive tests would be likely to have TTS but a lot would be missed. I have to admit that I am a bit lucky to have an excellent tester in my area, Dr. Saeed Mohammed of Tacoma, WA. A number of things in the canal in which the post. tib. nerve runs can place pressure on the nerve, including varicose veins--this is why a high resolution MRI can be very helpful. If the MRI shows impingement of the nerve then the NCV is probably not necessary.

Finally, if NCV and MRI are both negative, it is possible to still have TTS if there is overwhelming clinical evidence supporting it--may be your case. On the other hand, if you are being treated for TTS and not getting results (I don't know your history), I would be tempted to look further.
Ed

Re: me to but after reading all of that above I am more then lost

Tammie on 8/10/01 at 16:30 (056223)

This is all quite interesting um if you understand all of this medical talk, which leads me to believe that allot of our dr.s talk this way and we the lay person cannot retain all of what is said , or understand most except maybe a few words to work with! I liked allot of your explanations that were given and read and copied many but this above is like french to me, and gee I have trouble spelling and typing english. I think I feel more confused reading thease posts then I did before> Which let me tell u was pretty darn confused then! So where do you go and what do you do if your dr. says u have this tts and feels the testing is not necc>? And what if they think it is scar tissue from former surgery? My gosh this gets deep, What happened to easy solutions?And simple words for common people? I am a lost lamb being led to slaughter I feel!

Re: RE: NCV

elliott on 8/10/01 at 17:20 (056227)

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.

Re: Nerve Conduction Velocity Tests for TTS

elliott on 8/10/01 at 17:22 (056228)

I had an MRI on left foot pre-op which showed nothing, and then big-name TTS surgeon observed during surgery just about the largest vein he'd ever seen in his career. So does an MRI pick up a vein or not?

Re: RE: NCV

Ed Davis, DPM on 8/10/01 at hrmin (056238)

There are two areas to look at. The neurologic workup suggests TTS and I suspect that it is a correct diagnosis and that the surgery for it failed.
The second area, tibialis posterior dysfunction brings further questions.
We divide PTTD into 3 stages. The first stage involves primarily tenosynovitis, that is, inflammation and swelling of the tendon. I call this the 'warning phase' because it tells us that the tendon is in trouble.
The tibialis posterior tendon is the primary invertor (rolls the foot out) of the foot. It attaches primarily to the navicular bone (bone at the top of the arch) and also to other bones in the tarsus. The reason to consider a synovectomy would be for symptomatic relief of tendon pain but also, in your case, to prevent the swollen tendon from pressing on the posterior tibial nerve. The synovial tissue surrounding the tendon does have a role in providing nutrition to the tendon.

Stage I PTTD tends to go on to Stage 2 (degeneration with intrasubstance tear) if strain is not removed from the post. tibial tendon. There are a number of specialized orthotic designs out there for this purpose. A larger factor than the synovectomy in leading to what sounds like a progression to Stage 3 (atrophy and tendon tear) is the degree of orthotic or biomechanical control provided--it is critical.

Do not run and minimize activity on the right foot if it feels 'like it is going to collapse.' If your doc cannot tell you what is going on, see someone who does. I will try to come up with some names if I know what city you live in.
Ed

Re: High resolution MRI for diagnosis

Ed Davis, DPM on 8/10/01 at hrmin (056241)

We do not expect any MRI to have sufficiently high resolution to be able to look at the small nerves of the foot. What we are using the MRI for is to find other structures (eg. varicosities, growths, cysts) that exist in proximity to the nerve and are compressing the nerve.

A number of MRIs can help but the best resolution I have seen is from a unit using a flexible coil that is wrapped around the foot or ankle. Cascade MRI in the Northgate area of Seattle is the closest one to my area.
Ed

Re: Nerve Conduction Velocity Tests for TTS

Ed Davis, DPM on 8/10/01 at hrmin (056242)

Varicose veins within the tarsal tunnel may be responsible for up to 25% of TTS cases. The MRI which I use would almost certainly pick up a varicose vein in the tarsal tunnel. A number of MRI units out there may have insufficient resolution to do so.

I use Cascade MRI in the Northgate section of Seattle because they have a flexible coil scanner that is wrapped around the ankle and provides very good resolution. Patients appreciate it because they don't get the claustrophobia that occurs with the large units. I have been using them since about 1996 so it really isn't new technology.
Ed

Re: me to but after reading all of that above I am more then lost

Ed Davis, DPM on 8/10/01 at hrmin (056243)

Tammie:

People on this forum enter with varying levels of background knowledge. The doctors will do their best to answer things in a way that makes sense to you.

Keep in mind that there are individuals who have done a lot of research before posing questions here. They will tend to ask questions based on their knowledge level. If you enter into their dialogue strings, you may find it more advanced than you desire. Consider starting a new question on your own, an original post in which the answer will come directly to you.

It is important that you feel comfortable with the doctor you have chosen, not like 'a lost lamb led to slaughter.' We expect doctors to be good communicators, not just good technicians. If you are not communicating well with your doctor, consider a switch, even if he or she is considered a 'good' doctor.
Ed

Re: Nerve Conduction Velocity Tests for TTS

wendyn on 8/10/01 at 21:26 (056257)

Thanks Dr Ed - I look forward to continuing this conversation in a few weeks - I'm going on vacation!!!
Talk to you then!

Re: Ok then I will repost my ?

Tammie on 8/10/01 at 21:46 (056260)

This is my Docs plan what do u think of it? He feels tts is a issue had the pf surgery back in april side incision, lots of pain in area of incision and a hard lump wich sends me into a orbit if touched.Lots of tingling and foot pain inside ankle area to bottom heel arch area to toes, sometimes like a bruise area feeling worsens as the day progresses stiffness in am and throughout day, Night time I feel as tho I have a demon loose in my foot, wont allow me to sleep without something that( just recently the last week ) My dr. gave me to help. His plan is this, gave one shot of cortisone last wed. send me to pt for 3 tms a week (using ultrosound & that ion?? spelling sorry?) try to calm the nerve down he says , may use ice or heat or both, gave me Mobic which havve been on a bit over a week now,(had celebrex, relefen,vioxx) No change, states he will give another cortisone this wed. and continue the plan and will give me up to 4 shots of cortisone, if no changes or no improvment will talk about the surgery . I was closed minded to it did not even want to hear the word. I was the same for the pf and spur removal but we did this similar plan and I ended up with none of thease things working and had the surgery. So what next and how long before I should have some changes if they are going to occur, oh yes orthodics were in this to and I have them as he did them for the pf and he has checked them and seemed to think they are fine , so did the pt lady she liked them to. But then she is the one who stretched me to and had me stretch in barefeet toe stretches wall stretches ankle rotations that I could have commited a crime right then and left me in so much pain that I called my dr. which I do NOT do. My dr. is ok it is me, I have a problem with not being calm and nervous as a bat, I cant remember and I get upset as soon as I hear the shot word, I do usually take hubby with me, to be my ears. I do not like to hear when he says I cant return to work either, I have been off since april 17 I want to go back but I want to be able to walk and to sleep at night to! So now here it is all on the line in my words, what do U think of the plan?In case you wonder my job it is a nurses aide , in geriatrics. Oh Thank u if u decide to read this and try to answer! I have seen a ortho dr. and 2 other pods during the pf thing. My dr. is a D.P.M.FACFS but is a very busy dr. as he has 3 offices and there is one other dr. with him, so his load is large I am sure! We may wait hours for a appointment sometimes! Thanks again

Re: I'd bet it's not even TTS

susanm on 8/10/01 at 21:59 (056261)

elliot,
Thank you for your response. You have addressed some issues that have really concerned me.

First, I have never thought my symptoms were classic TTS. The pain is specific to the balls of both feet with sort of sparking pains in my toes. Sometimes my feet cramp. Sometimes my ankles burn. Sometimes I have buzzing sensations in my feet. They are both warm to the touch. I frequently awaken at night because of these pains. A co-worker tells me I walk as if I dread putting my feet down.

I see my foot doc on Monday afternoon and I plan to pursue a custom orthotic. He talked surgery at the last appointment; however, I have decided against that for all of the reasons that have been brought up in response to my plea for advice.

About shoes...I have not worn fashionable shoes for two years. I can't. Right now I am wearning Birkenstocks with the cushioned footbeds. They seem to work better than anything else I have tried, and believe me, I have spent a boat load of money on shoes I can't wear. I saw a chiropractor last week who could find nothing amiss except for something with my left shoulder. I'm thinking about acupuncture too.

Please continue with any suggestions at all.

Re: Ok then I will repost my ?

Ed Davis, DPM on 8/10/01 at hrmin (056269)

It sounds like you may have painful scar tissue about the incision. Consider a shot of triamcinolone acetonide plus Wydase (an enzyme) to get rid of the scar tissue (pass this message on to your doc).
Ed

Re: Ok Thank u wrote it down to ask him about

Tammie on 8/11/01 at 08:38 (056299)

I will ask him not that i like any more shots, but he would give me the cortisone or whatever anyways no doubt! And I am looking for a answer so not objectable to a trial of anything to help. Did I mention that thease other symptoms of the nervy stuff have been there even before the surgery for the pf stuff? Not that this will not take care of the problem, as maybe it will I am hopeful, but what if it does not, does his plan of treatment sound resonable?Should I ask for more tests? He might be open to trying this shot,but what if he is not?He did not seem to concerned with this lump area as he had said scar tissue to,but seemed more worried about when he squeezed my ankle and then the heel area that the lovely jolts and tingling was worse? I am just wondering as more knowledge has to be to my advantage! And really thank u for answering I do appreciate it, I just am trying to help by helping myself find answers, I cannot keep sitting here on hold forever,I am driving my poor family nuts! They wish me to return to workto if not as a empoyee then as aresident so that I can drive them nuts with whining about being bored and missing my job not to mention keeping hubby awake with my constant trying to get comfortable and up and down as i cannot sleep, but son will leave for college this week so will have another bed as sometimes the couch is in use with kids friends. So U see I am a not so good patient, or patient person.Always looking for a way to heal this quicker and trying anything offered! Thank u again!

Re: Nerve Conduction Velocity Tests for TTS--ps

Carol C on 8/11/01 at 11:03 (056314)

Can you advise me of the diagnostic value of a cortisone injection in
the evaluation of TTS? I am in the evaluation stages for TTS and
don't like the thought of an injection although my orhtopaedic surgeon
would like to proceed with the injection prior to consideration of
surgical options.

Re: RE: varicose veins

elliott on 8/11/01 at 22:28 (056385)

My ortho told me that as a matter of course, varicose veins are not removed during TTS surgery because doing so could cause more harm than good, e.g., disrupting the soundness of area, complications with redirected blood flow, etc. Do you agree? Also, if one is already post-op and still has serious TTS troubles possibly due to those varicose veins, is it then in order to have them removed?

Re: more details

elliott on 8/11/01 at 22:53 (056386)

I live in Baltimore and have been to the best and the brightest here. If you you have an email address, I'll converse further in private. If you know names of podiatrists or others who are especially good with things like orthotic and biomechanical devices and other nonsurgical treatments regarding TTS, heel pain, and PTTD, I'm especially interested. I certainly don't feel like getting a tendon transfer (stage 2?) or a bone fusion (stage 3?) unless I'm sure of the diagnosis and have no choice.

Thanks for the rundown on PTTD, even though I've seen it before. I haven't run in over 10 months; doubt I ever will again. Don't even walk much either. My pain feels just like what I'd imagine serious PTTD to be (again, I didn't have this pre-op). Months and months of rest and inactivity didn't make it any better. Sometimes after a few blocks of walking, my foot loosens up and feels better (although then my heel hurts; my heel pain has not been definitively diagnosed either, but I had that pre-surgery and it's still there; the numbness and burning is not, though, which is why I asked about NCV false positives). Also, after cycling (the last aerobic thing left on earth I can still do) a long distance, my foot feels better for a few hours. That sounds more like scar tissue. I know some tissue extending from that area has been torn further. Any thoughts on scar tissue, both regarding surgery to remove it or other ways to get rid of it? Thanks.

Re: Nerve Conduction Velocity Tests for TTS--ps

Ed Davis, DPM on 8/12/01 at hrmin (056460)

Carol:
Most shots like the one you are referring to include 'cortisone' and a local anesthetic such as lidocaine. Numbing nerves can often be helpful in order to narrow down the area of pathology. The post. tibial nerve gives sensation to most of the bottom of the foot so injecting an aneshtetic to that nerve would temporarily relieve pain from most painful conditions on the bottom of the foot--not bvery specific. Nevertheless, about 30 to 40% of TTS is helped by such shots so go for it.
Ed

Re: more details

Ed Davis, DPM on 8/12/01 at hrmin (056462)

Wow--you live in the city where the best tarsal tunnel surgeon lives: A. Lee Dellon, MD! If I needed surgery I would get on a plane from Seattle to Baltimore to see him. If you are considering a re-do of the TTS surgery--he is the man. I own a CD-ROM of TTS surgery that he has produced and have the podiatric surgical residents I train in Tacoma watch it several times a year.

The posterior tibial tendon dysfunction is a different ballgame and not in Dr. Dellon's armamentarium. The tendon transfer surgery you mention can be successful but conservative therapy is very successful BUT get going on the right orthotic ASAP--the tendon needs to be protected.

My email is: eddavisdpm@hotmail.com
I will be back in the office tommorrow and look up some names. Will be in Chicago from Wed thru Sunday.

There are two basic orthotics in use for Tib. post. tendon deficiency:

1) Ritchie Brace -- has a foot plate as well as a portion that
attaches above the ankle joint.

2) Mueller TPD -- looks more like a conventional foot orthotic.

I prefer the Mueller TPD as it is more comfortable. The Ritchie brace, in theory, could be used for more severe cases than the Mueller TPD
Ed

Re: RE: varicose veins

Ed Davis, DPM on 8/12/01 at hrmin (056513)

Varicose veins are diseased, abnormally enlarged veins. If they exist within the tarsal tunnel they will place pressure on the posterior tibial nerve and must be ligated (tied off). There are a number of papers which implicate varicosities within the tarsal tunnel in 25 to 40% of TTS cases.

Is it possible that he misunderstood your question? Did ask him specifically about varicosities within the tarsal tunnel as opposed to ankle/leg varicosities in general?
Ed

Re: Tammie...Sounds like we have some things in common..

CindyF on 8/13/01 at 15:49 (056604)

Tammie...I have been reading your post on here for some time...
It sounds to me like you might have something simular to what I have been going through...
Back in 1996...I had a surgery on my left heel...what I thought at the time was going to be a heel spur removed...but ended up being a nerve tumor...
Well..anyway...I developed lot's of scar tissue in the area....and I was seeing podiatrist after podiatrist...and all I seemed to get offered was the orthotics...which I bought 2 pair...and the injections...
I had limped on my foot so long...I started having more and more pain...
So I went to see an Orthopedic Dr....and he informed me I had formed scar tissue on my outer ankle also...from not walking straight...so..he first went in and did orthoscopic surgery to remove the scar tissue off the outer ankle...that was in April....I was off of work all this time...
I recently had surgery for Tarsal Tunnel on July 26th...with a second incision on top for more trapped nerves which was all caused by the origional surgery back in 1996....leaving lots of scar tissure throughout my foot...
You see....I had an infection that took a while to heel the wound...
Anyway...here I am...almost 3 weeks after the surgery...and I can tell a difference...even though I haven't bee allowed to walk yet..
I know it is going to be a hard road.....and a long one...but you need to go into this with the knowledge that this didn't happen over night...and it won't fix it's self over night either...
You seem in alot of your post that you don't treally trust your Doctor's oppinion...and that you are looking for something to find fault in your Doctor...
Maybe it is just how I read it...not sure...
I just wanted to say....you are not alone in all this....there are people here who try to post what we are going through in simple words...
I am a nurse...but I don't use all the medical terminology...
I guess what I am trying to say is....read further into these post....
There is alot of helpful information being offered here...
I didn't know one thing about TTS a little over a month ago...but before my surgery...I found this site...and beleive it or not...I have found that the people who have gone through the surgery and have posted how they were doing as time went by....has really helped me....and informed me before I got to that step....
Now...I hope by what I am going through....will help someone else also...
Just remember....PATIENTS is the key....
I would love to go back to work....but I was informed by the Ortho that it could be a year before I go back...
but...I would gladly wait a year if it meant me healing properly and being able to walk normal in the long run...

Re: Tammie...Sounds like we have some things in common../Cindy

Tammie on 8/13/01 at hrmin (056626)

Cindy,
Thanks for taking time to write me I do thank u! You have a lot of points that are true.I guess I might be more relaxed with all of this if I understood more I do not like when I feel like I am out of control with my self so to speak. I am a relitivly healthy person who never goes to a Dr. And Honestly except a gyn I dotn think I have been to a dr. in over 10 yrs.So then this happened and well I do not really like to go tot dr.s lol poor guy he proably is a great dr. I just am not happy about this whole thing, what was supposed to be 2 weeks or so and most of 8 turned into almost 4 months for something that everyone assured me was minor surgery on my foot.Now I have so many people questioning me on why I am still off and telling me I am abuser of the system and what kind of quack did I get, and on and on,I worry as I do not know what is right treatment and what I should expect next, I was upset as I took allot of flack for choosing a pod man to do the surgery,as most felt they are not qualified, I was most comfortable with him, he seemed honest and he did seem caring, and well He gave me the first dreaded cortisone shot when I was begging no, because I was afraid he promised me he would go easy he held my hand and let me collect myself and then said he would quit anytime I wanted! He kept his word. So there the trust began! He tryed many more treatments then the ortho guy did also.You see I work in a geriatric home and there are nurses and house docs and we have a pod to, well all have own thougths on things and trying to tell me what I was doing wrong,not to be mean they thought they were helping but no it was setting in some doubt, then I come here and most are against the surgery and what did I do well listened to my dr. whos said he thought it was best, he did not push me tho I will say he was for it along with the hubby who wanted this to all stop, I felt out of control and unable to make any decisions.I sometimes feel as tho they see me and hear me but dont understand me, I dont mean to doubt,as I want to trust him and believe what he says, but when u dont understand what is happening to you and your body and why or for how long or are u sure this is the right dx you do doubt! I want to be informed of what is going on and how we are going to fix it and get me back to work, I am sure by now u know I am impatient to go back to the work I love, and the need to return before my insurance runs out as I do have a son in college and a senior in hs and a daughter, not to mention a hubby who has his own medical problems and who knows if and when he will be able to continue working I have till Oct. to get well enough to get back without a financial problem.I guess this is also weighing on my mind.This pod I am seeing has all along had a feeling that nerves were involved he stated from the start, but he was hoping it was nothing that would or could not be relieved with conservitive treatment and felt the first surgery of pf release and the spur taken care of would be all that was needed or hoped. Now he is starting from start again with the dx he is giving of tts and we are working with the first shot and a new inflam and ultram and pt which I am feeling and seeing no improvement and am of course wondering and worring what is next. Time is a frame in my mind for me always I am impatient. I do feel better after seeing him and he reasures me I guess that I am not completely nuts and that yes he knows I have real pain and we just have to try things . But when people start questioning me it gets me going again! I am not oposed to any treatment he has ever offered , except I am a bit nervous about the cortisone shots. I read so much that it makes me wonder just how man I should get. I did have 3 all before may, and now I had 1 two weeks ago, I feel he will hit it again this wed. morning, after last expierance I am really scared I mean really I would rather get beat with a belt then do it again, but if he assures me that is waht i need I will do it as I do want to get better. Now I hope I have not bored u to tears as not my intent, I do feel awful of any bad mouth I might have given my pod, as really when I had a bad expierance with new pt and they did not follow his script he was wonderful and he took care of it and took care of me in the most compassionate way. So tho he is a very busy man he did come thru in my so called hour of need and at that time I thought I would rather die then live with the pain. So back on course and things are calmed down and now it is just the wondering and the waiting for something anything to feel as tho we progressed. Just a little tunnel of hope would make me feel better, I fear another surgery which could be in the cards, as look how long it has taken for the first to get better, and yes I would say it was better as I could not even walk on foot now I can put weight on hole foot! So in any case thanks for the support and encouragement, I know I whine on but must admit I always feel better to tell someone and get it out as here at home I cant as that shows I am weak and I have never ever been weak lol. I do repeat that NEVER lol.Thanks Cindy!

Re: Nerve Conduction Velocity Tests for TTS--ps

Carol C on 8/13/01 at hrmin (056662)

As rediculous as it may seem...I have a great fear of the injection in my foot. At this time, I am on one week into a four week trial of VIOXX.
No results as of yet. Is there anything anything I can do to allay my
fear of the injection into the foot or is is going to be as painful as
I think and I just need to bite the bullet and take the injection and
deal with it? Am I the only one with this fear of this injection in
the foot?

Re: more details

kim on 8/18/01 at 08:23 (057074)

Ed Davis DPM when you mention A. lEE dELLON IN BALTIMORE DO YOU MEAN AT JOHN HOPKINS OR THE UNIVERSITY OF MARYLAND. GIVE ME MORE SPECIFIC DIRECTIONS AS TO HOW TO FIND THIS DOCTOR. I LIVE IN CHAMBERSBURG PENNSYLVANIA. MAYBE YOU COULD GIVE ME THE NAME OF A GOOD DOCTOR IN THIS AREA AS WELL AS DIRECTIONS TO DR. dELLON

Re: more details

Dr.Zuckerman on 8/18/01 at 10:57 (057085)

He is at John Hopkins Uninversity. His web site is http://www.dellon.com

Re: RE: varicose veins

ken G on 8/28/01 at hrmin (058254)

I have had a surgery-epf and morton's neuroma still more
pain in arch pulls on step i take and balls of the foot
really hurts when tip toes it fells like the toes are
going through the floor.My emg/ncv said compatible with
tarsal tunnel-posterior tibial nerve irriatation and mri
said venous engorgement in tarsal tunnel.

Can you access this and make good recommendations about
my condition?
wwww.kpgbus1@hotmail.com