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About to have surgery-maybe not TTS?? Please help..

Posted by jdimiceli on 2/01/02 at 16:00 (072207)

I have had foot pain for most of my life (15 years, and I am almost 25). Surgery in both feet in 1989 to remove accessory navicular (extra bone/cartilage?). Surgery in 1995 to repair severely damaged tendon in left foot (due to cut made in first surgery??). 6 months post-op developed severe pain just under the outside area of both feet and down to bottom of heels. Orthopedic surgeon couldn't find the cause of pain or treat it. Last saw him 4 years ago, until yesterday. Explained to him that pain has intensified- can't stand even long enough to shower, can't walk without significant pain (6 years now with this particular pain). He announced that I show some characteristics of distal tarsal tunnel syndrome and recommends trying tarsal tunnel release on both feet. I'm willing to try anything to not be in pain anymore, but I don't seem to exhibit the symptoms of TTS that I have noted on the internet (numbness, tingling). Only severe pain when standing and walking. Also, pain is on outside of foot, and nerve is on inside of foot..

Anyone out there with definite TTS that exhibit my symptoms (severe pain on outside edge of feet and bottom of heels; no numbness or tingling)? Or anyone who thinks I could have something else that wouldn't be detected in tests?? I don't want to put myself through unnecessary surgery..Please help.

Re: About to have surgery-maybe not TTS?? Please help..

Ed Davis, DPM on 2/02/02 at 17:08 (072313)

I think that you need more evidence to back up the tentative diagnosis of TTS before proceeding with surgery. Consider a second opinion.

Why did you have the accessory navicular bones removed? Did you have orthotics made before that surgery?

Ed

Re: About to have surgery-maybe not TTS?? Please help..

jdimiceli on 2/02/02 at 19:52 (072342)

I trust this doctor's opinion. He's supposed to be one of the best. He did my surgery in 1995, and I have been seeing him since. There isn't anyone in town whose opinion I would trust over his. And since no one has been able to find any other cause, and tests have been run, I've tried orthotics (which make the pain worse), physical therapy, immobilization in a cast, pain medication, to no avail, I'm at the point where any diagnosis that explains my pain is worth looking into. 4-5 years ago, I had 3 other doctors look into my case (one I even went out of town to since he was supposed to be one of the best in the country), and no one was able to diagnose anything, or find a way to treat my pain.

As to the accessory navicular, I had sprained my ankle as a child. Anti-inflammatory medication, physical therapy, orthotics, and 6 weeks in a cast did nothing. Apparently the tendon that was inflamed was attached to this extra bone. So my orthopedic surgeon at the time (not the one I see now) opted to remove the bone. Since I had the same bone in my other foot, he assumed I would develop pain later and removed that one as well...

Re: About to have surgery-maybe not TTS?? Please help..

elliott on 2/02/02 at 23:09 (072373)

Some questions:

What activities do you do?

Which tendon was repaired?

When you say pain 'down to bottom of heels', do you mean still on the outside of your feet? This is crucial.

---

Re: About to have surgery-maybe not TTS?? Please help..

jdimiceli on 2/02/02 at 23:35 (072376)

I don't do any activities because I can't. It hurts me to go to the grocery store even, or do housework. I am a full-time college student (park handicap, so don't walk around campus), work as an administrative associate part-time (sit at a desk all afternoon). Then come home. That's basically my life.

I have 13 years of doctors' notes from my files, so I can tell you exactly what has been done to me: 1st surgery (1989)- posterior tibial tendon was split, and accessory navicular was removed. Repeated in other foot (even though no noted pain in second foot).Second surgery (1995)- posterior tibial tendon in left foot 70% degenerated. Direct repair of tendon not feasible, so healthy flexor digitorum longus tendon was woven through the degenerated tendon. About 6 months post-op I developed significant pain along the bottom of my feet (outer edge) when standing and walking. Pain has intensified over the years, and occurs in conjuction with pain on the bottom of my heels. So, pain doesn't travel. It hurts in both places at same time, and in both feet. Have some permanent swelling underneath incisions on both feet, and will have pain there after being on my feet for a long time. The outside of foot and heel pain will come on after only a minute or two of standing..

Re: followup

elliott on 2/02/02 at 23:54 (072378)

It's still unclear to me. Is the heel pain also on the outer edge of your foot? If not, describe exactly where. Thanks.

--

Re: followup

jdimiceli on 2/03/02 at 00:12 (072380)

Sorry. I misunderstood. The pain is predominantly on the bottom of heel, but also inside of heel and some even behind heels. Some pain on outside edge of right heel. Basically, the only places I really don't have pain at all is at the arches and balls of my feet...

Re: followup

elliott on 2/03/02 at 08:57 (072396)

So you first had surgery to remove accessory naviculars (I have them too, and they may be causing me problems). That weakened your PT tendon. You then had tendon transfer and now have problems mostly on outer foot. My guess would be you shifted your footstrike to the outer edge to compensate for your inner foot weakness, bringing on a whole new set of serious structural problems. I wouldn't rush into TTS surgery; not at all clear you have TTS. Maybe get a nerve conduction test first. Suggest getting an MRI and Xray if you haven't recently. Despite your respect for your current doc, maybe try another to get a different view of things.

---

Re: followup

Dr. Zuckerman on 2/03/02 at 09:51 (072405)

Hi elliot your extra navicular bones are fine don't be concerned with them. This patients shoud have a computized gait analysis and possbile EMG.
The gait analysis would show exacting the timing of the foot strike and where it is. I am betting that your evaluaiton is correct and is a major factor in this case At the least a visual gait analysis is needed by a trained foot and ankle specialist who understands the biomechanics of the human foot and lower extremity. Now are to what can be done to help this
person will depend on just how bad the supination compensation has changed the structure of this patients foot.

Re: followup

jdimiceli on 2/03/02 at 10:43 (072414)

Due to the fact that the new pain started 6 months after my tendon transfer, and since I had 3 months of non-weight bearing and the physical therapy was stopped as soon as I was able to wean myself to one crutch, I did consider that since I wasn't continued with PT as I was learning to walk again, that I did compensate by leaning toward the outside of my foot to get off of the area giving me pain. But this surgery was only performed on my left foot. How would that explain the same pain on my right foot? Also, how does that explain the intense heel pain? And why wouldn't anything show up in the MRI?
My orthopedic surgeon does specialize in the lower extremities. Is there another type of doctor I should see?

I certainly don't want to create a whole new set of problems by having TTS surgery, but my doctor told me there's no real way to test for it b/c it's hard to detect, even with an EMG.

Thanks to all for your input..

Re: my accessory naviculars

elliott on 2/03/02 at 12:08 (072423)

You can tell that just by looking? I'm usually able to walk up to around a mile before major problems set in, so appearances (in to your office on my own two feet!) may be a bit deceptive. My foot has never felt right since surgery (for TTS and posterior tibial tenosynovectomy). Something is really very wrong. Attempting to run when cleared to do so probably was not a good idea and may have worsened things; haven't tried in well over a year (sob). I still have something pulling into my medial heel (which I think caused it all to start with), and although MRI shows the PT tendon to be OK, the surgery gave me some new problems (weak foot and a talonavicular joint often near collapse, although the latter might finally be fading).

I went to a big big-name foot/ankle orthopedist last week. He looked at my MRIs and bone scans, took Xrays, and came up with an immediate diagnosis supposedly explaining all my symptoms: Besides a flattened foot contributing, I have a raised first metatarsal and accessory navicular (the latter bilateral); this is also tugging on my posterior tibial tendon. I'm going back to see him next week; he wants to look at the orthotics I don't wear (first ortho to ever ask to see them). Wants to see if there's some orthotic or insert concoction that will help. I don't have my notes in front of me, but if my foot does not improve, he talked about some combinations of something like cuneiform fusion of the first metatarsal or some equivalent surgery using bone from a bone bank, possible placement of PT tendon somewhere, and removing my accessory naviculars. Wild! He's the big name. Any comments?

----

Re: About to have surgery-maybe not TTS?? Please help..

Ed Davis, DPM on 2/02/02 at 17:08 (072313)

I think that you need more evidence to back up the tentative diagnosis of TTS before proceeding with surgery. Consider a second opinion.

Why did you have the accessory navicular bones removed? Did you have orthotics made before that surgery?

Ed

Re: About to have surgery-maybe not TTS?? Please help..

jdimiceli on 2/02/02 at 19:52 (072342)

I trust this doctor's opinion. He's supposed to be one of the best. He did my surgery in 1995, and I have been seeing him since. There isn't anyone in town whose opinion I would trust over his. And since no one has been able to find any other cause, and tests have been run, I've tried orthotics (which make the pain worse), physical therapy, immobilization in a cast, pain medication, to no avail, I'm at the point where any diagnosis that explains my pain is worth looking into. 4-5 years ago, I had 3 other doctors look into my case (one I even went out of town to since he was supposed to be one of the best in the country), and no one was able to diagnose anything, or find a way to treat my pain.

As to the accessory navicular, I had sprained my ankle as a child. Anti-inflammatory medication, physical therapy, orthotics, and 6 weeks in a cast did nothing. Apparently the tendon that was inflamed was attached to this extra bone. So my orthopedic surgeon at the time (not the one I see now) opted to remove the bone. Since I had the same bone in my other foot, he assumed I would develop pain later and removed that one as well...

Re: About to have surgery-maybe not TTS?? Please help..

elliott on 2/02/02 at 23:09 (072373)

Some questions:

What activities do you do?

Which tendon was repaired?

When you say pain 'down to bottom of heels', do you mean still on the outside of your feet? This is crucial.

---

Re: About to have surgery-maybe not TTS?? Please help..

jdimiceli on 2/02/02 at 23:35 (072376)

I don't do any activities because I can't. It hurts me to go to the grocery store even, or do housework. I am a full-time college student (park handicap, so don't walk around campus), work as an administrative associate part-time (sit at a desk all afternoon). Then come home. That's basically my life.

I have 13 years of doctors' notes from my files, so I can tell you exactly what has been done to me: 1st surgery (1989)- posterior tibial tendon was split, and accessory navicular was removed. Repeated in other foot (even though no noted pain in second foot).Second surgery (1995)- posterior tibial tendon in left foot 70% degenerated. Direct repair of tendon not feasible, so healthy flexor digitorum longus tendon was woven through the degenerated tendon. About 6 months post-op I developed significant pain along the bottom of my feet (outer edge) when standing and walking. Pain has intensified over the years, and occurs in conjuction with pain on the bottom of my heels. So, pain doesn't travel. It hurts in both places at same time, and in both feet. Have some permanent swelling underneath incisions on both feet, and will have pain there after being on my feet for a long time. The outside of foot and heel pain will come on after only a minute or two of standing..

Re: followup

elliott on 2/02/02 at 23:54 (072378)

It's still unclear to me. Is the heel pain also on the outer edge of your foot? If not, describe exactly where. Thanks.

--

Re: followup

jdimiceli on 2/03/02 at 00:12 (072380)

Sorry. I misunderstood. The pain is predominantly on the bottom of heel, but also inside of heel and some even behind heels. Some pain on outside edge of right heel. Basically, the only places I really don't have pain at all is at the arches and balls of my feet...

Re: followup

elliott on 2/03/02 at 08:57 (072396)

So you first had surgery to remove accessory naviculars (I have them too, and they may be causing me problems). That weakened your PT tendon. You then had tendon transfer and now have problems mostly on outer foot. My guess would be you shifted your footstrike to the outer edge to compensate for your inner foot weakness, bringing on a whole new set of serious structural problems. I wouldn't rush into TTS surgery; not at all clear you have TTS. Maybe get a nerve conduction test first. Suggest getting an MRI and Xray if you haven't recently. Despite your respect for your current doc, maybe try another to get a different view of things.

---

Re: followup

Dr. Zuckerman on 2/03/02 at 09:51 (072405)

Hi elliot your extra navicular bones are fine don't be concerned with them. This patients shoud have a computized gait analysis and possbile EMG.
The gait analysis would show exacting the timing of the foot strike and where it is. I am betting that your evaluaiton is correct and is a major factor in this case At the least a visual gait analysis is needed by a trained foot and ankle specialist who understands the biomechanics of the human foot and lower extremity. Now are to what can be done to help this
person will depend on just how bad the supination compensation has changed the structure of this patients foot.

Re: followup

jdimiceli on 2/03/02 at 10:43 (072414)

Due to the fact that the new pain started 6 months after my tendon transfer, and since I had 3 months of non-weight bearing and the physical therapy was stopped as soon as I was able to wean myself to one crutch, I did consider that since I wasn't continued with PT as I was learning to walk again, that I did compensate by leaning toward the outside of my foot to get off of the area giving me pain. But this surgery was only performed on my left foot. How would that explain the same pain on my right foot? Also, how does that explain the intense heel pain? And why wouldn't anything show up in the MRI?
My orthopedic surgeon does specialize in the lower extremities. Is there another type of doctor I should see?

I certainly don't want to create a whole new set of problems by having TTS surgery, but my doctor told me there's no real way to test for it b/c it's hard to detect, even with an EMG.

Thanks to all for your input..

Re: my accessory naviculars

elliott on 2/03/02 at 12:08 (072423)

You can tell that just by looking? I'm usually able to walk up to around a mile before major problems set in, so appearances (in to your office on my own two feet!) may be a bit deceptive. My foot has never felt right since surgery (for TTS and posterior tibial tenosynovectomy). Something is really very wrong. Attempting to run when cleared to do so probably was not a good idea and may have worsened things; haven't tried in well over a year (sob). I still have something pulling into my medial heel (which I think caused it all to start with), and although MRI shows the PT tendon to be OK, the surgery gave me some new problems (weak foot and a talonavicular joint often near collapse, although the latter might finally be fading).

I went to a big big-name foot/ankle orthopedist last week. He looked at my MRIs and bone scans, took Xrays, and came up with an immediate diagnosis supposedly explaining all my symptoms: Besides a flattened foot contributing, I have a raised first metatarsal and accessory navicular (the latter bilateral); this is also tugging on my posterior tibial tendon. I'm going back to see him next week; he wants to look at the orthotics I don't wear (first ortho to ever ask to see them). Wants to see if there's some orthotic or insert concoction that will help. I don't have my notes in front of me, but if my foot does not improve, he talked about some combinations of something like cuneiform fusion of the first metatarsal or some equivalent surgery using bone from a bone bank, possible placement of PT tendon somewhere, and removing my accessory naviculars. Wild! He's the big name. Any comments?

----