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

Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Posted by Ron B on 1/28/02 at 11:10 (071628)

First I would like to thank Elliot, Wendyn, Ed Davis, Janet, Carmen, Laurie, Carol, Tammie & Chris for responding to my questions. I really appreciate it!

Have any of you heard of FDAL?

It took 7 months and a second opinion from a board certified surgeon to correctly diagnose the contributing causes of my Bilateral TTS. It is called FDAL or Flexor Digitorum Longus Accessorius. Instead of the normal 3 tendons in the foot, I have a forth tendon that reduces the volume of the tunnel and causes an irritation of the posterior tibial nerve. My pod showed me an article in the Nov/Dec, 2001 Journal of foot and Ankle Surgery describing this as a cause of TTS. The 4th tendon occurs in less than 5% of the population.

The other contributing factor was the collapse of my arches / flat feet. The result was a fairly drastic change in the shape of my orthotics and a scheduled surgery to remove the 4th tendon w/ release.

When my MRI was initially done the report from the doctor was that my tendons were swollen. Upon further examination by my 2nd pod it was found that they were indeed swollen but I also had a 4th tendon!

The key was a good set of x-rays and a through review of the MRI by a foot surgeon. I had gathered all of my treatment history to present for the 2nd opinion. This included doctor's notes from my 1st pod, neurologist, and physical therapist.

My new pod has an 85% success rate with TTS and believes that he can get me back to about 90%. I will be firming up the details for surgery on my right foot this Friday. Wish me luck.
Ron

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

elliott on 1/28/02 at 13:01 (071634)

While the FDL is a tendon, I believe the FDAL is a muscle, not a tendon. It's relationship with TTS certainly precedes the article shown you, and is more well known than you might realize (there's whole lists out there with rarer causes of TTS, and yours is but one). Here is the link to the abstract of your article:

http://www.jfas.org/abstracts/November_2001.html#nov_g

I hope the following link works; let me give it a try, as you may find the abstracts there interesting too:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=PubMed

Some of the abstracts in this link talk about misdiagnosis of MRIs, others that the MRIs clearly show what's going on (maybe it depends on who's reading them, as you've observed). I know you're happy to get a diagnosis and you should be, but I'd be bit cautious over your pod's stated success rate and how one defines success; check the link talking about the results of the six FDAL surgical cases. And it seems you need two surgeries to go well, not just one. Even accepting 85% success whatever that means, assuming independent events, the prospective chances for both your feet going well is .85 * .85 = 72%. If the odds are inflated a bit and it's really 70%, then the chances both go well is less than 50%. Clearly, not all people with FDALs get TTS (otherwise, more than 5% of the population would get TTS), so it may help to ask yourself why your FDALs gave you trouble. Also, it would be nice if possible to know more about what produced the swelling and if surgery is likely to make it disappear or eliminate it as a problem. And sometimes things unusual show up that are benign with repsect to the problem until tinkered with at surgery and then they become problems. Good luck; hope things work out for you.

--

Re: second link didn't take

elliott on 1/28/02 at 13:10 (071635)

Click on the second link given in my first post. In the box at top, type in the words

tarsal tunnel flexor digitorum

and hit Go. Out will pop the abstract links. For the one on surgical results, see link 7.

---

Re: direct link to abstract on surgical results

elliott on 1/28/02 at 13:19 (071636)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8077260&dopt=Abstract

Yes, six is a small sample size (and one involved a different muscle), but that's what you get with rarer causes of TTS. Of note is that these two authors are real big names, both with unusual expertise in TTS (Conti's a big PTTD guy too), and their results were that only one out of six was pain-free, and only 4 out of 6 said they were happy with the surgical results.

---

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Ed Davis, DPM on 1/28/02 at 15:36 (071649)

I am also more familiar with an actual muscle belly as opposed to a tendon that can form over the tarsal tunnel. Muscle bellies originating within the foot are termed 'brevis' while muscles originating in the leg and sending their tendons into the foot are termed 'longus'. I have seen TTS caused by an accessory muscle--accessory flexor digitorum brevis or possibly accessory abductor hallucis. Was an MRI performed?
Best of luck.
Ed

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Laurie R on 1/28/02 at 16:03 (071651)

Hi Ron , Wow you never know how things can turn out with the eyes of another doctor .. This sounds good , I am so happy you got the answers you were looking for .. When do you think you may be having surgery ? So you said that your doctor is going to remove your extra tendon? Wow that sounds so painful , but if it gets you back to 90% it will be wroth it . I feel any type of treatment or surgery that is going to help in the long run is worth the pain to go through .. At the end you will be much better . If you don't mind I would love to hear about the surgery for this... I find it very interesting .....

My very best to you Ron, also keep up your great attitude , remember a good attitude is about 95 % of anything .....

Laurie R

Re: with TTS surgery...

elliott on 1/28/02 at 22:55 (071739)

good attitude is only about 10% of anything.

---

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Dr. Marlene Reid on 1/28/02 at 23:58 (071749)

Keep in mind, it is an accessory muscle, meaning it is usuallly not there. That is why an MRI is so important in aiding the diagnosis. TTS can be caused by inflammation of surrounding tissues, edema of the leg, a soft tissue mass, injury, pronation, etc. The key to success in treating and keeping the TTS away is treating the cause!

Re: You are right - it is a muscle!!!

Ron B on 1/29/02 at 09:36 (071771)

Thank you for the info. You are right. It is an accessory muscle!
For some reason I mistook our discussion (pod & I) of extra to mean extra tendon.
Sorry, Lost in the Latin.

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Ron B on 1/29/02 at 09:42 (071772)

Yes. The MRI was key in the diagnosis.
I will ask for a more detailed description of the cause on my next Dr visit this Friday.

Re: Cause, Questions & Your Thoughts

Ron B on 1/29/02 at 10:43 (071786)

Thank you for the response.
My cause was originally attributed to excessive pronation (flat feet). Does this aggravate the nerve by stretching it?

My new pod described my arches as collapsed and said that with age and wear that most persons experience some collapse their lifetime. My feet were fairly flat to begin with and now I have almost no arch. My orthotics have been adjusted to compensate for this.

My new pod/surgeon also mentioned that during release surgery that he could place a titanium pin in my foot to hold the arch in the correct position. Your thoughts?

Re: Cause, Questions & Your Thoughts

Dr. Marlene Reid on 1/29/02 at 22:17 (071876)

There are proceedures for supporting the arch and the newer ones can now be used on adults. I don't know if I'd do them at the same time, but I don't think I'd fault anyone for doing them together. The implant that I use does require a few weeks of immobilization, so there is no conflict there. It does require the foot to be manipulated during the procedure, so I'd probably do that first and then do the release.

Pronation or structural flat feet cause TTS by direct pressure over the nerve.

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

elliott on 1/28/02 at 13:01 (071634)

While the FDL is a tendon, I believe the FDAL is a muscle, not a tendon. It's relationship with TTS certainly precedes the article shown you, and is more well known than you might realize (there's whole lists out there with rarer causes of TTS, and yours is but one). Here is the link to the abstract of your article:

http://www.jfas.org/abstracts/November_2001.html#nov_g

I hope the following link works; let me give it a try, as you may find the abstracts there interesting too:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?CMD=search&DB=PubMed

Some of the abstracts in this link talk about misdiagnosis of MRIs, others that the MRIs clearly show what's going on (maybe it depends on who's reading them, as you've observed). I know you're happy to get a diagnosis and you should be, but I'd be bit cautious over your pod's stated success rate and how one defines success; check the link talking about the results of the six FDAL surgical cases. And it seems you need two surgeries to go well, not just one. Even accepting 85% success whatever that means, assuming independent events, the prospective chances for both your feet going well is .85 * .85 = 72%. If the odds are inflated a bit and it's really 70%, then the chances both go well is less than 50%. Clearly, not all people with FDALs get TTS (otherwise, more than 5% of the population would get TTS), so it may help to ask yourself why your FDALs gave you trouble. Also, it would be nice if possible to know more about what produced the swelling and if surgery is likely to make it disappear or eliminate it as a problem. And sometimes things unusual show up that are benign with repsect to the problem until tinkered with at surgery and then they become problems. Good luck; hope things work out for you.

--

Re: second link didn't take

elliott on 1/28/02 at 13:10 (071635)

Click on the second link given in my first post. In the box at top, type in the words

tarsal tunnel flexor digitorum

and hit Go. Out will pop the abstract links. For the one on surgical results, see link 7.

---

Re: direct link to abstract on surgical results

elliott on 1/28/02 at 13:19 (071636)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8077260&dopt=Abstract

Yes, six is a small sample size (and one involved a different muscle), but that's what you get with rarer causes of TTS. Of note is that these two authors are real big names, both with unusual expertise in TTS (Conti's a big PTTD guy too), and their results were that only one out of six was pain-free, and only 4 out of 6 said they were happy with the surgical results.

---

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Ed Davis, DPM on 1/28/02 at 15:36 (071649)

I am also more familiar with an actual muscle belly as opposed to a tendon that can form over the tarsal tunnel. Muscle bellies originating within the foot are termed 'brevis' while muscles originating in the leg and sending their tendons into the foot are termed 'longus'. I have seen TTS caused by an accessory muscle--accessory flexor digitorum brevis or possibly accessory abductor hallucis. Was an MRI performed?
Best of luck.
Ed

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Laurie R on 1/28/02 at 16:03 (071651)

Hi Ron , Wow you never know how things can turn out with the eyes of another doctor .. This sounds good , I am so happy you got the answers you were looking for .. When do you think you may be having surgery ? So you said that your doctor is going to remove your extra tendon? Wow that sounds so painful , but if it gets you back to 90% it will be wroth it . I feel any type of treatment or surgery that is going to help in the long run is worth the pain to go through .. At the end you will be much better . If you don't mind I would love to hear about the surgery for this... I find it very interesting .....

My very best to you Ron, also keep up your great attitude , remember a good attitude is about 95 % of anything .....

Laurie R

Re: with TTS surgery...

elliott on 1/28/02 at 22:55 (071739)

good attitude is only about 10% of anything.

---

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Dr. Marlene Reid on 1/28/02 at 23:58 (071749)

Keep in mind, it is an accessory muscle, meaning it is usuallly not there. That is why an MRI is so important in aiding the diagnosis. TTS can be caused by inflammation of surrounding tissues, edema of the leg, a soft tissue mass, injury, pronation, etc. The key to success in treating and keeping the TTS away is treating the cause!

Re: You are right - it is a muscle!!!

Ron B on 1/29/02 at 09:36 (071771)

Thank you for the info. You are right. It is an accessory muscle!
For some reason I mistook our discussion (pod & I) of extra to mean extra tendon.
Sorry, Lost in the Latin.

Re: Finally the Cause of my TTS! It's called FDAL. The Key was a 2nd Opinion

Ron B on 1/29/02 at 09:42 (071772)

Yes. The MRI was key in the diagnosis.
I will ask for a more detailed description of the cause on my next Dr visit this Friday.

Re: Cause, Questions & Your Thoughts

Ron B on 1/29/02 at 10:43 (071786)

Thank you for the response.
My cause was originally attributed to excessive pronation (flat feet). Does this aggravate the nerve by stretching it?

My new pod described my arches as collapsed and said that with age and wear that most persons experience some collapse their lifetime. My feet were fairly flat to begin with and now I have almost no arch. My orthotics have been adjusted to compensate for this.

My new pod/surgeon also mentioned that during release surgery that he could place a titanium pin in my foot to hold the arch in the correct position. Your thoughts?

Re: Cause, Questions & Your Thoughts

Dr. Marlene Reid on 1/29/02 at 22:17 (071876)

There are proceedures for supporting the arch and the newer ones can now be used on adults. I don't know if I'd do them at the same time, but I don't think I'd fault anyone for doing them together. The implant that I use does require a few weeks of immobilization, so there is no conflict there. It does require the foot to be manipulated during the procedure, so I'd probably do that first and then do the release.

Pronation or structural flat feet cause TTS by direct pressure over the nerve.