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Fads in Medicine

Posted by Ed Davis, DPM on 8/13/01 at hrmin (056582)

I have been in practice since 1982. I have seen thousands of cases of plantar fasciitis. I have seen far fewer cases of tarsal tunnel. The number of cases of plantar fasciitis and tarsal tunnel combined is, in my opinion, very tiny. Yet, I am reading numerous posts about people planning to have or having had combined tarsal tunnel and plantar fasciitis surgery.

Perhaps this is so because this message board contains a lot of tough or unusual cases.

Anyone who has been around for a while has seen trends in medicine come and go. Remember the 1960's when everyone was having their tonsils out.

Dr. Z, Dr. Biehler---help me out on this one. Are there a group of, perhaps foot and ankle orthopods, perhaps on the East Coast ( I practice in the Seattle area) that is 'popularizing' that type of surgery. If so, I must say 'caveat emptor.'(let the buyer beware)
Ed

Re: Fads in Medicine

elliott on 8/13/01 at 15:30 (056602)

I think it's coming primarily from Baxter in Houston.

Check out the link below:

http://wheeless.belgianorthoweb.be/o16/1060.htm

Look whose name is at the bottom of the page. Then click on distal tibial TTS, and read about the connection to the abductor and plantar fascia.

I think they're groping for reasons why TTS releases fail too often, and one popular theory is that there is a PF/TTS connection, and failure to release at least part of the fascia is a reason for some of those failures.

My neighbor across the street from me, a research neurologist who actually has nothing to do with surgery and TTS (he works for a pharmaceutical company), told me that within the last year or so he read in one of those widely circulated health/fitness magazines (can't remember if it's Prevention, Survival, Outdoors--he likes wilderness-type vacations, hence the subscription) a detailed article (believe it or not) claiming that TTS and PF were part and parcel of the same thing. I'd bet anything Baxter was quoted. Regardless, it got wide distribution.

Re: Fads in Medicine

Maureen S on 8/13/01 at 15:30 (056603)

DR Davis,

I understand where you are coming from!! The first pod that I saw was adimant that I couldn't have both pf and tt at the same time let alone in both feet the odds were against it he even said impossible. I followed all his advise ice, taping stretching, orthotics even had him approve of any shoes that I wore, rest, limit on activities. This went on for almost a year and I had no significant improvement so I started PT and accupuncture. When these things were not working as well as they should I started to do some research on foot pain and found info on tts. (oh initially his dx was only pf and I knew nothing about tts) when I came to him about this notion about possible tts thats when he said impossible and that since my symptoms were not improving as they should I should find another job and consider ESWT before a surgical option for the pf. I was very interested in ESWT but wanted to make sure that I didn't in fact have any other foot abnormalities. Since I am a nurse I asked the Dr that I worked for to order the NCV test and I went to a Neurologist and the test was very positive bilaterally!! After knowing this I went back to the pod with these results. He then ordered a bunch of labs to find if I had any other reasons for the foot pain , all blood tests were normal( thank god!! ) But I still had to deal with what we knew, Even with this information he was not convinced about the tts. I decided to get another opinin. I had been in contact with my sister-in-law who had worked for a pod for 11 years and I also knew him personally but I hadn;t thought about seeing him as a patient since he was so far away. She convinced me to come and it was the best thing that I ever did. He went over all the previous tests and gave me a thourough exam. He believed that I did have tts and pf in both feet. He then ordered an MRI to r/o the cause of intrapment. The MRI also confirmed these dx and I decided after 3 more months of conservative tx even nerve blocks that surg was necessary. As you know from my prev. post that I am post-op today 4 1/2 wks (Lft. foot). My sutures were removed on friday and I have a cam walker now and need to gradually bear wt and use the crutches for the next two weeks. At this time my L foot feels great but the R has not liked the burden its been under. I know that I need to take things slowly and hopefully I am on the right track. Sorry for the long post but I thought my story would help and this is only a very condensed version.
Maureen

Re: Fads in Medicine

Ed Davis, DPM on 8/13/01 at hrmin (056622)

Maureen:

Sounds like your case was definitely the real thing.
Ed

Re: Fads in Medicine

Ed Davis, DPM on 8/13/01 at hrmin (056627)

Elliot:

I agree that there is some groping for a 'cure' in frustration. I am not comfortable with doing more surgery than is really necessary.

One of the interesting things in Lee Dellon's CD-ROM on tarsal tunnel surgery is a release done at the porta pedis. The porta pedis is the area in the arch area of the foot where the medial and lateral plantar nerves enter the foot after emerging from the actual tarsal tunnel. He feels that a significant portion of entrapment occurs at that area-- an area that is technically difficult to release and thus few surgeons do it. I started doing releases in that area as have a number of my colleagues and feel that it has improved our results. The symptoms of entrapment at the porta pedis are similar to entrapment in the tarsal tunnel except that the paresthesias (abnormal sensations and pain) may be along the distributions of just the medial plantar nerve or lateral plantar nerve BUT definitely different than plantar fasciitis.

There is a branch off the lateral plantar nerve that has been named after Baxter--called Baxter's nerve. It wraps around the base of the heel bone (calcaneal tuberosity) and has been implicated in heel pain by Baxter. A lot of people talk about it, but on a more practical basis, few have confirmed it as a problem in their heel pain patients.
Ed

Re: Ed: I don't see that much true TTS

Dr. Zuckerman on 8/13/01 at 19:43 (056649)

I really don't see that much true TTS. I am seeing alot of pf releases and TTS surgeries alot of Dr. Baxter or someone he trained. The first combination TTS /pfrelease I ever saw was when John H. came to New Jersey for ESWT treatment.

I have been in practicc since 1979 and still can't remember that much TTS

I work with two four year trained foot and ankle surgeons one trained at Doctor hospital and still don't see that much TTS. I have one case in my office that is a real TTS due to an inversion sprain .

I also haven't seen Dr. Baxter nerve in twenty two year either. I guess it is either one or two things. Either it doesn't exist or I don't know what I am looking at . Who knows

Re: Fads in Medicine

Dr. Zuckerman on 8/13/01 at 19:46 (056651)

Or was a part of the pf released also ?

Re: Fads in Medicine

Scott2 on 8/15/01 at 12:13 (056791)

Dr. Davis,

I am not a doctor, but a patient that had a distal tarsal tunnel release and partial plantar fascia release on Feb 16, 2001. The information I provide below is my account and for whatever it is worth, perhaps can help with why I had this type of operation done.

Prior to the surgery, I went through 18 months of different types of treatments and methods for determining what was causing me so much pain in my heel. Quick history - I am 33 yrs old, male, very active (was training for a marathon when the pain caused me to stop running), no other health problems or history with health problems.

I stopped all running and had the following done over a 12 month period:

- Icing
- Rest
- Stretching
- Ibuprofen
- Taping
- Cortisone shots (two different occasions)
- Orthotics (pre and post surgery - different pairs)
- Casting (for three weeks - did nothing)
- MRI (nothing abnormal found)
- Night brace
- Lots and lots of visits to the Podiatrist (two different ones)

None of these cured my condition. I had no pain in the morning getting out of bed and then lots of pain later in the day (which is somewhat different than traditional PF). When my podiatrist performed the simple tapping for a positive Tinel sign, I definitely had tingling throughout the foot and toes.

My best friend is an Orthopaedic surgeon located back East (I am in southern CA) and he was the first person (MD) to recommend having both a distal tarsal tunnel release and partial plantar fascia release because it was in his opinion to take care of both at the same time when doing one operation because the success rate was higher than just doing a PF release.

My podiatrist, again, located in southern CA, agreed and because none of the other treatments worked, he performed the operation. Post-op he said I definitely had nerve entrapment. Now as to the plantar fascia release, I don't know if that was really necessary or not, but I had it done anyway because it could not be ruled out.

I did not have any nerve conduction tests done because from speaking with both of them, the results of the test could not prove or disprove TTS.

Six months post-op, I am running again. I wear orthotics when I run and I feel that the surgery was a success. I was actually cleared to run a little sooner, but seemed to have developed a mild case of plantar fascitis in the non-surgery foot from all of the weight bearing it took on during my recovery.

In my personal opinion, I think if I would have only done a plantar fascia release, my situation would not have gotten better because of the nerve entrapment. It was one of those things where my body told me that it was more than just a bad case of tissue inflammation.

My foot is still funny at times, and I still ice and stretch everyday. I am not running that much or that far, but my pain tolerance and amount of pain is almost nothing compared to my situation prior to surgery.

I could not walk for any period of time prior to surgery without major pain and an immediate need to get off of my feet.

As to your concern for perhaps unnecessary surgery, I don't know - you may or may not have a case. I am sure all of us here really appreciate you taking the time to post your thoughts and provide input. It helps all of us when we have professional input to add to our posts in search of answers.

As you mentioned, many people here do have some extreme cases. The proper diagnosis, from many of the messages I have read, seems extremely difficult to pinpoint - and surgery success rates are not great. Foot problems are really tough to deal with and even harder to deal with when there are no clear answers.

Perhaps that is why so many of us are willing to try almost anything or have 'extra' procedures done in the hopes of not having pain. If the surgery did not work, I am sure I would have sought out more answers until the pain was gone and I could return to my active lifestyle. I think more than anything, each case is very unique which makes it hard to find a solution that works for each person.

Sorry this is so long, but I hope it helped, and perhaps helped others. Again, thank you for taking the time to provide your input. It helps all of us.

- scott

Re: Fads in Medicine

elliott on 8/13/01 at 15:30 (056602)

I think it's coming primarily from Baxter in Houston.

Check out the link below:

http://wheeless.belgianorthoweb.be/o16/1060.htm

Look whose name is at the bottom of the page. Then click on distal tibial TTS, and read about the connection to the abductor and plantar fascia.

I think they're groping for reasons why TTS releases fail too often, and one popular theory is that there is a PF/TTS connection, and failure to release at least part of the fascia is a reason for some of those failures.

My neighbor across the street from me, a research neurologist who actually has nothing to do with surgery and TTS (he works for a pharmaceutical company), told me that within the last year or so he read in one of those widely circulated health/fitness magazines (can't remember if it's Prevention, Survival, Outdoors--he likes wilderness-type vacations, hence the subscription) a detailed article (believe it or not) claiming that TTS and PF were part and parcel of the same thing. I'd bet anything Baxter was quoted. Regardless, it got wide distribution.

Re: Fads in Medicine

Maureen S on 8/13/01 at 15:30 (056603)

DR Davis,

I understand where you are coming from!! The first pod that I saw was adimant that I couldn't have both pf and tt at the same time let alone in both feet the odds were against it he even said impossible. I followed all his advise ice, taping stretching, orthotics even had him approve of any shoes that I wore, rest, limit on activities. This went on for almost a year and I had no significant improvement so I started PT and accupuncture. When these things were not working as well as they should I started to do some research on foot pain and found info on tts. (oh initially his dx was only pf and I knew nothing about tts) when I came to him about this notion about possible tts thats when he said impossible and that since my symptoms were not improving as they should I should find another job and consider ESWT before a surgical option for the pf. I was very interested in ESWT but wanted to make sure that I didn't in fact have any other foot abnormalities. Since I am a nurse I asked the Dr that I worked for to order the NCV test and I went to a Neurologist and the test was very positive bilaterally!! After knowing this I went back to the pod with these results. He then ordered a bunch of labs to find if I had any other reasons for the foot pain , all blood tests were normal( thank god!! ) But I still had to deal with what we knew, Even with this information he was not convinced about the tts. I decided to get another opinin. I had been in contact with my sister-in-law who had worked for a pod for 11 years and I also knew him personally but I hadn;t thought about seeing him as a patient since he was so far away. She convinced me to come and it was the best thing that I ever did. He went over all the previous tests and gave me a thourough exam. He believed that I did have tts and pf in both feet. He then ordered an MRI to r/o the cause of intrapment. The MRI also confirmed these dx and I decided after 3 more months of conservative tx even nerve blocks that surg was necessary. As you know from my prev. post that I am post-op today 4 1/2 wks (Lft. foot). My sutures were removed on friday and I have a cam walker now and need to gradually bear wt and use the crutches for the next two weeks. At this time my L foot feels great but the R has not liked the burden its been under. I know that I need to take things slowly and hopefully I am on the right track. Sorry for the long post but I thought my story would help and this is only a very condensed version.
Maureen

Re: Fads in Medicine

Ed Davis, DPM on 8/13/01 at hrmin (056622)

Maureen:

Sounds like your case was definitely the real thing.
Ed

Re: Fads in Medicine

Ed Davis, DPM on 8/13/01 at hrmin (056627)

Elliot:

I agree that there is some groping for a 'cure' in frustration. I am not comfortable with doing more surgery than is really necessary.

One of the interesting things in Lee Dellon's CD-ROM on tarsal tunnel surgery is a release done at the porta pedis. The porta pedis is the area in the arch area of the foot where the medial and lateral plantar nerves enter the foot after emerging from the actual tarsal tunnel. He feels that a significant portion of entrapment occurs at that area-- an area that is technically difficult to release and thus few surgeons do it. I started doing releases in that area as have a number of my colleagues and feel that it has improved our results. The symptoms of entrapment at the porta pedis are similar to entrapment in the tarsal tunnel except that the paresthesias (abnormal sensations and pain) may be along the distributions of just the medial plantar nerve or lateral plantar nerve BUT definitely different than plantar fasciitis.

There is a branch off the lateral plantar nerve that has been named after Baxter--called Baxter's nerve. It wraps around the base of the heel bone (calcaneal tuberosity) and has been implicated in heel pain by Baxter. A lot of people talk about it, but on a more practical basis, few have confirmed it as a problem in their heel pain patients.
Ed

Re: Ed: I don't see that much true TTS

Dr. Zuckerman on 8/13/01 at 19:43 (056649)

I really don't see that much true TTS. I am seeing alot of pf releases and TTS surgeries alot of Dr. Baxter or someone he trained. The first combination TTS /pfrelease I ever saw was when John H. came to New Jersey for ESWT treatment.

I have been in practicc since 1979 and still can't remember that much TTS

I work with two four year trained foot and ankle surgeons one trained at Doctor hospital and still don't see that much TTS. I have one case in my office that is a real TTS due to an inversion sprain .

I also haven't seen Dr. Baxter nerve in twenty two year either. I guess it is either one or two things. Either it doesn't exist or I don't know what I am looking at . Who knows

Re: Fads in Medicine

Dr. Zuckerman on 8/13/01 at 19:46 (056651)

Or was a part of the pf released also ?

Re: Fads in Medicine

Scott2 on 8/15/01 at 12:13 (056791)

Dr. Davis,

I am not a doctor, but a patient that had a distal tarsal tunnel release and partial plantar fascia release on Feb 16, 2001. The information I provide below is my account and for whatever it is worth, perhaps can help with why I had this type of operation done.

Prior to the surgery, I went through 18 months of different types of treatments and methods for determining what was causing me so much pain in my heel. Quick history - I am 33 yrs old, male, very active (was training for a marathon when the pain caused me to stop running), no other health problems or history with health problems.

I stopped all running and had the following done over a 12 month period:

- Icing
- Rest
- Stretching
- Ibuprofen
- Taping
- Cortisone shots (two different occasions)
- Orthotics (pre and post surgery - different pairs)
- Casting (for three weeks - did nothing)
- MRI (nothing abnormal found)
- Night brace
- Lots and lots of visits to the Podiatrist (two different ones)

None of these cured my condition. I had no pain in the morning getting out of bed and then lots of pain later in the day (which is somewhat different than traditional PF). When my podiatrist performed the simple tapping for a positive Tinel sign, I definitely had tingling throughout the foot and toes.

My best friend is an Orthopaedic surgeon located back East (I am in southern CA) and he was the first person (MD) to recommend having both a distal tarsal tunnel release and partial plantar fascia release because it was in his opinion to take care of both at the same time when doing one operation because the success rate was higher than just doing a PF release.

My podiatrist, again, located in southern CA, agreed and because none of the other treatments worked, he performed the operation. Post-op he said I definitely had nerve entrapment. Now as to the plantar fascia release, I don't know if that was really necessary or not, but I had it done anyway because it could not be ruled out.

I did not have any nerve conduction tests done because from speaking with both of them, the results of the test could not prove or disprove TTS.

Six months post-op, I am running again. I wear orthotics when I run and I feel that the surgery was a success. I was actually cleared to run a little sooner, but seemed to have developed a mild case of plantar fascitis in the non-surgery foot from all of the weight bearing it took on during my recovery.

In my personal opinion, I think if I would have only done a plantar fascia release, my situation would not have gotten better because of the nerve entrapment. It was one of those things where my body told me that it was more than just a bad case of tissue inflammation.

My foot is still funny at times, and I still ice and stretch everyday. I am not running that much or that far, but my pain tolerance and amount of pain is almost nothing compared to my situation prior to surgery.

I could not walk for any period of time prior to surgery without major pain and an immediate need to get off of my feet.

As to your concern for perhaps unnecessary surgery, I don't know - you may or may not have a case. I am sure all of us here really appreciate you taking the time to post your thoughts and provide input. It helps all of us when we have professional input to add to our posts in search of answers.

As you mentioned, many people here do have some extreme cases. The proper diagnosis, from many of the messages I have read, seems extremely difficult to pinpoint - and surgery success rates are not great. Foot problems are really tough to deal with and even harder to deal with when there are no clear answers.

Perhaps that is why so many of us are willing to try almost anything or have 'extra' procedures done in the hopes of not having pain. If the surgery did not work, I am sure I would have sought out more answers until the pain was gone and I could return to my active lifestyle. I think more than anything, each case is very unique which makes it hard to find a solution that works for each person.

Sorry this is so long, but I hope it helped, and perhaps helped others. Again, thank you for taking the time to provide your input. It helps all of us.

- scott