Home The Book Dr Articles Products Message Boards Journal Articles Search Our Surveys Surgery ESWT Dr Messages Find Good Drs video

I saw Dr. Zuckerman yesterday!

Posted by elliott on 11/30/01 at 10:21 (065716)

Real nice, honest guy. Knowledgeable and competent too. I feel guilty; he gave me an awful lot of time, especially considering he's not exactly going to get rich off his initial consult fee (hint: what number, when you multiply it by any other number, still equals that same number?), so I thought I'd put in this plug for him.

In case you ever had this thought that Dr. Z's office consists only of an ESWT trailer outside and a 4' x 4' cubicle with internet chat computer inside, you would be wrong, because I think he's also a dentist on the side; that's all you can think of in the exam room when you see the patient chair and drill next to it. But I'm still wondering what that was in the bathroom behind the shower curtain-an ESWT prototype that croaked? :-) BTW, I got to see the ESWT trailer, and the orbasone inventor just happened to be in there too! Exchanged gifts with Dr. Z: I gave him some journal articles, and he gave me something I can use to drink the coffee water left out overnight. :-) (Thanks!)

I'm glad I made the trip out from Baltimore. It's just about exactly 100 miles, and I made it in well under 2 hours. BTW, if you ever get to his office real early or have time afterwards, he's less than a 15-minute drive from the Camden waterfront, a soon-to-be major tourist attraction. The aquarium there is especially worth seeing. Just take 295 a few miles further north, and you'll see the sign for it. I've been there a couple of times already. While the fish there aren't that exotic--it looks like they plucked them right out of the Camden River just out the back window-the panoramic tank views of sharks, turtles, and the like are nothing short of breathtaking; you'll never forget it. They have an outdoor porpoise show as well. I like this aquarium much better than the highly acclaimed Baltimore aquarium, which is more into exotic fish each enclosed in a 2' x 2' tank with 50 people crowded around not able to get a glimpse.

Anyway, if you decide to visit Dr. Z for ESWT or anything else foot-related, you're in very good hands, unless he happened to play football the week before. :-)

Dr Z, you gave me a lot of time and helped cleared up some things in my complicated case. Thanks again.

----------

Re: Elliott, did Dr. Z

Matt L on 11/30/01 at 11:00 (065721)

Did Dr. Z give you any encouagement that ESTW may eventually be utilized for TTS scar tissue issues?

Re: no

elliott on 11/30/01 at 11:16 (065724)

He has repeatedly stated on these boards that it's not appropriate for nerve problems. But part of my problem in one foot is most likely bone-related, and I did mean to ask him how the ESWT research was progressing for bone fusion and the like (the ESWT articles on the exam room wall say that it shows promise for this) but forgot to ask him.

How's your lateral plantar nerve diagnosis coming along? I was surprised to see you post that the TTS pros you no doubt are seeing were having trouble getting a handle on it.

-------

Re: Elliott, did Dr. Z

Dr. Zuckerman on 11/30/01 at 11:50 (065733)

No ! ESWT still only beneficial for insertional tendonitis problems, such as heel spur, plantar , achilles tendonitis. patellar, elbow and shoulders

Re: I saw Dr. Zuckerman yesterday!

Richard, C.Ped on 11/30/01 at 12:30 (065736)

What is behind the shower curtain is on a foot care professional need to know basis....We are not allowed to tell you what is back there. Ha ha...Just kidding!!! He does have a pretty cool office though.
Richard

Re: lateral plantar nerve involvement

Matt L on 11/30/01 at 13:29 (065742)

The orthopeadic surgeon that I am seeing (who is known to you) is not sure where exactly on my ankle that the problem is originating from. If it is in an area that was previously released during my first surgery then my surgical options are limited due to scar tissue involvement. If it is in 'virgin' territory (above or below the existing scar area) a traditional release may be an option. I tend to believe (unfortunately) that it is probably within the existing scar area. There doesn't appear to be anyway to know with certainty one way or the other. Thank for asking.

Re: lateral plantar nerve involvement

elliott on 11/30/01 at 13:48 (065746)

Is it possible that the plantar fasciotomy you had later or its after-effects has anything to do with your lateral foot pain?

Re: lateral plantar nerve involvement

Matt L on 12/03/01 at 08:17 (065971)

It has been considered and is possible but I feel unlikely. I based this primarily on the fact that I can't manipulate/create any symptoms by pressing in this area. However, I can most of the time by pressing/tapping in the traditional tarsal tunnel area.

Re: lateral plantar nerve involvement

elliott on 12/03/01 at 09:40 (065974)

Any chance a careful NCV might zone in on the location of entrapment? If you need the name of a good electromyographer or would like to give him a call to ask, let me know. Wouldn't the reaction evoked by tapping in the traditional TT area suggest it's in the original area?

-------

Re: lateral plantar nerve involvement

Matt L on 12/03/01 at 13:20 (065986)

Yes, I think it does suggest it's in the original area. It's just odd that the involvement is principally lateral. Who do you recommend for the NCV test? I'm not sure whether it would show any abnormalitites or not- as the nerve may be irritated but not (yet)damaged. Have you heard of any successful surgical options, short of the vein wrap, for reoccurences of tts?

Re: lateral plantar nerve involvement

elliott on 12/03/01 at 15:01 (065995)

Maye not so odd. Pre-TTS release on my left foot, I had tingling only in the medial four toes (medial plantar nerve). Post-TTS release, after a severe recurrence of sorts, I had lateral plantar nerve tingling as well (sole at fourth and fifth metatarsals at ball joint, and lateral two toes), sometimes in isolation, and its source hard to place, although this tingling was not unbearable at all (the medial ankle clearly being the source of the bigtime trouble, just as it was pre-surgery). My foot is much improved since then (I can now wear shoes, albeit with discomfort, for a few hours, but could not at all before, and the pain level also has dropped considerably). Still hard to imagine living the rest of my life as is, but at least I'm having some hope of this foot eventually straightening out. Based on pain location, I am suspicious a more minor nerve branch is entrapped and which was also the main culprit pre-surgery, making my case especially strange. There are other possible causes I'd rather not go into now. Just got to wait it out. He warned me not to rush into another surgery and risk all without giving it time. (But how many years does one have to wait?! It's now 1.5 years post-op.). If it does come round, I'll have to call him and thank him profusely and apologize for doubting him. Anyway, when they do the standard release, current practice is that they go at least as far distally as the first branch of the lateral plantar nerve (to not do so risks an incomplete release). Based only on what you said and no other info, assuming the PF release had nothing to do with it, my guess would be that it was due to the usual post-surgical scar tissue (a risk I'm sure you're aware of) forming over the first branch of the lateral plantar nerve released. And then yes, as you say, a re-release in the same area (short of a vein wrap) would not offer good chances.

Yes, the vein wrap is extreme. I saw a patient in the waiting room who had had it (by one of you know who's junior colleagues). Nice person. She was obese, in case that's relevant, and told me she had a blue collar job demanding she stand much of the day on a cold concrete assembly line. First two surgeons in a neighboring state messed up and made things worse, each blaming the other. By that point, she had had nervy electricity running from toes all the way up to top of leg. Severe case. The vein wrap leaves a hideous incision scar from ankle to knee (didn't stop her from wearing shorts in summer), but she was thrilled, as she had 75% relief post-op and was able to return to her job after two failed releases and a long time on disability. It gave her a last chance at life and she won (at least till then). But if it fails, your foot has been permanently rewired and may have more problems than before, which is why the standard is so high. If it reaches the point where you feel you must have surgery, between the two, I'd be inclined to try one more standard release before the vein wrap. Just MHO.

You don't need damage in order for the NCV to pick it up. The fact that you have tingling is suggestive of a slowing of the nerve conductivity. It's just possible that by placing the nodes at strategic intervals, the source of entrapment can be located. Well, it's worth asking, isn't it?

Neuroelectrodiagnostician's name is Emanuel Rechthand. Has offices in Owings Mills, Sinai, Towson, Westminster. Qualified neurologist as well as electromyographer. One of the best in the state, and real nice guy too. Email me if you need further info such as his telephone no. or have more personal questions to ask me.

Re: lateral plantar nerve involvement

Matt L on 12/05/01 at 13:38 (066212)

Elliott, thanks for the detailed response. Intuitively, I feel there must be simpler solutions than the vein wrap. Doesn't mean there is- just seems like there should. For all the amazing medical procedures out there, keeping scar tissue from squeezing a nerve doesn't sound like it should be so complicated.

By the way, have you heard of a Dr. John Campbell at Hopkins? He supposedly has some experience in recurrent TTS cases.

Re: Campbell?

elliott on 12/05/01 at 15:02 (066221)

No. Never heard of him. Started looking around. Checked the references of a big chronic pain paper in my possession and found a few J Campbells quoted, references 28 and 29. Apparently two different Campbells, as one is JN, the other JT. If it's JT, his solution to solving recurrent TTS cases may be the very same vein wrap. Here's the abstract:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9840207&dopt=Abstract

But actually, I think it's JN. You sure it's John? Maybe it's James, since I found a listing for James N. Campbell (JN!), neurosurgeon, at Hopkins, in a local Blue Cross comprehensive listing. Based on the abstracts of his research papers, he seems to be doing neurological/neurosurgical research and experiments all over the body, and not just on humans. You sure he's focussed on TTS? If so and you go see him and have a positive experience, please let me know. I'm switching to Blue Cross come January and will have freedom to go anywhere then.

Yeah, intuitively, there should be something simpler than a vein wrap for yor kind of problem, but I think part of the problem is that they don't always know exactly what goes wrong with a release when it does.

Papers on surgical success in second releases in general show results that aren't pretty. But they find that the odds are much better if there was insufficient release the first time round or a different area involved.

I've seen some articles talk about putting fatty tissue in as a barrier between nerve and other obstructions in a successful standard release, but who knows how much difference that really made, i.e. maybe it was the standard release part that was successful rather than the technique.

If you pain is localized enough, did you consider trying a cortisone or lidocaine/marcaine shot? That might be worth a 'stab'.

--------

Re: JT

Matt L on 12/05/01 at 15:41 (066227)

It is JT. The url to his bio follows. Looks like he worked with Dr. S at one point. I'm not sure if anything would be gained by seeing him- may have the same tricks in his bag.

I asked Dr. S about the 'fat wrap'- said it didnt work. Didnt say why it didnt.

I've had 2 cortisone injections into the TT area- mild improvement for a few days, then back to 'normal'. Not sure if lidocaine is also being injected- however it is an ingrediant in the topical cream Dr. S prescribed.

http://www.hopkinsmedicine.org/orthopedicsurgery/physicians/faculty/campbell.html

Re: so what are you going to do?

elliott on 12/05/01 at 15:59 (066235)

Is nothing an option? How's the pain level these days?

Re: so what are you going to do?

Matt L on 12/06/01 at 08:08 (066314)

The pain level varies from mild to moderate. For the most part I been living with it for 8 1/2 years. It definitely effects the quality of my life and has changed my mental outlook. I don't look forward to getting out of bed in the morning because I know the day will be a struggle to get through. Yet, I realize the pain could be/get much worse-particularly with a failed surgery. Therefore, any surgical option is a tough call. As to the vein wrap, I don't think I'm there yet- at this point the potential upside vs. the potential downside isn't sufficient to justify it-at lease based on what I know.
So, as to what I'm going to do- I truly don't know. I feel I need to keep on searching for additional viable options- both surgical and non-surgical. Sitting around doing nothing means no hope. So I read the message boards, research the net, etc. looking for something new to try. The problem is that it's getting more difficult finding anything new to consider-clearly the world isn't searching for solutions to TTS along the lines of a cure to cancer (nor should it of course). Sorry for the rambling. I may try another opinion (possibly at Hopkins) but I've spoken to enough doctors over the years that my expectation that I'm missing something (an easy option)is not high.

Re: Elliott, did Dr. Z

Matt L on 11/30/01 at 11:00 (065721)

Did Dr. Z give you any encouagement that ESTW may eventually be utilized for TTS scar tissue issues?

Re: no

elliott on 11/30/01 at 11:16 (065724)

He has repeatedly stated on these boards that it's not appropriate for nerve problems. But part of my problem in one foot is most likely bone-related, and I did mean to ask him how the ESWT research was progressing for bone fusion and the like (the ESWT articles on the exam room wall say that it shows promise for this) but forgot to ask him.

How's your lateral plantar nerve diagnosis coming along? I was surprised to see you post that the TTS pros you no doubt are seeing were having trouble getting a handle on it.

-------

Re: Elliott, did Dr. Z

Dr. Zuckerman on 11/30/01 at 11:50 (065733)

No ! ESWT still only beneficial for insertional tendonitis problems, such as heel spur, plantar , achilles tendonitis. patellar, elbow and shoulders

Re: I saw Dr. Zuckerman yesterday!

Richard, C.Ped on 11/30/01 at 12:30 (065736)

What is behind the shower curtain is on a foot care professional need to know basis....We are not allowed to tell you what is back there. Ha ha...Just kidding!!! He does have a pretty cool office though.
Richard

Re: lateral plantar nerve involvement

Matt L on 11/30/01 at 13:29 (065742)

The orthopeadic surgeon that I am seeing (who is known to you) is not sure where exactly on my ankle that the problem is originating from. If it is in an area that was previously released during my first surgery then my surgical options are limited due to scar tissue involvement. If it is in 'virgin' territory (above or below the existing scar area) a traditional release may be an option. I tend to believe (unfortunately) that it is probably within the existing scar area. There doesn't appear to be anyway to know with certainty one way or the other. Thank for asking.

Re: lateral plantar nerve involvement

elliott on 11/30/01 at 13:48 (065746)

Is it possible that the plantar fasciotomy you had later or its after-effects has anything to do with your lateral foot pain?

Re: lateral plantar nerve involvement

Matt L on 12/03/01 at 08:17 (065971)

It has been considered and is possible but I feel unlikely. I based this primarily on the fact that I can't manipulate/create any symptoms by pressing in this area. However, I can most of the time by pressing/tapping in the traditional tarsal tunnel area.

Re: lateral plantar nerve involvement

elliott on 12/03/01 at 09:40 (065974)

Any chance a careful NCV might zone in on the location of entrapment? If you need the name of a good electromyographer or would like to give him a call to ask, let me know. Wouldn't the reaction evoked by tapping in the traditional TT area suggest it's in the original area?

-------

Re: lateral plantar nerve involvement

Matt L on 12/03/01 at 13:20 (065986)

Yes, I think it does suggest it's in the original area. It's just odd that the involvement is principally lateral. Who do you recommend for the NCV test? I'm not sure whether it would show any abnormalitites or not- as the nerve may be irritated but not (yet)damaged. Have you heard of any successful surgical options, short of the vein wrap, for reoccurences of tts?

Re: lateral plantar nerve involvement

elliott on 12/03/01 at 15:01 (065995)

Maye not so odd. Pre-TTS release on my left foot, I had tingling only in the medial four toes (medial plantar nerve). Post-TTS release, after a severe recurrence of sorts, I had lateral plantar nerve tingling as well (sole at fourth and fifth metatarsals at ball joint, and lateral two toes), sometimes in isolation, and its source hard to place, although this tingling was not unbearable at all (the medial ankle clearly being the source of the bigtime trouble, just as it was pre-surgery). My foot is much improved since then (I can now wear shoes, albeit with discomfort, for a few hours, but could not at all before, and the pain level also has dropped considerably). Still hard to imagine living the rest of my life as is, but at least I'm having some hope of this foot eventually straightening out. Based on pain location, I am suspicious a more minor nerve branch is entrapped and which was also the main culprit pre-surgery, making my case especially strange. There are other possible causes I'd rather not go into now. Just got to wait it out. He warned me not to rush into another surgery and risk all without giving it time. (But how many years does one have to wait?! It's now 1.5 years post-op.). If it does come round, I'll have to call him and thank him profusely and apologize for doubting him. Anyway, when they do the standard release, current practice is that they go at least as far distally as the first branch of the lateral plantar nerve (to not do so risks an incomplete release). Based only on what you said and no other info, assuming the PF release had nothing to do with it, my guess would be that it was due to the usual post-surgical scar tissue (a risk I'm sure you're aware of) forming over the first branch of the lateral plantar nerve released. And then yes, as you say, a re-release in the same area (short of a vein wrap) would not offer good chances.

Yes, the vein wrap is extreme. I saw a patient in the waiting room who had had it (by one of you know who's junior colleagues). Nice person. She was obese, in case that's relevant, and told me she had a blue collar job demanding she stand much of the day on a cold concrete assembly line. First two surgeons in a neighboring state messed up and made things worse, each blaming the other. By that point, she had had nervy electricity running from toes all the way up to top of leg. Severe case. The vein wrap leaves a hideous incision scar from ankle to knee (didn't stop her from wearing shorts in summer), but she was thrilled, as she had 75% relief post-op and was able to return to her job after two failed releases and a long time on disability. It gave her a last chance at life and she won (at least till then). But if it fails, your foot has been permanently rewired and may have more problems than before, which is why the standard is so high. If it reaches the point where you feel you must have surgery, between the two, I'd be inclined to try one more standard release before the vein wrap. Just MHO.

You don't need damage in order for the NCV to pick it up. The fact that you have tingling is suggestive of a slowing of the nerve conductivity. It's just possible that by placing the nodes at strategic intervals, the source of entrapment can be located. Well, it's worth asking, isn't it?

Neuroelectrodiagnostician's name is Emanuel Rechthand. Has offices in Owings Mills, Sinai, Towson, Westminster. Qualified neurologist as well as electromyographer. One of the best in the state, and real nice guy too. Email me if you need further info such as his telephone no. or have more personal questions to ask me.

Re: lateral plantar nerve involvement

Matt L on 12/05/01 at 13:38 (066212)

Elliott, thanks for the detailed response. Intuitively, I feel there must be simpler solutions than the vein wrap. Doesn't mean there is- just seems like there should. For all the amazing medical procedures out there, keeping scar tissue from squeezing a nerve doesn't sound like it should be so complicated.

By the way, have you heard of a Dr. John Campbell at Hopkins? He supposedly has some experience in recurrent TTS cases.

Re: Campbell?

elliott on 12/05/01 at 15:02 (066221)

No. Never heard of him. Started looking around. Checked the references of a big chronic pain paper in my possession and found a few J Campbells quoted, references 28 and 29. Apparently two different Campbells, as one is JN, the other JT. If it's JT, his solution to solving recurrent TTS cases may be the very same vein wrap. Here's the abstract:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9840207&dopt=Abstract

But actually, I think it's JN. You sure it's John? Maybe it's James, since I found a listing for James N. Campbell (JN!), neurosurgeon, at Hopkins, in a local Blue Cross comprehensive listing. Based on the abstracts of his research papers, he seems to be doing neurological/neurosurgical research and experiments all over the body, and not just on humans. You sure he's focussed on TTS? If so and you go see him and have a positive experience, please let me know. I'm switching to Blue Cross come January and will have freedom to go anywhere then.

Yeah, intuitively, there should be something simpler than a vein wrap for yor kind of problem, but I think part of the problem is that they don't always know exactly what goes wrong with a release when it does.

Papers on surgical success in second releases in general show results that aren't pretty. But they find that the odds are much better if there was insufficient release the first time round or a different area involved.

I've seen some articles talk about putting fatty tissue in as a barrier between nerve and other obstructions in a successful standard release, but who knows how much difference that really made, i.e. maybe it was the standard release part that was successful rather than the technique.

If you pain is localized enough, did you consider trying a cortisone or lidocaine/marcaine shot? That might be worth a 'stab'.

--------

Re: JT

Matt L on 12/05/01 at 15:41 (066227)

It is JT. The url to his bio follows. Looks like he worked with Dr. S at one point. I'm not sure if anything would be gained by seeing him- may have the same tricks in his bag.

I asked Dr. S about the 'fat wrap'- said it didnt work. Didnt say why it didnt.

I've had 2 cortisone injections into the TT area- mild improvement for a few days, then back to 'normal'. Not sure if lidocaine is also being injected- however it is an ingrediant in the topical cream Dr. S prescribed.

http://www.hopkinsmedicine.org/orthopedicsurgery/physicians/faculty/campbell.html

Re: so what are you going to do?

elliott on 12/05/01 at 15:59 (066235)

Is nothing an option? How's the pain level these days?

Re: so what are you going to do?

Matt L on 12/06/01 at 08:08 (066314)

The pain level varies from mild to moderate. For the most part I been living with it for 8 1/2 years. It definitely effects the quality of my life and has changed my mental outlook. I don't look forward to getting out of bed in the morning because I know the day will be a struggle to get through. Yet, I realize the pain could be/get much worse-particularly with a failed surgery. Therefore, any surgical option is a tough call. As to the vein wrap, I don't think I'm there yet- at this point the potential upside vs. the potential downside isn't sufficient to justify it-at lease based on what I know.
So, as to what I'm going to do- I truly don't know. I feel I need to keep on searching for additional viable options- both surgical and non-surgical. Sitting around doing nothing means no hope. So I read the message boards, research the net, etc. looking for something new to try. The problem is that it's getting more difficult finding anything new to consider-clearly the world isn't searching for solutions to TTS along the lines of a cure to cancer (nor should it of course). Sorry for the rambling. I may try another opinion (possibly at Hopkins) but I've spoken to enough doctors over the years that my expectation that I'm missing something (an easy option)is not high.