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

Q esp for docs re: TTS and irritating shoes

Posted by elliott on 1/31/02 at 22:12 (072153)

If one wears shoes that increase the TTS nerve irritation, is that person at higher risk to cause further nerve damage, either directly to that nerve or neighboring nerves, or indirectly by possibly causing things like double-crush phenomenon or RSD? If your answer depends (e.g. on how long and how much discomfort, types of symptoms produced, if the TTS cause is known, if it's pre- or post-TTS release, etc.) please say on what.

The dilemma is that TTS is often caused by, or exacerbated by, lack of motion control, but motion control shoes do their job by offering great support, which often means greater TTS irritation at that ankle area. Or perhaps one's feet have diametrically opposite needs: the non-TTS foot is weak and screaming for a support shoe, while the TTS foot is begging to be left barefoot (purely hypothetical case, of course). If it's safe, one might be willing to put up with temporary discomfort for long term gain. Any insight much appreciated.

---

Re: Q esp for docs re: TTS and irritating shoes

wendyn on 1/31/02 at 22:48 (072156)

Elliott - I have no insight so to speak, but I do know that my TTS symptoms were greatly aggravated by motion control shoes. No relief until I switched to Birks. I have not gone back and tried the motion control shoes again.

Re: suggestion for TTS tender spot

Donna SL on 2/01/02 at 02:36 (072168)

Elliott,

I just saw this section on the Pro-lab orthotics web site written by a DPM named Dr. Schere that you might be interested in. He desribes how a pair of orthotics should be made for TTS, plus some other pathologies. In his example he uses a correction for a pronated foot, because he mentions inverting the orthotic, using medical skives, etc.. He points out that although this correction is needed it will put more force on the medial aspect of the heel. He makes a great suggestion about putting a sweetspot under the Porta pedis to avoid irritation to this already sensitive area.

I have TTS, but have a high arch, and over-supinate, so I couldn't use this type of prescription, but have not been able to tolerate orthotics lately, because even in a neutral orthotic this area irritates the nerves. I'm just wondering myself why no doctor that I've dealt with so far has thought of this.

Here's the article.

http://www.prolaborthotics.com/Education/PathologySpecificOrthotics.cfm#h7

I suppose if someone got enough control from the MC shoe alone then a cped, dpm, or even a shoe repair place that does orthopedic corrections could excavate an area out in the same spot, and fill it with silicone, or another soft material.

Donna

Re: Q esp for docs re: TTS and irritating shoes

rebecca h on 2/01/02 at 18:54 (072246)

This is a good question. I don't have TTS. Or at least I haven't been diagnosed with it, but I do have irritation in the posterior tibial tendon which is in the same area. I have had an seemingly hopeless shoe search. Some (like the Brooks Addictions) are good for sesamoiditis, which I also have, but irritate the post tib. I tried on some A N D 1 basketball shoes today and they felt really good. I almost bought them but because they bend in the middle of the shoe instead of the forefoot I didn't since I also have plantar fasciitis which is supposed to be aggravated by a shoe that bends in the middle. Birkenstocks feel good in the arch but hurt my forefeet. Other shoes were good for one problem but not another. I hope someday to find a shoe that is good for all the pain areas in my foot.

Re: Q esp for docs re: TTS and irritating shoes

Ed Davis, DPM on 2/02/02 at 17:18 (072316)

Elliott:

It may depend on HOW the motion control shoes control motion. There are a number of means, with a stiff medial counter being one. A stiff medial counter that extends too far forward (toward the arch) or if the medial counter comes up too high then it is very probable that TTS can be exaccerbated. One way around this is to insert a medial heel wedge--reduces eversion of the heel thus reducing contact between the medial counter and the tarsal tunnel area.
Ed

Re: suggestion for TTS tender spot

Ed Davis, DPM on 2/02/02 at 17:28 (072317)

An orthotic casted with the subtalar joint held in mild pronation often works better for an individual with a high arch and supinated foot. It is possible to get much closer orthotic conformation to the contours of the foot, but less irritation of the plantar fascia or porta pedis with a 'pronated' orthotic. Sensitivity in the porta pedis is usually associated with distal tarsal tunnel syndrome.
Ed

Re: suggestion for TTS tender spot PS

Ed Davis, DPM on 2/02/02 at 17:31 (072319)

PS The ASICS MC Plus is a terrific shoe but watch out for the medial counter which has the potential to irritate the porta pedis. An individual with a high arch foot, especially if calcaneal varus is present, will not get the benefit from the medial heel wedge I had suggested to Elliott.
Ed

Re: Q esp for docs re: TTS and irritating shoes

elliott on 2/02/02 at 22:30 (072366)

It's the Brooks Addiction walker I'm talking about. It does not have an irritating wedge (that some including me find uncomfortable, even without nerve problems) like those found in some Asics MC shoes I've tried. It is basically a perfect fit in all respects. My right foot is screaming for support and gets it. But my left foot still has some post-surgical nerve irritation. Any shoe that laces up in a nice snug way and gives support is going to cross and irritate that area. But my right foot is making progress with these shoes. Even my left foot might slowly be coming round (by eliminating any nerve irritation due to pronation). It is in this context (assuming I am considering continuing to wear these shoes for lack of better given the circumstances) that I am asking about whether the nerve irritation caused might have any longlasting effects, or whether they are just temporary while the shoes are on. Any insight? Thanks!

---

Re: so is the Addiction a failure for you?

elliott on 2/02/02 at 22:32 (072367)

If so, sorry things didn't work out better.

--

Re: suggestion for TTS tender spot

elliott on 2/02/02 at 22:43 (072369)

Thanks for that info. His discussion of surgery outcomes seems a bit too negative. For me, orthotics is not the problem, it's the shoes. (OTOH, orthotic construction for me may be more complicated than laid out on that site, since they would have to take into account different things going on in both my feet.)

Can I ask you about ART? You've posted repeatedly about it. You claim the treatemnts are great, but I surmise they didn't outright cure you, as you still have problems. I am considering trying it out, especially for my right foot, where I think a tight muscle might be contributing to my problems, and maybe the deep massage of ART could help for this, as well as for any scar tissue that might be there. I'd also consider it for my other foot. Is ART's deep masssage totally safe even though we're dealing with possibly entrapped nerves? Can you tell me how much it costs per visit? Is it counted as chiro for insurance purposes (insurance info usually states alignments must be for your back). Thanks for any input.

---

Re: ART Re: suggestion for TTS tender spot

Donna SL on 2/03/02 at 11:59 (072422)

Elliott,

I still think ART is incredible, and don't know where I would have been without it. I have improved considerably, and am at the point where I can walk, and stand for hours instead of minutes. I'm trying to go the entire day, like I did in the past. My problems are minor compared to what they where 6 months ago, and considering I have not had any surgery, and am feeling 70% to 80% improved so far is a great feat. (no pun intended) The physiatrist feels that a lot of the remaining pain is because the nerves sustained a lot of damage, and just need to heal, and feels I should see continued improvement within the next year. He thinks I'm somewhat impatient. At times I think of trying a cortisone shot to see if it brings down some possible deep remaining swelling, but I know if I had attempted that before it probably would have done nothing. I've had other complications besides TTS which included several lower lumbar disc injuries, peroneal entrapment, etc. which have improved dramatically with chiropractic, ART, and acupuncture treatments. These conditions can affect the lower extremities too.

All these injures also left me with more of an unstable gait, even though that's improved considerably with various treatment. I've been attempting off, and on to try to find in orthotic that was tolerable in the hopes that if I was more stable, there would be less chance of reinjury. Also with having high arched rigid feet I don't have the most stable gait as it is, plus this type of foot causes other problems, and discomfort. Functional orthotics are tough to prescribe for a cavus foot even without any injuries. I may have to accept only a accomadative orthotic. I don't wear any at the moment.

I've mentioned many times before that ART is not deep tissue massage, and explained how ART treats tight fascia, adhesions, etc., and it's purpose is to relieve nerve entrapment, so I'm sure if you have entrapped nerves this would help you tremendously, and not do harm. Why don't you just try a couple of sessions, and see for yourself?

As far as insurance, I've never seen an insurance company say chiropractic treatment was limited to the back. Chirpractors can treat all parts the body, and do foot adjustments, treat carpal tunnel, hips, the pelvis, neck, etc. I don't think they are that specific though when they submit a claim, and just submit for chiropractic treatments, and therapy.

I can't specify exactly what my doctor charges, but ART is pretty reasonable. I've seen charges as low as $40.00 per 15 minute session to as high as $125.00 (unusal though). I think the average is around $60.00 I have a friend who's paying $75.00 in Manhattan, so it depends on the area you're in. BTW she was ready for a wheelchair before she had ART, and is now much improved.

Also, I think TTS, or any long term chronic injury requires a multi care approach, and can benefit from many treatments including acupuncture which I've had, plus various nerve medications, both orally, and topically. My physiatrist felt a lot of the remaining pain I was having was due to chronic pain syndrome that I had developed too. Actual changes to the nervous system can occur, when chronic pain is left untreated for so long, and the nerves can sometimes continue to over fire, even though the condition is cured. Also I've just started pilates which is supposed to help stablilze weakened muscles, regain balance, etc.

I found this article on chronic pain that you may find interesting.

http://www.hosppract.com/issues/2000/07/brook.htm

Donna

Re: so is the Addiction a failure for you?

rebecca h on 2/05/02 at 18:57 (072698)

No, Elliot, they are the best shoes I've found so far, and believe me, I have spent hours and hours in my seemingly never ending shoe quest. They have been the shoes that have been most helpful with forefoot pain so far. I just wish I could find a shoe that helped both the forefoot and the inner arch/inner ankle pain. I appreciate your helping me locate them and who knows, maybe when my feet are more healed they will feel better. Didn't you say you couldn't wear them for a long time because of TTS irritation, but now they feel good?

Re: so is the Addiction a failure for you?

elliott on 2/05/02 at 21:38 (072732)

Could you try changing the inserts to others? Maybe it will shift the location of your medial pain.

Due to that TTS irritation in the one foot, I couldn't wear any shoes at all for 10 months, with the Brooks being just about the worst, I believe precisely because it gives better support. It's not the shoe's fault when it's doing what it's supposed to do. Sometimes (but not always) it may be worth going through initial discomfort if the shoe will help it clear (that was my question starting off this thread). Most people's orthotics are initially uncomfortable too.

---

Re: Q esp for docs re: TTS and irritating shoes

wendyn on 1/31/02 at 22:48 (072156)

Elliott - I have no insight so to speak, but I do know that my TTS symptoms were greatly aggravated by motion control shoes. No relief until I switched to Birks. I have not gone back and tried the motion control shoes again.

Re: suggestion for TTS tender spot

Donna SL on 2/01/02 at 02:36 (072168)

Elliott,

I just saw this section on the Pro-lab orthotics web site written by a DPM named Dr. Schere that you might be interested in. He desribes how a pair of orthotics should be made for TTS, plus some other pathologies. In his example he uses a correction for a pronated foot, because he mentions inverting the orthotic, using medical skives, etc.. He points out that although this correction is needed it will put more force on the medial aspect of the heel. He makes a great suggestion about putting a sweetspot under the Porta pedis to avoid irritation to this already sensitive area.

I have TTS, but have a high arch, and over-supinate, so I couldn't use this type of prescription, but have not been able to tolerate orthotics lately, because even in a neutral orthotic this area irritates the nerves. I'm just wondering myself why no doctor that I've dealt with so far has thought of this.

Here's the article.

http://www.prolaborthotics.com/Education/PathologySpecificOrthotics.cfm#h7

I suppose if someone got enough control from the MC shoe alone then a cped, dpm, or even a shoe repair place that does orthopedic corrections could excavate an area out in the same spot, and fill it with silicone, or another soft material.

Donna

Re: Q esp for docs re: TTS and irritating shoes

rebecca h on 2/01/02 at 18:54 (072246)

This is a good question. I don't have TTS. Or at least I haven't been diagnosed with it, but I do have irritation in the posterior tibial tendon which is in the same area. I have had an seemingly hopeless shoe search. Some (like the Brooks Addictions) are good for sesamoiditis, which I also have, but irritate the post tib. I tried on some A N D 1 basketball shoes today and they felt really good. I almost bought them but because they bend in the middle of the shoe instead of the forefoot I didn't since I also have plantar fasciitis which is supposed to be aggravated by a shoe that bends in the middle. Birkenstocks feel good in the arch but hurt my forefeet. Other shoes were good for one problem but not another. I hope someday to find a shoe that is good for all the pain areas in my foot.

Re: Q esp for docs re: TTS and irritating shoes

Ed Davis, DPM on 2/02/02 at 17:18 (072316)

Elliott:

It may depend on HOW the motion control shoes control motion. There are a number of means, with a stiff medial counter being one. A stiff medial counter that extends too far forward (toward the arch) or if the medial counter comes up too high then it is very probable that TTS can be exaccerbated. One way around this is to insert a medial heel wedge--reduces eversion of the heel thus reducing contact between the medial counter and the tarsal tunnel area.
Ed

Re: suggestion for TTS tender spot

Ed Davis, DPM on 2/02/02 at 17:28 (072317)

An orthotic casted with the subtalar joint held in mild pronation often works better for an individual with a high arch and supinated foot. It is possible to get much closer orthotic conformation to the contours of the foot, but less irritation of the plantar fascia or porta pedis with a 'pronated' orthotic. Sensitivity in the porta pedis is usually associated with distal tarsal tunnel syndrome.
Ed

Re: suggestion for TTS tender spot PS

Ed Davis, DPM on 2/02/02 at 17:31 (072319)

PS The ASICS MC Plus is a terrific shoe but watch out for the medial counter which has the potential to irritate the porta pedis. An individual with a high arch foot, especially if calcaneal varus is present, will not get the benefit from the medial heel wedge I had suggested to Elliott.
Ed

Re: Q esp for docs re: TTS and irritating shoes

elliott on 2/02/02 at 22:30 (072366)

It's the Brooks Addiction walker I'm talking about. It does not have an irritating wedge (that some including me find uncomfortable, even without nerve problems) like those found in some Asics MC shoes I've tried. It is basically a perfect fit in all respects. My right foot is screaming for support and gets it. But my left foot still has some post-surgical nerve irritation. Any shoe that laces up in a nice snug way and gives support is going to cross and irritate that area. But my right foot is making progress with these shoes. Even my left foot might slowly be coming round (by eliminating any nerve irritation due to pronation). It is in this context (assuming I am considering continuing to wear these shoes for lack of better given the circumstances) that I am asking about whether the nerve irritation caused might have any longlasting effects, or whether they are just temporary while the shoes are on. Any insight? Thanks!

---

Re: so is the Addiction a failure for you?

elliott on 2/02/02 at 22:32 (072367)

If so, sorry things didn't work out better.

--

Re: suggestion for TTS tender spot

elliott on 2/02/02 at 22:43 (072369)

Thanks for that info. His discussion of surgery outcomes seems a bit too negative. For me, orthotics is not the problem, it's the shoes. (OTOH, orthotic construction for me may be more complicated than laid out on that site, since they would have to take into account different things going on in both my feet.)

Can I ask you about ART? You've posted repeatedly about it. You claim the treatemnts are great, but I surmise they didn't outright cure you, as you still have problems. I am considering trying it out, especially for my right foot, where I think a tight muscle might be contributing to my problems, and maybe the deep massage of ART could help for this, as well as for any scar tissue that might be there. I'd also consider it for my other foot. Is ART's deep masssage totally safe even though we're dealing with possibly entrapped nerves? Can you tell me how much it costs per visit? Is it counted as chiro for insurance purposes (insurance info usually states alignments must be for your back). Thanks for any input.

---

Re: ART Re: suggestion for TTS tender spot

Donna SL on 2/03/02 at 11:59 (072422)

Elliott,

I still think ART is incredible, and don't know where I would have been without it. I have improved considerably, and am at the point where I can walk, and stand for hours instead of minutes. I'm trying to go the entire day, like I did in the past. My problems are minor compared to what they where 6 months ago, and considering I have not had any surgery, and am feeling 70% to 80% improved so far is a great feat. (no pun intended) The physiatrist feels that a lot of the remaining pain is because the nerves sustained a lot of damage, and just need to heal, and feels I should see continued improvement within the next year. He thinks I'm somewhat impatient. At times I think of trying a cortisone shot to see if it brings down some possible deep remaining swelling, but I know if I had attempted that before it probably would have done nothing. I've had other complications besides TTS which included several lower lumbar disc injuries, peroneal entrapment, etc. which have improved dramatically with chiropractic, ART, and acupuncture treatments. These conditions can affect the lower extremities too.

All these injures also left me with more of an unstable gait, even though that's improved considerably with various treatment. I've been attempting off, and on to try to find in orthotic that was tolerable in the hopes that if I was more stable, there would be less chance of reinjury. Also with having high arched rigid feet I don't have the most stable gait as it is, plus this type of foot causes other problems, and discomfort. Functional orthotics are tough to prescribe for a cavus foot even without any injuries. I may have to accept only a accomadative orthotic. I don't wear any at the moment.

I've mentioned many times before that ART is not deep tissue massage, and explained how ART treats tight fascia, adhesions, etc., and it's purpose is to relieve nerve entrapment, so I'm sure if you have entrapped nerves this would help you tremendously, and not do harm. Why don't you just try a couple of sessions, and see for yourself?

As far as insurance, I've never seen an insurance company say chiropractic treatment was limited to the back. Chirpractors can treat all parts the body, and do foot adjustments, treat carpal tunnel, hips, the pelvis, neck, etc. I don't think they are that specific though when they submit a claim, and just submit for chiropractic treatments, and therapy.

I can't specify exactly what my doctor charges, but ART is pretty reasonable. I've seen charges as low as $40.00 per 15 minute session to as high as $125.00 (unusal though). I think the average is around $60.00 I have a friend who's paying $75.00 in Manhattan, so it depends on the area you're in. BTW she was ready for a wheelchair before she had ART, and is now much improved.

Also, I think TTS, or any long term chronic injury requires a multi care approach, and can benefit from many treatments including acupuncture which I've had, plus various nerve medications, both orally, and topically. My physiatrist felt a lot of the remaining pain I was having was due to chronic pain syndrome that I had developed too. Actual changes to the nervous system can occur, when chronic pain is left untreated for so long, and the nerves can sometimes continue to over fire, even though the condition is cured. Also I've just started pilates which is supposed to help stablilze weakened muscles, regain balance, etc.

I found this article on chronic pain that you may find interesting.

http://www.hosppract.com/issues/2000/07/brook.htm

Donna

Re: so is the Addiction a failure for you?

rebecca h on 2/05/02 at 18:57 (072698)

No, Elliot, they are the best shoes I've found so far, and believe me, I have spent hours and hours in my seemingly never ending shoe quest. They have been the shoes that have been most helpful with forefoot pain so far. I just wish I could find a shoe that helped both the forefoot and the inner arch/inner ankle pain. I appreciate your helping me locate them and who knows, maybe when my feet are more healed they will feel better. Didn't you say you couldn't wear them for a long time because of TTS irritation, but now they feel good?

Re: so is the Addiction a failure for you?

elliott on 2/05/02 at 21:38 (072732)

Could you try changing the inserts to others? Maybe it will shift the location of your medial pain.

Due to that TTS irritation in the one foot, I couldn't wear any shoes at all for 10 months, with the Brooks being just about the worst, I believe precisely because it gives better support. It's not the shoe's fault when it's doing what it's supposed to do. Sometimes (but not always) it may be worth going through initial discomfort if the shoe will help it clear (that was my question starting off this thread). Most people's orthotics are initially uncomfortable too.

---