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MD with TTS has questions about TTS for Doc and fellow TTS suffers

Posted by GaryZ on 10/18/01 at 20:46 (063257)

Sometime about July 2001 I developed severe burning and tingling on the
bottoms of both of my feet as well as fasiculations of my calf muscles. The symptoms wax and wane. Both feet hurt at rest as well as with walking.
I saw my MD and have since saw a podiatrist, Orhtopod, and a neurologist. Lab work, xrays and initial motor EMG's were negative. I am do to have sensory nerve studies. Orthothotics seem to help although, at times they are uncomfortable on my arches ( I bring two pairs of shoes to work and at times switch off).

I am a ER Physician and am on my feet all day. My hobbie is cycling and I am on a bicycle team and previously rode 200 miles a week (this has curtailed significantly since my feet started hurting). The symptoms are at times worse the day after a ride.

I saw a neurologist that started me on Neurontin. I got tired and slept 5 hours after the first 300mg dose. Currently my feet are soaking in ice water (my daughter has her feet in as well out of sympathy ).

Most of the MD's in my medical community have not seen many if any cases of
TTS.

My questions are:

Is it common to have both feet act up at the same time ?

Is bicycling associated with TTS ? If so what can I do to be able to continue my favorite sport ?

With new onset TTS are there any specific treatments that need to occur ASAP ?

Are there centers of excellence for evaluation and treatment of TTS ?

Any other suggestions are appreciated.

Gary

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

wendyn on 10/18/01 at 22:28 (063268)

Welcome Gary...

Many of us have symptoms in both feet - although most people notice it usually starts in one - then in the other.

With you lab tests, I would think they would test you for diabetes, low B12, thyroid, RH factor, and for lupus.

Although many doctors have told me that biking should not aggravate TTS - it does.

A recumbent bike may help - but listen to your bod.

TTS seems to be very misunderstood, often misdiagnosed, and somewhat of a mystery. Are your orthotics new? Can you describe them?

Re: welcome

elliott on 10/19/01 at 08:20 (063280)

I thought it was theoretically impossible for docs to get TTS. :-) I have had bilateral athletic TTS (running induced). I also cycle. You say you have fasiculations. That's such a big word I had to look it up. It think it's spelled 'fasciculations'. (No wonder I didn't know what it was. :-))

I have two questions for you:

1. Where exactly on the bottoms of your feet are your symptoms (heel, arch, ball, other, medial, lateral, middle, etc.)? This is extremely important. Also, any medial ankle discomfort? Any back trouble at all?

2. Did you dramatically increase your cycling mileage shortly before onset or make other bike changes (e.g. seat height)?

Partial answers to your questions (pending your response to the above):

It may be common for both feet to act up at exactly the same time for one reason or another, but it would be extremely uncommon for bilateral simultaneous (peripheral) TTS entrapment caused by trauma or overuse. There would typically be a lag between the two. However, if something more systemic is going on (diabetes, rheumatoid arthritis, MS, etc.), or if the source of trouble is coming from your back, then 'TTS' could happen simultaneously.

I haven't really seen any evidence that cycling is associated with TTS, but once your foot is aggravated, the motion or even the cycling shoes may possibly bother you. I can now cycle even high mileage without a problem, but for a while, one of the shoes was irritating my ankle. But I am post-surgery bilaterally, I stil have complications, and my case is complex. Can I ask what pedal system you use and how much float it has? Did you change this recently? Let me know, and maybe I can offer some advice.

If your cause is biomechanical, then early detection may help if the problem is corrected through things like orthotics. Even if they work, don't expect immediate results, as you can't undo years of abuse in days or weeks. You can try the RICE thing; can't hurt. While PTs make much of catching it early to prevent further nerve damage, the experience of most here is that little seems to work anyway: stretching, masssage, cortisone shots, even surgery. Hope you're not among them.

Centers of excellence? Not really. Individual docs or practices with more experience and perhaps somewhat higher surgical success rates than others? Yes. Where do you live? Maybe we can help you out.

What type of foot do you have (high, low, medium arch) and what type of shoes and orthotics do you wear? Not knowing anything else, I would speculate that standing on your feet all day can cause all kinds of foot problems, including TTS.

Re: welcome

GaryZ on 10/19/01 at 19:48 (063313)

Thank you Wendy and Elliot for your fast response.
I will try to expand on my history.

My problem which is felt by a few Docs to be TTS started in July. I was
training for a one day 128 mile ride in Colorado called the 'Triple Bypass'.

At the same time I was working a string of four night shifts. By the
end of the 4th shift I had severe pain on the bottom of both feet
R > L. My feet felt like they were on fire. None of my shoes felt comfortable. The pain was mostly across the entire service of the bottom of my feet but, more painful laterally. I also had radiation of the
tingling up the medial (inner) part of my calf. This was associated with muscle twitching of the inner calf . The pain is more burning and pins and needles like.
I was able to complete the ride without any problem, but the foot pain has
persisted. I have since significantly cut back my riding.

I saw a neurologist at my hospital to rule out ALS and had a EMG. The
EMG was negative for pathological fasiculations ('twitching'). My initial
lab work has been negative (although I did have a B12 level today).
The neurologist has refered me to a academic center for specialized
sensory nerve conduction studies.

I saw a podiatrist initially who could not find much wrong and suggested orthotics and stretching. He felt it was not plantar fascitits.
My arches are medium, my feet are wide. I have a 2 month old set of orthotics that are custom made they were made by having my feet placed in a compressable styrofoam like substance. They are firm on the top with a softer two bottom layers.

My orthopedic spine specialist and neurologist felt it may be TTS. I have no back pain and no pain with straight leg raising. I do have ulnar nerve tingling in my left hand ( as a cyclist I have had mild hand nerve compression symptoms for years).

I have used the same brand of cycling shoes for 10 years (SIDI).
My road pedals are Look brand with red cleats (tried Speedplay but did not like that they held you feet in a fixed horizontal position).
I use Time mountain bike pedals. My bike position has been constant for
several years.

I live in the Chicago area. Any recommendations of MD's that are experienced in evaluating and treating this in this area would be appreciated as well as other suggestions.

Re: welcome

Ed Davis, DPM on 10/19/01 at 21:41 (063324)

A couple of thoughts....

Consider a repeat NCV/EMG. The problem is the relative rarity of TTS--there is a considerable amount of variability in results from electromyographer to electromyographer. Try finding someone who has done a lot of diagnostics for TTS--ask around. I am sort of lucky having an electromyographer whom I believe is one of the best in the US in nearby Tacoma, WA---Mohammed Saeed, MD (may be worth a short vacation to the Northwest--bargain airfares abound).

Change your pedalling position such that your feet are mildly inverted--can be done via pedal adjustments. I don't have a lot of experience with this but a lot of bike shops can do this. Howard Schaengold, DPM who practices in Redmond, WA knows a lot about this and I can look up his tel. number if you are having any difficulty getting this done.

Ed

Re: Boy to you have a wealth of podiatric information

Dr. Zuckerman on 10/20/01 at 11:40 (063343)

Dr. Ed,

I have decided that I going to read your post instead of some of the medical journal. Thanks for you efforts cause you have a true love of our field of podiatric medicine and surgery.

Re: some thoughts

elliott on 10/20/01 at 22:44 (063367)

Where exactly is the lateral sole pain? Along the whole foot? Just in the front? Under the heel too? Not sure your description matches the path the TTS nerves folow. That calf twitching and lack of complaint of medial ankle pain sounds likle something other than TTS, although nerve-related. Take it slow, don't rush into anything like surgery yet, as it's still relatively new.

My ortho felt Speedplay (which I just happened to be using) would be the best, as the float would take the stress off the repetitive cycling motion, and I think he's right. Not sure what you're saying about Speedplay keeping your feet in a fixed horizontal position; all pedal systems prevent vertical movement, and most allow horizontal float on the plane the foot's in. Speedplay just has way more float than others, and also is not self-centering. I believe the red Looks (as opposed to the black) have zero float. Is that correct? While perhaps helping slightly in an all-out sprint, these are not recommended for distance, as your hip, knees and ankles can take a beating. If so, recommend switching to pedals with more float and see if that takes the stress off.

In general, try and stay off your feet as much as you can to see if you can recover. You don't want this to become disabling.

-----------

Re: some thoughts

GaryZ on 10/21/01 at 11:47 (063384)

Elliott

I am scheduled for additional nerve testing and an LS spine MRI.
Even being a physician it is difficult to find neurologists/ Orthopedists/Podiatrists that are comfortable making the call. I will be going to the Chicago Rehabilitation Institute for further diagnostic testing/consultation. The foot parasthesias are at times the whole foot bottom of the foot and up into my medial calf. Sometimes I just have intense burning sensation on the bottoms of both feet.The lateral part of my right foot is at times tender as well. I do not have back pain although I have had back pain a few years ago. I did have 3 major bike crashes this season and broke 3 ribs in one. One crash was about a week prior to onset of symptoms.
Interesting though I have no ankle pain.

Many riders on my team use Speedplay and swear by them.. They do allow tremendous float.
I tried them on my two road bikes one whole season and could not get comfortable.
I tend to tilt my lateral foot down (pronate ?) and Speedplay platform prevents pronation/supination of the foot. The red Look pedals allow some float (the black are fixed)and I can get some pronation/supination out of them. Look also has a wider platform and I have wide feet. I would get 'hot spots' with speedplay.

Anti-inflamatories hane not helped. One MD suggested a course of prednisone.

Does the lack of medial ankle pain make TTS unlikely ?

Re: some thoughts

Dr. Zuckerman on 10/21/01 at 13:29 (063387)

Hi,

Lack of pain in the medial aspect of the ankle doesn't rule out TTS. There is a Dr. Dillon who is a neurologoist at John Hopkins in Baltimore. I will enclose his web site. He developed a local sensory device which is very effective in diagnosing TTS and or medial calcaneal nerve entrapement. He is considers an expert in the TTS and neuropathy in the Medical Community around the country .Has written many bookds article.
Entrapement of the first branch of the lateral plantar nerve is also a possible cause but if the lower spine is cleared for any pathology or cause, you are pointing to either TTS or neuropathy. There is an excellent article written by Dr. Dellon just this month on how to rule out neural involvement in the heel.

If you e-mail me your fax number I will be very happy to fax a copy of this very interesting article.

Dr. Z

footcare@home.com

Re: Dr. Dellon's web site address

Dr. Zuckerman on 10/21/01 at 13:32 (063388)

http://www.dellon.com/

Re: some thoughts

elliott on 10/21/01 at 21:25 (063397)

When people claim to have paresthesias on their whole foot or whole sole, and especially bilaterally and with simultaneous onset, my first inclination is to rule out specific TTS entrapment, at least as it's narrowly defined, because the nerves associated with it follow a specific course. The main, posterior tibial nerve comes down the calf and splits at the medial ankle, and then the nerve branches follow specific paths: one along the medial part of the foot, one to the medial heel, and one to the lateral part of the foot and toes. (Some loosely use the unfortunate terminology 'anterior TTS' for entrapment of other major nerves coming down the other side of the foot, but anyway, if you had that, it would give you problems more on the top of your foot rather than the sole). I don't think enough attention is paid, both by many who visit this forum and, judging by their surgical results, apparently even some of their docs who operate on them, to exactly where the discomfort is felt. It is not good enough to just say 'nervy pain all over the foot' as many here do. They could end up with their doc simply doing the standard TTS release (at the medial ankle, at the so-called tarsal tunnel, the most common source of entrapment due to the tightness there and the interaction with the ankle and the complications created) and they get no relief because that's not where their problem was. OTOH, when their foot is irritated and things are complicated, it's sometimes hard to zone in on exactly where the problem is, and if enough is going on, irritation over a wider area could be felt. One can even end up with a positive nerve conduction test because the foot is irritated all over, but it may still be hard to zone in. I keep asking exactly where on the lateral side. The TTS nerve on the lateral side, the lateral plantar nerve, courses under the foot from medial to lateral side and heads to the toes. There can be more distal entrapment of the individual nerves further along their course as opposed to right as they split in the tarsal tunnel. One would typically feel lateral plantar nerve entrapment either on the medial side (burning is common here) before it swings under the foot forward of the instep, under the foot forward of the instep, or on the lateral side along the 4th and 5th metatarsals (tingling is common here). But it shouldn't be the whole lateral side, because the lateral plantar nerve just doesn't run back towards the heel on this side. But I can't deny that you seem to have a neuropathy of some sort. You just have to be careful exactly what you have. The source of lateral plantar nerve entrapment can still be at the medial ankle. If there's no entrapment at the medial ankle (the most common location for release), then the question is exactly where the distal entrapment is. A surgeon would have to have a good idea or else he would have to cut up too much foot. It still seems to be as if something global is going on, especially given the simultaneous bilateral occurrence, whole sole, and both calves thing. It's as if the calves are tugging and messing up the feet. That just does not sound like specific peripheral entrapment, or standard tarsal tunnel entrapment, especially without medial ankle pain. You might want to read up on compartment syndrome as well (still hard to fathom the simultaneous thingy, unless something pulled on both calves at the same time). Given how much you're on your feet as well as possible bike-related causes, I'd tend to guess it's not some disease either. But hey, this is the internet. Guesses are free and the ones making them might not even exist. :-)

Hey, Looks are great pedals too, and pedals are a personal preference thing. If they work, why switch? If you have some float and have been using the pedals for some time, then that's probably not the culprit. Good luck.

Re: some thoughts

wendyn on 10/21/01 at 22:14 (063400)

Gary - I'll be interested to hear what your B12 level turns out to be...please let us know.

What happens if you lay off the biking completely for 7 days or so?

Prednisone has worked well for some here...and you are aware of the risks vs. benefits with this heavy drug....but then you still may be left with the same problem if you don't identify what went wrong in the first place.

Re: some thoughts

GaryZ on 10/22/01 at 02:29 (063406)

Elliott, Wendi, & Dr Zuckerman,

In addition to the diffuse plantar parasthesias on my L foot. I have
lateral foot pain between my 4th and 5th metatarsals.
This pain occurs with cycling and walking.
I have had two sets of X - rays (2 months apart) to assess for stress
fractures. Both sets of films are negative. The lateral foot pain
can be exacerbated by squeezing my 4th and 5th metarsals together.
The pain is not in the metatarsal-phalangeal joints, but in distal third
of the space between the 4th & 5th bones.

My burning pain is diffuse on the bottom of my left foot and to a much lesser extent my right foot. I have little pain in the arches unless I wear my
orthotics (they help shift the pain). The problem is that the combination of the onset of the diffuse parasthesias and burning on the bottom of my feet has been hard for my local Docs to figure out. The addition of the periodic fasciculations in my medial calf are confusing. My initial EMG did not show any 'pathologic' fasiculations.

As an ER doc that has been working on his feet in a busy ER I have had tired feet in the past, however the acute onset of this problem is unique. I have stayed off the bike for over 10 days put the problem has persisted.
The symptoms persist if I sit or stand and sitting at times can increase the parasthesias ( and calf twithing).

I appreciate all your intuition and thoughts on this matter. It is somewhat frustating to have a persistant medical problem that can not be easily diagnosed (and doctors generally are at times difficult patients).

BTW I may try a short course of prednisone, as it was also suggested by an associate of mine as well.

Are any of you aware of other acute neuropathies or neuritis that could fit this picture ?

Thanks,

Gary

Re: some thoughts

wendyn on 10/22/01 at 07:54 (063409)

Gary - from what I've read (as a non-medical person) - sometimes neuropathies occur for all kinds of assorted reasons. Sometimes no one can determine why.

About a year and a half into what was eventually diagnosed as TTS in me...my B12 levels were checked and found to be 145 approx. After supplementation, actually very shortly after - a lot of the burning and numbness subsided. Now - I have no proof that the two were connected, and no idea if they really were. Perhaps B12 can have a theraputic effect on nerve damage? If nothing else - some supplementation might be in order to see if it helps any.

I still have foot pain and problems - but the pain, burning and numbness is NO WHERE near the level it was before my B12 levels came up.

We can all relate to the frustration of having an unexplained medical problem!!!! Many of us have had doctors imply that we are suffering from some type of mental issue rather than a physical one.

'Fortunately' (and I use the term loosley) I have sufficient structural problems with my feet - no doctor has used this in my case. I certainly feel for the people it's happened to though.

Re: some thoughts

Stephanie Adams on 10/23/01 at 10:33 (063452)

GaryZ just a thought, check out Lateral Column Syndrome also called Cubiod Syndrome, some of the symptoms that you have mentioned sound like the ones I have and I have been dx with it. I have pain and sweeling on the lateral side of my foot between the metatarsals and the cubiod if I touch that spot I have severe pain, burning pain on the bottom of my foot on the lateral side, the ball of my foot is swollen and 4 toes have a numb feeling, I have swelling on the top of my foot and around my ankle and it goes up the back near the achilles tendon and is move up. I had TTS and PF and heel spur removal in May and had various complications then was dx with the lateral column syndrome, after a while one of my docs thought it maybe a fracture because it was not better after being casted for two weeeks I had an MRI done neg for fracture but it showed fluid in the joints and along a tendon.
Just check out Lateral Column Syndrome.
Good Luck

Re: some thoughts

GaryZ on 10/23/01 at 22:45 (063515)

Update MRI LS spine was negative, actually pretty clean given my bike crashes. On Prednisone,B12 level pending. I'll update you all in a few days.

Thanks,

Gary

Re: some thoughts

wendyn on 10/24/01 at 08:07 (063525)

Thanks Gary - I hope the prednisone helps....please keep us posted.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

Ricki O . on 11/11/01 at 20:00 (064699)

i was first diagnosed with heel spur's by a Podiatrist in OHIO in july 2001, and received three cortisone injection's, which proved little if any relief. in Sept. i came to S.C. and the heel pain increased,
saw another Dr. he diagnosed my pain as Plantar Fascitis, and TTS,he made an orthodic for my shoe to support the ligament , it has been a little over a week, it has not helped , and the pain is almost uberable. even when i am not on my feet that much. the burning sensation on the bottom of my foot was the first symptom. and just the tenderness of the bottom of my foot, now the heel pain is almost more then i can stand. i sleep with my foot on a pillow, and with a pillow between my knee's as i also have back problem's.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

GaryZ on 11/18/01 at 23:22 (064972)

Since the onset of my foot pain I have discovered the difficulty in determining the correct diagnosis. Unlike other areas of medicine that I deal with on a day to day basis the specific cause of foot pain can be tough to diagnose. I have had several diagnosis's made by qualified MD's and podiatrists. These have included tarsal tunnel syndrome, over exertion, plantar fascitis, spinal stenosis. I have been prescribed several medications, some that had no effect and some that made me ill and spinal epidural injections. The only viable treatment has been orthotics and tegretal. I was finally diagnosed with peripheral neuropathy most likely Hereditary Neuropathy with Liability to Pressure Palsy (HNPP). My bilateral foot pain was from prolonged sitting and pressure on my proximal tibial nerves. This diagnosis can be made by a blood test. Tegretal (unlike neurotin) has worked great with no apparent side effects thus far. I would encourage those with tough complex foot pain suspicous for TTS to see a neurologist with expertise in neuropathy to evaluate for HNPPand other neuropathy's. Those that have had TTS and Carpal tunnel syndrome may very well have HNPP as it predisposes one to tunnel syndromes. Interesting though is that surgery is not suggested for HNPP. Perhaps the reason that some of these surgerys don't work is that the condition is not pure TTS but HNPP or some other condition (Idiopathic Sensory Neuropathy) that also causes neurogenic foot pain.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

wendyn on 11/19/01 at 23:07 (064980)

Gary - are you the emergency room doctor who was posting here a little while ago? I think you confirm a long held belief of mine (and others) - anyone presenting with unexplained neurological symptoms, especially if they are in other parts of the body....needs to be very cautious about surgery.

How was your diagnosis finally confirmed? Weren't you recently diagnosed with something else? (I am having trouble remembering where you were at when we last heard from you).

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

wendyn on 10/18/01 at 22:28 (063268)

Welcome Gary...

Many of us have symptoms in both feet - although most people notice it usually starts in one - then in the other.

With you lab tests, I would think they would test you for diabetes, low B12, thyroid, RH factor, and for lupus.

Although many doctors have told me that biking should not aggravate TTS - it does.

A recumbent bike may help - but listen to your bod.

TTS seems to be very misunderstood, often misdiagnosed, and somewhat of a mystery. Are your orthotics new? Can you describe them?

Re: welcome

elliott on 10/19/01 at 08:20 (063280)

I thought it was theoretically impossible for docs to get TTS. :-) I have had bilateral athletic TTS (running induced). I also cycle. You say you have fasiculations. That's such a big word I had to look it up. It think it's spelled 'fasciculations'. (No wonder I didn't know what it was. :-))

I have two questions for you:

1. Where exactly on the bottoms of your feet are your symptoms (heel, arch, ball, other, medial, lateral, middle, etc.)? This is extremely important. Also, any medial ankle discomfort? Any back trouble at all?

2. Did you dramatically increase your cycling mileage shortly before onset or make other bike changes (e.g. seat height)?

Partial answers to your questions (pending your response to the above):

It may be common for both feet to act up at exactly the same time for one reason or another, but it would be extremely uncommon for bilateral simultaneous (peripheral) TTS entrapment caused by trauma or overuse. There would typically be a lag between the two. However, if something more systemic is going on (diabetes, rheumatoid arthritis, MS, etc.), or if the source of trouble is coming from your back, then 'TTS' could happen simultaneously.

I haven't really seen any evidence that cycling is associated with TTS, but once your foot is aggravated, the motion or even the cycling shoes may possibly bother you. I can now cycle even high mileage without a problem, but for a while, one of the shoes was irritating my ankle. But I am post-surgery bilaterally, I stil have complications, and my case is complex. Can I ask what pedal system you use and how much float it has? Did you change this recently? Let me know, and maybe I can offer some advice.

If your cause is biomechanical, then early detection may help if the problem is corrected through things like orthotics. Even if they work, don't expect immediate results, as you can't undo years of abuse in days or weeks. You can try the RICE thing; can't hurt. While PTs make much of catching it early to prevent further nerve damage, the experience of most here is that little seems to work anyway: stretching, masssage, cortisone shots, even surgery. Hope you're not among them.

Centers of excellence? Not really. Individual docs or practices with more experience and perhaps somewhat higher surgical success rates than others? Yes. Where do you live? Maybe we can help you out.

What type of foot do you have (high, low, medium arch) and what type of shoes and orthotics do you wear? Not knowing anything else, I would speculate that standing on your feet all day can cause all kinds of foot problems, including TTS.

Re: welcome

GaryZ on 10/19/01 at 19:48 (063313)

Thank you Wendy and Elliot for your fast response.
I will try to expand on my history.

My problem which is felt by a few Docs to be TTS started in July. I was
training for a one day 128 mile ride in Colorado called the 'Triple Bypass'.

At the same time I was working a string of four night shifts. By the
end of the 4th shift I had severe pain on the bottom of both feet
R > L. My feet felt like they were on fire. None of my shoes felt comfortable. The pain was mostly across the entire service of the bottom of my feet but, more painful laterally. I also had radiation of the
tingling up the medial (inner) part of my calf. This was associated with muscle twitching of the inner calf . The pain is more burning and pins and needles like.
I was able to complete the ride without any problem, but the foot pain has
persisted. I have since significantly cut back my riding.

I saw a neurologist at my hospital to rule out ALS and had a EMG. The
EMG was negative for pathological fasiculations ('twitching'). My initial
lab work has been negative (although I did have a B12 level today).
The neurologist has refered me to a academic center for specialized
sensory nerve conduction studies.

I saw a podiatrist initially who could not find much wrong and suggested orthotics and stretching. He felt it was not plantar fascitits.
My arches are medium, my feet are wide. I have a 2 month old set of orthotics that are custom made they were made by having my feet placed in a compressable styrofoam like substance. They are firm on the top with a softer two bottom layers.

My orthopedic spine specialist and neurologist felt it may be TTS. I have no back pain and no pain with straight leg raising. I do have ulnar nerve tingling in my left hand ( as a cyclist I have had mild hand nerve compression symptoms for years).

I have used the same brand of cycling shoes for 10 years (SIDI).
My road pedals are Look brand with red cleats (tried Speedplay but did not like that they held you feet in a fixed horizontal position).
I use Time mountain bike pedals. My bike position has been constant for
several years.

I live in the Chicago area. Any recommendations of MD's that are experienced in evaluating and treating this in this area would be appreciated as well as other suggestions.

Re: welcome

Ed Davis, DPM on 10/19/01 at 21:41 (063324)

A couple of thoughts....

Consider a repeat NCV/EMG. The problem is the relative rarity of TTS--there is a considerable amount of variability in results from electromyographer to electromyographer. Try finding someone who has done a lot of diagnostics for TTS--ask around. I am sort of lucky having an electromyographer whom I believe is one of the best in the US in nearby Tacoma, WA---Mohammed Saeed, MD (may be worth a short vacation to the Northwest--bargain airfares abound).

Change your pedalling position such that your feet are mildly inverted--can be done via pedal adjustments. I don't have a lot of experience with this but a lot of bike shops can do this. Howard Schaengold, DPM who practices in Redmond, WA knows a lot about this and I can look up his tel. number if you are having any difficulty getting this done.

Ed

Re: Boy to you have a wealth of podiatric information

Dr. Zuckerman on 10/20/01 at 11:40 (063343)

Dr. Ed,

I have decided that I going to read your post instead of some of the medical journal. Thanks for you efforts cause you have a true love of our field of podiatric medicine and surgery.

Re: some thoughts

elliott on 10/20/01 at 22:44 (063367)

Where exactly is the lateral sole pain? Along the whole foot? Just in the front? Under the heel too? Not sure your description matches the path the TTS nerves folow. That calf twitching and lack of complaint of medial ankle pain sounds likle something other than TTS, although nerve-related. Take it slow, don't rush into anything like surgery yet, as it's still relatively new.

My ortho felt Speedplay (which I just happened to be using) would be the best, as the float would take the stress off the repetitive cycling motion, and I think he's right. Not sure what you're saying about Speedplay keeping your feet in a fixed horizontal position; all pedal systems prevent vertical movement, and most allow horizontal float on the plane the foot's in. Speedplay just has way more float than others, and also is not self-centering. I believe the red Looks (as opposed to the black) have zero float. Is that correct? While perhaps helping slightly in an all-out sprint, these are not recommended for distance, as your hip, knees and ankles can take a beating. If so, recommend switching to pedals with more float and see if that takes the stress off.

In general, try and stay off your feet as much as you can to see if you can recover. You don't want this to become disabling.

-----------

Re: some thoughts

GaryZ on 10/21/01 at 11:47 (063384)

Elliott

I am scheduled for additional nerve testing and an LS spine MRI.
Even being a physician it is difficult to find neurologists/ Orthopedists/Podiatrists that are comfortable making the call. I will be going to the Chicago Rehabilitation Institute for further diagnostic testing/consultation. The foot parasthesias are at times the whole foot bottom of the foot and up into my medial calf. Sometimes I just have intense burning sensation on the bottoms of both feet.The lateral part of my right foot is at times tender as well. I do not have back pain although I have had back pain a few years ago. I did have 3 major bike crashes this season and broke 3 ribs in one. One crash was about a week prior to onset of symptoms.
Interesting though I have no ankle pain.

Many riders on my team use Speedplay and swear by them.. They do allow tremendous float.
I tried them on my two road bikes one whole season and could not get comfortable.
I tend to tilt my lateral foot down (pronate ?) and Speedplay platform prevents pronation/supination of the foot. The red Look pedals allow some float (the black are fixed)and I can get some pronation/supination out of them. Look also has a wider platform and I have wide feet. I would get 'hot spots' with speedplay.

Anti-inflamatories hane not helped. One MD suggested a course of prednisone.

Does the lack of medial ankle pain make TTS unlikely ?

Re: some thoughts

Dr. Zuckerman on 10/21/01 at 13:29 (063387)

Hi,

Lack of pain in the medial aspect of the ankle doesn't rule out TTS. There is a Dr. Dillon who is a neurologoist at John Hopkins in Baltimore. I will enclose his web site. He developed a local sensory device which is very effective in diagnosing TTS and or medial calcaneal nerve entrapement. He is considers an expert in the TTS and neuropathy in the Medical Community around the country .Has written many bookds article.
Entrapement of the first branch of the lateral plantar nerve is also a possible cause but if the lower spine is cleared for any pathology or cause, you are pointing to either TTS or neuropathy. There is an excellent article written by Dr. Dellon just this month on how to rule out neural involvement in the heel.

If you e-mail me your fax number I will be very happy to fax a copy of this very interesting article.

Dr. Z

footcare@home.com

Re: Dr. Dellon's web site address

Dr. Zuckerman on 10/21/01 at 13:32 (063388)

http://www.dellon.com/

Re: some thoughts

elliott on 10/21/01 at 21:25 (063397)

When people claim to have paresthesias on their whole foot or whole sole, and especially bilaterally and with simultaneous onset, my first inclination is to rule out specific TTS entrapment, at least as it's narrowly defined, because the nerves associated with it follow a specific course. The main, posterior tibial nerve comes down the calf and splits at the medial ankle, and then the nerve branches follow specific paths: one along the medial part of the foot, one to the medial heel, and one to the lateral part of the foot and toes. (Some loosely use the unfortunate terminology 'anterior TTS' for entrapment of other major nerves coming down the other side of the foot, but anyway, if you had that, it would give you problems more on the top of your foot rather than the sole). I don't think enough attention is paid, both by many who visit this forum and, judging by their surgical results, apparently even some of their docs who operate on them, to exactly where the discomfort is felt. It is not good enough to just say 'nervy pain all over the foot' as many here do. They could end up with their doc simply doing the standard TTS release (at the medial ankle, at the so-called tarsal tunnel, the most common source of entrapment due to the tightness there and the interaction with the ankle and the complications created) and they get no relief because that's not where their problem was. OTOH, when their foot is irritated and things are complicated, it's sometimes hard to zone in on exactly where the problem is, and if enough is going on, irritation over a wider area could be felt. One can even end up with a positive nerve conduction test because the foot is irritated all over, but it may still be hard to zone in. I keep asking exactly where on the lateral side. The TTS nerve on the lateral side, the lateral plantar nerve, courses under the foot from medial to lateral side and heads to the toes. There can be more distal entrapment of the individual nerves further along their course as opposed to right as they split in the tarsal tunnel. One would typically feel lateral plantar nerve entrapment either on the medial side (burning is common here) before it swings under the foot forward of the instep, under the foot forward of the instep, or on the lateral side along the 4th and 5th metatarsals (tingling is common here). But it shouldn't be the whole lateral side, because the lateral plantar nerve just doesn't run back towards the heel on this side. But I can't deny that you seem to have a neuropathy of some sort. You just have to be careful exactly what you have. The source of lateral plantar nerve entrapment can still be at the medial ankle. If there's no entrapment at the medial ankle (the most common location for release), then the question is exactly where the distal entrapment is. A surgeon would have to have a good idea or else he would have to cut up too much foot. It still seems to be as if something global is going on, especially given the simultaneous bilateral occurrence, whole sole, and both calves thing. It's as if the calves are tugging and messing up the feet. That just does not sound like specific peripheral entrapment, or standard tarsal tunnel entrapment, especially without medial ankle pain. You might want to read up on compartment syndrome as well (still hard to fathom the simultaneous thingy, unless something pulled on both calves at the same time). Given how much you're on your feet as well as possible bike-related causes, I'd tend to guess it's not some disease either. But hey, this is the internet. Guesses are free and the ones making them might not even exist. :-)

Hey, Looks are great pedals too, and pedals are a personal preference thing. If they work, why switch? If you have some float and have been using the pedals for some time, then that's probably not the culprit. Good luck.

Re: some thoughts

wendyn on 10/21/01 at 22:14 (063400)

Gary - I'll be interested to hear what your B12 level turns out to be...please let us know.

What happens if you lay off the biking completely for 7 days or so?

Prednisone has worked well for some here...and you are aware of the risks vs. benefits with this heavy drug....but then you still may be left with the same problem if you don't identify what went wrong in the first place.

Re: some thoughts

GaryZ on 10/22/01 at 02:29 (063406)

Elliott, Wendi, & Dr Zuckerman,

In addition to the diffuse plantar parasthesias on my L foot. I have
lateral foot pain between my 4th and 5th metatarsals.
This pain occurs with cycling and walking.
I have had two sets of X - rays (2 months apart) to assess for stress
fractures. Both sets of films are negative. The lateral foot pain
can be exacerbated by squeezing my 4th and 5th metarsals together.
The pain is not in the metatarsal-phalangeal joints, but in distal third
of the space between the 4th & 5th bones.

My burning pain is diffuse on the bottom of my left foot and to a much lesser extent my right foot. I have little pain in the arches unless I wear my
orthotics (they help shift the pain). The problem is that the combination of the onset of the diffuse parasthesias and burning on the bottom of my feet has been hard for my local Docs to figure out. The addition of the periodic fasciculations in my medial calf are confusing. My initial EMG did not show any 'pathologic' fasiculations.

As an ER doc that has been working on his feet in a busy ER I have had tired feet in the past, however the acute onset of this problem is unique. I have stayed off the bike for over 10 days put the problem has persisted.
The symptoms persist if I sit or stand and sitting at times can increase the parasthesias ( and calf twithing).

I appreciate all your intuition and thoughts on this matter. It is somewhat frustating to have a persistant medical problem that can not be easily diagnosed (and doctors generally are at times difficult patients).

BTW I may try a short course of prednisone, as it was also suggested by an associate of mine as well.

Are any of you aware of other acute neuropathies or neuritis that could fit this picture ?

Thanks,

Gary

Re: some thoughts

wendyn on 10/22/01 at 07:54 (063409)

Gary - from what I've read (as a non-medical person) - sometimes neuropathies occur for all kinds of assorted reasons. Sometimes no one can determine why.

About a year and a half into what was eventually diagnosed as TTS in me...my B12 levels were checked and found to be 145 approx. After supplementation, actually very shortly after - a lot of the burning and numbness subsided. Now - I have no proof that the two were connected, and no idea if they really were. Perhaps B12 can have a theraputic effect on nerve damage? If nothing else - some supplementation might be in order to see if it helps any.

I still have foot pain and problems - but the pain, burning and numbness is NO WHERE near the level it was before my B12 levels came up.

We can all relate to the frustration of having an unexplained medical problem!!!! Many of us have had doctors imply that we are suffering from some type of mental issue rather than a physical one.

'Fortunately' (and I use the term loosley) I have sufficient structural problems with my feet - no doctor has used this in my case. I certainly feel for the people it's happened to though.

Re: some thoughts

Stephanie Adams on 10/23/01 at 10:33 (063452)

GaryZ just a thought, check out Lateral Column Syndrome also called Cubiod Syndrome, some of the symptoms that you have mentioned sound like the ones I have and I have been dx with it. I have pain and sweeling on the lateral side of my foot between the metatarsals and the cubiod if I touch that spot I have severe pain, burning pain on the bottom of my foot on the lateral side, the ball of my foot is swollen and 4 toes have a numb feeling, I have swelling on the top of my foot and around my ankle and it goes up the back near the achilles tendon and is move up. I had TTS and PF and heel spur removal in May and had various complications then was dx with the lateral column syndrome, after a while one of my docs thought it maybe a fracture because it was not better after being casted for two weeeks I had an MRI done neg for fracture but it showed fluid in the joints and along a tendon.
Just check out Lateral Column Syndrome.
Good Luck

Re: some thoughts

GaryZ on 10/23/01 at 22:45 (063515)

Update MRI LS spine was negative, actually pretty clean given my bike crashes. On Prednisone,B12 level pending. I'll update you all in a few days.

Thanks,

Gary

Re: some thoughts

wendyn on 10/24/01 at 08:07 (063525)

Thanks Gary - I hope the prednisone helps....please keep us posted.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

Ricki O . on 11/11/01 at 20:00 (064699)

i was first diagnosed with heel spur's by a Podiatrist in OHIO in july 2001, and received three cortisone injection's, which proved little if any relief. in Sept. i came to S.C. and the heel pain increased,
saw another Dr. he diagnosed my pain as Plantar Fascitis, and TTS,he made an orthodic for my shoe to support the ligament , it has been a little over a week, it has not helped , and the pain is almost uberable. even when i am not on my feet that much. the burning sensation on the bottom of my foot was the first symptom. and just the tenderness of the bottom of my foot, now the heel pain is almost more then i can stand. i sleep with my foot on a pillow, and with a pillow between my knee's as i also have back problem's.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

GaryZ on 11/18/01 at 23:22 (064972)

Since the onset of my foot pain I have discovered the difficulty in determining the correct diagnosis. Unlike other areas of medicine that I deal with on a day to day basis the specific cause of foot pain can be tough to diagnose. I have had several diagnosis's made by qualified MD's and podiatrists. These have included tarsal tunnel syndrome, over exertion, plantar fascitis, spinal stenosis. I have been prescribed several medications, some that had no effect and some that made me ill and spinal epidural injections. The only viable treatment has been orthotics and tegretal. I was finally diagnosed with peripheral neuropathy most likely Hereditary Neuropathy with Liability to Pressure Palsy (HNPP). My bilateral foot pain was from prolonged sitting and pressure on my proximal tibial nerves. This diagnosis can be made by a blood test. Tegretal (unlike neurotin) has worked great with no apparent side effects thus far. I would encourage those with tough complex foot pain suspicous for TTS to see a neurologist with expertise in neuropathy to evaluate for HNPPand other neuropathy's. Those that have had TTS and Carpal tunnel syndrome may very well have HNPP as it predisposes one to tunnel syndromes. Interesting though is that surgery is not suggested for HNPP. Perhaps the reason that some of these surgerys don't work is that the condition is not pure TTS but HNPP or some other condition (Idiopathic Sensory Neuropathy) that also causes neurogenic foot pain.

Re: MD with TTS has questions about TTS for Doc and fellow TTS suffers

wendyn on 11/19/01 at 23:07 (064980)

Gary - are you the emergency room doctor who was posting here a little while ago? I think you confirm a long held belief of mine (and others) - anyone presenting with unexplained neurological symptoms, especially if they are in other parts of the body....needs to be very cautious about surgery.

How was your diagnosis finally confirmed? Weren't you recently diagnosed with something else? (I am having trouble remembering where you were at when we last heard from you).