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

Nerve conduction studies

Posted by Sharon W on 3/01/02 at 09:11 (075369)

I have both tarsal tunnel syndrome & plantar facaetis in my right foot. My podiatrist sent me to a neurologist for nerve conduction studies next month. I get shooting pains up the posterior tibial nerve up into my calf; sometimes these pains seem to build on each other other, it feels as if one pain impulse doesn't finish firing before the next one begins, and the pain increases each time this happens. What can nerve conduction studies show that will help to diagnose or treat this problem? I can live with the numbness and tingling and burning and arch pain, but I've GOT to find something that works to stop (or at least control) these clusters of shooting pain up my ankle! Is there anyone out there who has experienced this and can give me some advice on what may help or some insight on what to expect from the nerve conduction studies?

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 12:37 (075391)

Sharon,

Have you tried any medications to help the nerve pain? If not Neurontin is usally the most effective for this , and possibly the addition of a tricyclic anti-depressant like nortriptyline (little safter), or elavil. Usually only 10mg of nortriptyline is needed at bedtime. These should calm down the nerves from over-firing.

There is no reason to suffer this type of pain, and in fact it's important to control the pain, and quiet the nerves, so you don't develop a chronic pain syndrome. I would recommend seeing you're family doctor, or ask him/her who is familar with prescribing these medications. These drugs should work better than a narcotic type drug. Neurontin alone may do the trick. You would start at a low dose, and build up as needed. Give it time to build up in your system. Also anti-inflammatory drugs like vioxx are important to reduce any possible swelling that is putting pressure on the nerves.

Have you done any conservative treatment as of yet for your condition? For now even icing the area several times a day for 20 minutes should help. Just put it along the inside of your ankle behind the bump, and follow the course of the PT nerve to the inside of the heel. I had a very bad case of TTS, and PF, and had much improvement with conservative methods. I've read something like 90% of TTS cases can be cured, with conservative methods. I did ART (active release technique), and acupuncture, and the medications. Some people are helped by orthotics, cortisone, or other forms of PT. It helps to try to determine what caused this in the first place, ie. poor biomechanics, something systemic, tendonitis, some type of trauma, etc.

A nerve conduction study may, or may not show any slowing of the nerves unless the TTS is advanced as was in my case. I still had an MRI to rule out any mass, etc. pressing on the area. Regardless my nerves improved dramatically. I had two neves affected off the PTT (lateral, and medial plantar), and they are now showing normal conduction. Also a nerve branch off the LP nerve called the inferior calcaneal nerve aka the baxter's nerve is almost to the normal range now. I just had a repeat ncv test last week to confirm this. This was with 10 months of conservative treatment.

I'm sure when they do the ncv test they will test not only the nerves in your feet, but will also make sure the source is not coming from a higher course along the Posterior tibial nerve.

Good luck, and please keep me posted if you can. If you have any other questions don't hesitate to ask.

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 13:05 (075395)

Unfortunately, yes, several of those 'conservative measures' have already been tried. I've been on Vioxx 25 mg every day for 5 months; the Dr. tried upping it to 50 mg but that gave me too many stomach problems. I don't want addictive pain relievers -- not for a chronic problem. I do use Tylenol sometimes but I don't like the potential for liver damage, and anyway Tylenol doesn't help at all when I start getting those shooting pains! I have custom orthotics -- I can't really tell how much they help, if at all. I also have compression hose, because the MRI showed the compression in the TT is due to a swollen (varicose) vein. I've had steroid injections twice; that helps FAR more than anything else, but it also raises my blood pressure -- and I've had high blood pressure since I was 19. And it wears off after a few weeks; certainly not a long-term solution. As for Neurontin -- I already asked my pod about that; she says I can start it AFTER I get the nerve conduction studies done, that she doesn't want anything interfering with the results. So that's where I am right now. Thanks for responding -- I've visited this site several times but this is the first time I've posted anything. I am worried that the nerve conduction studies will show something distressing -- and worried that they WON'T... which would make me look like I'm faking this, or exaggerating, and I'm not. I'm also worried about what will happen, pain-wise, after the neurologist stimulates those nerves...

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 14:17 (075408)

Hi Sharon,

I've had a physiatrist MD treating me for this, and he didn't feel it was necessary to stop taking the meds before the test, but I did anyway. He also performed my ncv test, and does these test all the time. I would think vioxx more than anything would possibly affect it, because it reduces swelling, but a medication like neurontin is just controlling the nerve pain. It only stays in the system a very short time maybe 4-5 hours.

If there is any demylination, or any other damage to the nerve body itself, that will still show regardless of medications like neurontin. The only thing that could have a possible affect on a ncv test is a recent injection of cortisone. If it makes you feel better than just stop them a week to a few days before the test. Even the day before should be enough. Also, a low dose of narcotic drugs in a short period of time will not cause addiction, especially when you are in pain, and in the long run the results of chronic pain can be worse then the affects of taking these drugs, because there is literally pathological changes to the nervous system when you are constantly exposed to pain.

I've read that cortisone didn't help many people in the long run, so I never tried it. Also traditional PT for 6 months prior to the current treatments I had to didn't help me at all. I'm not familiar with swollen varicose veins, and TTS. I am seeing my chiropractor today who performed the ART on me which released the tight tissue on my nerves, and my physiatrist next week who did the acupuncture. I'll ask them both if they have ever treated anyone sucessfully in a case like yours with the treatments I had.

If you are not going to take these meds before the test than keep them around for immediately after the ncv test. When my nerves were really entrapped the ncv test seemed to irritate them more for a couple of weeks. This doesn't happen to everyone. After having the most recent test when my nerves were better the test didn't bother me at all.

There are many people that have TTS, and other problems that don't show on diagnostic testing, so don't worry that anyone will think that you are faking, or imagining it. Have you seen any other doctors other than your podiatrist like a neurologist, physiatrist, or even possibly a vascular specialist in regards to this?

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 16:20 (075419)

Dear Donna,
What's a physiatrist?
I never heard of ART (active release technique) before; what does it do?
No, the only doctors I've been to about this are our family practicioner she's the one who scripped the Vioxx and the Ambien, to help me sleep)and the pod. But once I go to the neurologist for NCV tests, I suppose I'll have a neurologist...
It's nice to communicate with someone else who has BOTH TTS and PF; it really doesn't seem to be that common a combination so there aren't a lot of people out there who know what I'm going through. And in spite of your reassurances, I DO sense that a lot of people are thinking, 'What's with all the whining about sore feet? EVERYBODY gets sore feet sometimes, i'ts no big deal...' I even have the impression, sometimes, that my pod thinks I'm faking it because MOST of the time I don't have anything worse than a slight limp and some tingling, and mild soreness, and she has never seen me when I happened to be having a cluster of shooting pains.
Anyway, thanks for your help.

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 16:46 (075421)

Hi Sharon,

A physiatrist is a doctor of physical medicine, and rehab. They are also good at diagnosing soft tissue, nerve injuries, etc., and treating them. They also conduct ncv test. I'm getting ready to run out door, but will try to write more either tonight or tommorrow. In the interim you can look at the postings on this board I did around April, and after that on ART. You should find the info using the search function, and my name.

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 19:47 (075425)

Donna,
I did a search using your name & learned quite a bit about ART (and other things) before my web connection timed out. I was very interested to find your postings about that first NCV study and how your foot responded to it. Being in pain for a couple of weeks after the test is more or less what I expected, because EVERY time my pod presses on those nerves during a routine clinical assessment, the rest of the day is painful for me. Actually, while the pod is doing her assessment, all I usually feel is some mildly painful tingling; it isn't until a couple of hours later that the real pain begins. I don't understand why, but my nerves seem to respond to that stimulation by firing off random pain signals for 12-48 hours afterward. So I figure the aftermath of the NCV is bound to be much WORSE...
I really don't know what symptoms you've experienced or whether they are much like mine at all. But, judging by your comments about ART, it sounds like you probably aren't as affected by mild pressure on those nerves as I am. Still, I'm very encouraged by the fact that you're doing so well with your treatment and even talking about being 'cured' eventually! I had finally resigned myself to the idea that my foot problems will probably never go away and that my focus needs to be on MANAGING the problem, not trying to cure it. After all, I HAVEN'T responded very well to the treatments that have been tried so far, and I certainly haven't gotten any encouragement from doctors about my prognosis. I thought my discouraging responses to treatment were probably because I have two problems going on at the same time. But here you are, writing about how much better you feel now and anticipating a 'cure'!
About the varicose vein in my tarsal tunnel: What happens with varicose veins is that the valves (in the veins) that ordinarily prevent blood from flowing back toward the feet due to the force of gravity are malfunctioning in my leg, causing the damaged veins to swell and leading to inflammation in the surrounding tissues. My pod says it's very unusual for this to occur with the vein that runs through the tarsal tunnel. She says that if she were to perform surgery she would strip the vein (remove it completely) from the tarsal tunnel so that it can't cause any more trouble. In doing that, she would (of course) have to cut the flexor retinaculum, which is the typical 'decompression' procedure for TTS. But she doesn't want to operate; she says I'm not a good candidate for surgery and she won't even consider it unless ALL other treatment options are exhausted first.

Re: Nerve conduction studies There are lots of things to try

wendyn on 3/01/02 at 21:21 (075432)

Sharon, I thought that a vericose vein (in the tunnel)was a fairly frequent (relatively) cause of TTS.

Have you had an MRI?

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 22:15 (075437)

Wendyn,
You may be right; my podiatrist said it was rare but I don't think she's had all THAT much experience with TTS. (She definitely looks like she's under 35, which means she can't possibly have that many years of experience.) And as for me, I'd never even HEARD of TTS until about 6 months ago, so...
-- Sharon

Re: Nerve conduction studies There are lots of things to try

wendyn on 3/01/02 at 22:56 (075438)

I think TTS itself is relatively uncommon...but if you look at causes of it, a vericose vein seems to be a common one, and I thought a fairly treatable one too.

Might be wise to get a second opinion...just to be sure.

Re: Varisose vein in TT rare?

Sharon W on 3/02/02 at 09:08 (075459)

Wendyn,
Yes, that's probably it. Obviously, plantar fascaetis and peripheral neuropathy are far more common than TTS, and I doubt if a pod sees TTS all that frequently. Mine commented that she'd done 2 TTS 'decompression' surgeries in the past 2 years.
It was my impression that inflammation itself was the most common cause, which is why MRIs often don't show up an obvious CAUSE for TTS. (They do show PF, though.) Oh -- and to answer your earlier question -- yes, the varicose vein showed up on the MRI, so it's been confirmed.
Yes, although I like my pod, I've been thinking of asking my family Dr. for a referral to another pod for a second opinion. At this point I'm not enthusiastic about the idea of surgery, anyway (although the family Dr. keeps talking about it) but if I do reach that point, I think I would want someone else to operate. It's clear that my pod is very uncomfortable with the idea and I see no sense in trying to 'talk her into it'.
-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/03/02 at 13:45 (075553)

Hi Sharon,

I only had a quick chance to ask my chiropractor about the varicose vein issue, but he said ART could be performed if there was no thrombophlebitis. I'm guessing if there is just phlebitis, and the vein is just being entrapped by soft tissue adhesions, fibrosis, etc. than the ART would probably be ok. That's why it's important to see a vascular specialist to find out why this vein in inflamed, and there aren't other vascular problems. They may have ways of treating the vein problem. From what I've read it is a rare condition in the ankle area. If you discuss ART with one of these doctors, and they are not familiar with it just say is it's a form of gentle myofascial tissue release, and they will understand.

There are so many factors that could be causing your pain, and sometimes conditions can overlap one another, and it gets confusing to what is causing each symptom. A lot of people start out with just PF, and then start to compensate in their gait, and the tissues become tight around the ankles calves, etc., and problems like tendonitis, tendinosis, fibrosis, etc., can develop around the TT area, causing pressure on the nerves. This compensatory walk can sometimes affect the back too, which happened in my case, which than can add to more complications by affecting the nerves in the back that travel to the feet. Then that has to be treated too. It can become a viscous cycle, and the best thing is to slowly un-do the many areas that have been affected. Every case is different, and the original cause could have been of a different nature. It takes the proper form of PT, and a lot of time, and patience to correct this conservatively along with right team of professionals.

Most nerve entrapment, or compression is due to some type of swelling on the nerves from tight tissue which causes the nerves to slow, and pain to result. Once the swelling is reduced, then the nerves will improve. A lot of the times the proper methods of reducing this swelling are not applied, and the person fails traditional conservative methods, or doesn't give alternative methods enough time, and ends up having unnecessary surgery which can make things worse by causing new trauma, and more scar tissue. Statically 90% of TTS should resolve with conservative care. On the other hand there are cases when people have had some type of lesion taking up space in the tunnel, and when it was removed their symptoms resolved. That may be the situation with your varicose vein. I''ve read that these types of cases have the greatest chance of succeeding in surgery Even in cases like this additional PT would help the surrounding structures that were affected. You could always try these conservative methods first before attempting surgery.

In your case you could have coexisting PF complicated by this inflamed vein that is causing all your symptoms. Or maybe none of the symptoms in
your feet are from the PF, and it is all because of the entrapment in the TTS area. The inflamed varicose vein may, or may not be what's even causing your symptoms. There are so many gray areas.

As far as increasing pain the intention of ART is not to inflame the nerve, but to move adhesions off of tissue, and chiropractors are very careful when working on nerve paths. My nerves were irritated in a fashion similar to yours when the pod palpated the trouble spots, but I only had some mild inflammation with the first couple of ART sessions. ART practitioners can tell by feeling your tissue if it feels normal or not, and will only work on the abnormal tissue, and are very aware of any existing medical conditions that might not be appropriate for ART. That's why with any form of nerve entrapment I would only trust a licensed medical practitioner like a chiropractor, because they do have medical training vs a massage therapist doing some sort of myofascial release. To take the ART course you have to be either a certified PT, MD, DO, chiropractor, or podiatrist. My chiropractor said at the most recent ART seminar there were several MD's and DPM's taking the course. If you decided on acupuncture treatment too, I would only recommend a certified medical acupuncturist. http://www.medicalacupuncture.com/

Also, I had mentioned that chronic pain syndrome can occur, and some of your symptoms may be due to that as the nerves become more irritable.
There is lot information on the web on this subject, but the most important thing to understand is the concept of wind-up pain that occurs in chronic pain situations which could be causing some of the intensity of your symptoms. Below are a couple of good articles that explain this. This has to be addressed, so a more serious condition like RSD doesn't develop.

http://www.hosppract.com/issues/2000/07/brook.htm
http://www.helpforpain.com/articles/understand-neuropathic-pain/understanding.htm
http://www.hosppract.com/issues/1998/10/bennett.htm

a good web site with animations
http://www.bayareapainmedical.com/

I'm not completely familiar with all your symptoms, but I had all kinds of horrendous pains throughout my feet, heels, ankles, etc., that ranged from dull aches, burning, stabbing electrical pains,etc. I got to the point where I couldn't stand for more than around 10 minutes before the symptoms began. After a while it took less and less outside stimulus to cause pain, which also kept increasing in intensity. Some of this may have been due to chronic pain syndrome, that's why you need to consider proper treatment for this too. I have little to none of the nerve pain most days now. I get some mild flare ups, and set backs from time to time, but in general I've been consistently improving from week to week. This week for example I've been out every single day on my feet between 3 and 4 hours, before I noticed any pain, and that is really only in the rims of the heels now, and it's a much lower pain level. Also, I have very rigid high arched feet which don't absorb shock very well. Getting out of orthotics for now helped too. I had to do it gradually with tape, but now I don't even use that. The muscles in your feet and legs will eventually get stronger, and that will put less strain on the fascia, etc.

If it is decided that you need surgery, and you choose a podiatrist for this make sure they are member of the American Board of Podiatric surgery, and have extensive experience in this area. I've read that the American podiatric medical association (APMA) recognizes only the American Board of Podiatric Surgery (ABPS) for certifying competency in performing ankle and foot surgery. Only about 3,700 podiatrists are certified by this board, and only about 2,500 of those are certified in both ankle and foot surgery. You can get the pods qualifications by looking on the APMA web site http://www.apma.org and then look under 'find a podiatrist'. The ABPS board charges $25.00 for 4 podiatrist name, that's why I recommend looking under the APMA board for no charge. Also, depending on what's going on with your foot, a vascular, or neurosurgeon may be the right choice. You need to use the same careful selection criteria no matter what type of doctor you choose. De. Lee Dellon specializes in nerve entrapment syndromes, and is supposed to be excellent. He's in Baltimore. http://www.dellon.com

You shouldn't be concerned if people don't understand your foot pain. I've had similar reactions even from MD's that didn't understand the intensity of the pain. If you say you have some type of neuropathy, or neuralgia, you'll be surprised how their expressions change. That they understand, and know that is a painful condition, and will have more empathy.

Donna

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 08:45 (075604)

My pod just called it a 'varicose vein,' although I suppose any swollen vein would technically qualify as phlebitis. I don't think mine is ALWAYS swollen, though; it seems to swell as the day wears on and I've been on my feet somewhat, and it gets really bad if I'm constantly on my feet for a couple of hours. And I probably have more than ONE varicose vein, although I don't have the problem as much as my mother or my sister. So yes, seeing a vascular specialist would be a good idea; I think there's only one in town though. (There are limited specialists available locally, and our medical insurance makes it VERY clear that they won't pay if we go to a someone outside the immediate area unless they specifically authorize it.)
My TTS is in the right foot; I don't think I have it in the left. At least the last time the pod palated the left side, she didn't get + Tinel's sign. My left foot wasn't viewed by the MRI, so this is unconfirmed, but I do think I have PF on that side; it's been bothering me quite a bit recently.
I'm going to send this before my internet connection times out and then send you a summary of my history with this foot in the next message.
-- Sharon
P.S: why did you stop the orthotics?

Why did you stop the orthotics?

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 12:22 (075626)

Donna,

This is my history: I'd been working as a hospital nurse (8 hrs on my feet). I kept telling myself that sore feet were an oppupational hazard and I just had to 'get used to it'. But those 'sore feet' would throb so painfully at night that I couldn't get to sleep for hours, and I usually woke up repeatedly at night because my feet were burning. I was constantly exhausted, and in SOME level of pain 24/7, even on my days off. The numbness and painful tingles SHOULD have set off alarms for me, but I was in denial. I didn't talk about sore feet to other nurses; I didn't want to be known as a 'whiner'. I didn't even tell my family Dr. I had a foot problem until mid-September 2001, when the pain got so bad I could no longer block it from my thoughts when I needed to focus on work. It was the pulsing, throbbing heel and the shooting pains all over my right foot that finally forced me to acknowledge I had a problem. My Dr. suspected PF, so she immediately started me on anti-inflammatories and made an appointment with the pod. But I think I'd already had TTS for a couple of months by then, and I might have had PF for as much as a year.

Two weeks later, early last October, I quit my job. I had assumed that if I got off my feet and followed medical advice, they would immediately begin to heal. I was taking Vioxx by then, and the pod started me on taping my foot. She asked me questions, did X-rays, found a + Tinel's sign in my right ankle, and detected some numbness in my right foot with the safety pin test. That's when she diagnosed TTS in my right foot. And based on my complaint of terrible (but temporary) arch pain first thing in the morning, she also said I had PD. She scheduled me to be fitted for custom orthotics, and I got them at the end of November. (I'm not really sure if they help at all; I really hated them at first, but now I've gotten comfortable with them and I still use them.)

I'm going to break here and start a new message, so my net connection won't time out on me...

-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 12:40 (075633)

Donna,

Continuing the history:
Actually, some of the pain DID get better after all of that; I no longer had low-level pain 24/7,and the heel throbbing improved quite a bit. But all my problems reappeared whenever I'd been on my feet for a couple of hours. And the shooting pains, which HAD been limited to my foot, expanded to include sharp 'electric shock' pains that zapped up my ankle past the medial malleolus. Those 'shooting ankle pains' (as I call them) grew much more frequent with the passage of time and became a bit slower, no longer 'zapping'. And then, at the beginning of December (AFTER I had my new orthotics), they began occurring in clusters occasionally. (By 'cluster' I mean when the next nerve fires its pain impulse before the first one is complete, and they build on each other, each time increasing the pain level.)

I think my PF has improved in the past 5 months, but the nerve pain in my right foot has definitely grown in intensity with the passage of time. Perhaps this is because the damage to my posterior tibial nerve is increasing and/or becoming permanent. Perhaps it is because that varicose vein is getting worse. Or perhaps it is because of chronic pain syndrome -- although I don't really think I've developed that yet. But the TTS seems to be getting steadily worse in spite of treatments. Fortunately, those 'clusters' of 'shooting ankle pains' are still rare -- they only happen a couple of times a month,and they've always begun to calm down within half an hour or so. And so far, I've always had enough warning to get off the road and to a safe place before it gets that bad. But I do worry about whether I could control the car if one hit me out of the blue, with no warning, and I couldn't easily pull of to the side of the road. It's a scary thought!

Thanks for all the info you sent; I found out that there IS a local podiatrist certified by the American Board of Podiatric surgery, and he has four DECADES of experience.

-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/04/02 at 14:35 (075641)

Hi Sharon,

You have a lot of things to do now, but the first priority is to get on nerve medications asap. It's not good in any case for your system be exposed to the pains you are feeling. If you have pain as long as you have you are in a chronic pain situation if you realize it, or not. If the doctors you know are not familiar with the proper meds ask them for the name of a good pain mgt clinic, or psychopharmacologist. (yes another new speciality) You need to be on meds until you figure out what's going on. My doc even had a great topical cream made up by a compound pharmacist.

I'm so glad you found the new pod. When are you going to see him? Hopefully he'll be able to give you a clear diagnosis of your problem. Bring your Mri's. Also it's critical to see the vascular specialist asap. You also need to make sure your orthotics aren't pressing on any nerves in the foot, or causing additional stress on the foot structures. ie. if you are over or under corrected this will put additional stress on everything. Also, you need to find out if anything else systemically is causing this problem, but it does sound like it's a local one. Believe it or not, it's hard to find a specialist that takes interest in the foot. I don't know why, it is a part of the body. I've gone to neurologists, orthopedic doctors, md's etc. that were totally ignorant on this subject. You sometimes have to keep digging until you find the proper one.

I stopped wearing orthotics, because I couldn't find a correction that didn't irritate some part of my foot especially the arch, or cause some other type of problem, once I developed these foot problems. I realized that my feet started to improve with nothing on them. One of the nerves that were entrapped (baxter's nerve) was being compressed more with the orthotics. (near the insertion point). Also, they restricted my motion even more which put additional stress on my feet. I had worn orthotics prior to this, and was fine. A prior pod gave me the wrong correction which caused most of these injuries. The new pod said I never really needed them in the first place, and was in the wrong correction anyway. At my insistance he attempted over a long period to to make many pairs, but I couldn't really tolerate them, and if he fixed one thing, then they caused another problem. My right foot had become severely unstable, because some of the nerves got affected in my back from all this, but the entire situation is improving now. I have a high arched foot which is tough to fit for orthotics anyway. Now that I'm feeling better, and not as sensitive, I could give them a try again. If I can continue to do without them I'd prefer that. They are sometimes more trouble then they are worth.

Sometimes people only a need stretching routine, foot strengthening program for the intrinsic foot muscles, PTT area, etc., or some other type of lower extremity program rather than orthotics, but a lot of pods have a tendency to over prescribe them. Sometimes they are needed until the injury is resolved.

Once you find out what's going on with your feet then you can determine the best course of action to take. If it's PTT for example then you need to get in rehab program for that. Usually a good set of prescribed exercises will help. Also find out about the varicose vein. It that's not a major problem then hopefully you could also get started on ART. At least start your other foot now, and the rest of the lower extremities, so things don't get worse. They can work not only on your feet, but your calves, legs, etc., which when tight contribute to all these problems. Acupuncture would also help with pain control, reduce additional swelling, and increase healing.

Keep me posted.

Donna

Re: NCV tests -- will they answer my questions?

Sharon W on 3/04/02 at 18:10 (075663)

Donna,

As for pain meds, I have a cream form of the anti-inflammatory medication, Voltaren. I bought it in Mexico, with the approval of my pod; if bought in THIS country it has to be specially formulated & is very expensive (although I had THAT done once, too). It does carry a slight risk of harming the liver but, in the topical form, that risk is MUCH lower than taking pills. And it helps with pain a LOT -- soaks right in exactly wehre you need it and helps with pain & inflammation a LOT. I will use it more often now, during this time before the NCV tests, but I will respect my pod's decision not to start me on it until after those tests have been done.

The NCV tests may help to answer some of the questions I have about all of this. And hopefully, it will also help to answer the one my pod is asking, which you also touched upon in your latest message: is there nerve damage in my spine, or in the sciatic nerve? She thinks she may have detected something, and it's an important qquestion to answer. Perhaps, like you, I may have damage the nerves in my back while compensating for my injured foot. I'm hoping that the NCV tests will show it, if there's anything wrong.

But I AM a little worried that if something IS found in my spine, my pod will decide I don't really have a foot problem, after all! And I don't see why it would have to be an either/or thing. I mean, it the problem were ONLY in my spine, how could those 2 steroid injections in my FOOT have given me so much relief -- albeit temporarily? And what about the plantar fascaetis that could so clearly be seen on the MRI? What about that swollen vein in the tarsal tunnel, and the positive Tinel's sign? Do you get all of those things from a spinal injury?

Would an NCV test even show the effects of nerve compression from a varicose vein if that vein were not really engorged at the time of the test? Common sense says, probably NOT!

Re: Correction

Sharon W on 3/04/02 at 18:34 (075666)

I was unable to edit my most recent message directly so I need to correct it.
The last sentence in the first paragraph of my recent message should read: 'I will use it [Voltaren cream] more often now, during this month before the NCV test, but I will respect my pod's decision not to start me on NEURONTIN until after those tests have been done.'

Re: NCV tests -- will they answer my questions?

Donna SL on 3/04/02 at 19:49 (075682)

Hi Sharon,

As I mentioned before you can have several things going on at once, and it's hard to know what's affecting what. Even if something else was going on it doesn't mean there is not local inflammation. That's why the cortisone shot helped you. It was found that I had 3 lumbar bulged disc, stenosis, and DDD. and also slight scoliosis, which I never knew. I had a Lumbar MRI, and x-ray. Also, I had a past radiculopathy determined by the emg/ncv test specifically for that. Yet I didn't have severe back pain, but had some, and it was getting worse way after the foot problems started. I also had peroneal nerve entrapment/injury in my right leg. It's hard to know how much was affecting what, but it seems like I'm improving from having 'All' areas treated. It's the chicken and the egg thing, and it's hard to know what came first. You may not have anything wrong with your back at all, and nothing else is related to your foot problem. Or it could be vascular. It's just good to have everything checked out. Also various blood test need to be done.

Sharon please don't be so concerned, and worried about what your pod thinks about you having, or not having a foot problem which you do. She at least seems very conservative, cautious, and caring enough to make sure nothing else is causing this. Even if it is, it doesn't mean she, or any other pod will not treat any concurrent foot problems which you can still have. I still think it's very important to see the more experienced pod, to clarify what's going on. with your feet though.

A good physiatrist is probably the best person to investigate any radiculopathy, and determine the source of your problems. Some things don't even show on NCV test, Mri's, etc, but it doesn't mean there isn't a problem. There's other criteria like a good exam used to determine things. Also, the ncv test may only be on your feet if they don't suspect back problems. It depends what the doctor is looking for, and orders. You need someone skilled enough to know what to look for, and what test to order. People can have bulged disc not pressing on nerves in the spine, yet an experienced professional will tell you that the disc can emit chemicals that irritates the entire nerve path. I hate to use the phrase double crush syndrome, because this is not exactly what it is, but it's the closest analogy I have.

I still think the first thing you need investigated is your vascular system. You may, or not have a vascular problem, but if it was me that would be the first place I would be if I was told I had an enlarged vein in my TTS.

Regardless if there is local swelling, and inflammation in the TTS area and foot, that needs to be taken care of as a seperate matter no matter what caused it. I don't just think being under a care of a podiatrist is enough for the multiple problems that you are having, and you need someone else to direct your medical care. Many doctors need to be involved. If your family doctor is not a good interist familiar with these areas, he/she will be no real help at all.

NCV test will show if there is any nerve damge. That's why there could be pressure, but not enough to register on a ncv test. From the amount of pain you are having I doubt if anything will not show up, but it could happen. None of the test are gold standards that's why you need a good doctor to look at other aspects.

The cream I had made consist of a combo of anti-inflammatories, and nerve pain meds. It consistes of 10% ketamine, ketoprophen, gabapentin, (neurontin), clonidine, all in a plo gel ibupropen base. This is a stronger PLO base to drive the meds throught thicker foot skin. The regular plo's are not always powerful enough. These not only stops pain, but prohibits the wind-up pain I had mentioned. Also some of the meds are substance p inhibitors. These have to be prescribed by someone who knows what they are doing. Voltaren cream will do nothing to stop the wind-up pain.

I must go, and do some exercise, but will check back later.

Donna

Re: NCV tests -- will they answer my questions?

Sharon W on 3/04/02 at 22:54 (075695)

Donna,
I have an interesting relationship with our family Dr. She knows better than to patronize me, and she listens with an open mind if I suggest a possibility to her. She knows that before I bring something up I have always done some research on my own. Usually she will say, 'Yes, let's test for that...' She is not an expert on feet but she doesn't BS; if she doesn't know something, she'll say so, and send me on to someone who WILL. When tests are done on me, I always ask them to fax her a copy or a report on the results. I trust her to keep on top of it. Which is fortunate, because I need HER referral or the insurance won't pay for specialists! Next time I see her I do intend to ask about a vascular specialist.

Re: To Sharon - re backs and feet

Julie on 3/05/02 at 01:50 (075703)

Sharon, problems with the feet can and do arise from spinal problems. A bulging disc intruding on the sciatic nerve is a very common cause. It's what happened to me: two weeks after a minor back injury, my PF started. When I saw the podiatrist recommended by my osteopath who suspected a connection, he said yes, that was almost certainly what had tipped me into heel pain, though I also had other predisposing factors (flat feet, over-pronation, advancing age). His view is that many, if not most, cases of PF have spinal involvement.

So please don't worry about what your pod thinks. He will know about the connection, he will know that very little goes on in the human body that isn't related to something else, and he certainly won't think you don't have a foot problem, as you obviously do. Even if your plantar fasciitis was directly caused by a spinal problem, it doesn't mean the the others were: they may have been knock-on effects of the PF. The important thing is to get the tests so that if there IS something going on in your spine, it can be treated too.

Re: To Sharon - re backs and feet

Sharon W on 3/05/02 at 08:33 (075716)

Julie,
I've seen references on the message board to PF 'causing' or 'leading to' TTS. How would that happen, do you know?
-- Sharon

Re: To Sharon - re backs and feet

Julie on 3/05/02 at 09:14 (075720)

Sharon, sorry, I can't answer that and will have to leave it to one our our multi-problem experts who've had both. I do know that the factors that predispose one to PF also predispose one to the various tendonitises and probably to TTS as well. But I hope someone who knows more than I do can answer this for you.

Re: To Sharon - re backs and feet

Sharon W on 3/05/02 at 11:23 (075737)

Julie,

Thanks for responding, anyway.

Concerning what you said before about DRs: I wish I shared your confidence that they all realize the body is a single entity and thus one part or system affects the others. I've heard that European DRs do tend to have that wholistic orientation, much more than Americans, but here in the U.S. I do not think one can simply ASSUME that a Dr. has that point of view. I really wish it were.

-- Sharon

Re: Varisose vein in TT rare?

Ed Davis, DPM on 3/09/02 at 16:12 (076057)

Surgical treatment of TTS is more successful when there is a confirmed structure such as a varicose vein pressing on the nerve. See a doctor with more experience in the area.
Ed

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 12:37 (075391)

Sharon,

Have you tried any medications to help the nerve pain? If not Neurontin is usally the most effective for this , and possibly the addition of a tricyclic anti-depressant like nortriptyline (little safter), or elavil. Usually only 10mg of nortriptyline is needed at bedtime. These should calm down the nerves from over-firing.

There is no reason to suffer this type of pain, and in fact it's important to control the pain, and quiet the nerves, so you don't develop a chronic pain syndrome. I would recommend seeing you're family doctor, or ask him/her who is familar with prescribing these medications. These drugs should work better than a narcotic type drug. Neurontin alone may do the trick. You would start at a low dose, and build up as needed. Give it time to build up in your system. Also anti-inflammatory drugs like vioxx are important to reduce any possible swelling that is putting pressure on the nerves.

Have you done any conservative treatment as of yet for your condition? For now even icing the area several times a day for 20 minutes should help. Just put it along the inside of your ankle behind the bump, and follow the course of the PT nerve to the inside of the heel. I had a very bad case of TTS, and PF, and had much improvement with conservative methods. I've read something like 90% of TTS cases can be cured, with conservative methods. I did ART (active release technique), and acupuncture, and the medications. Some people are helped by orthotics, cortisone, or other forms of PT. It helps to try to determine what caused this in the first place, ie. poor biomechanics, something systemic, tendonitis, some type of trauma, etc.

A nerve conduction study may, or may not show any slowing of the nerves unless the TTS is advanced as was in my case. I still had an MRI to rule out any mass, etc. pressing on the area. Regardless my nerves improved dramatically. I had two neves affected off the PTT (lateral, and medial plantar), and they are now showing normal conduction. Also a nerve branch off the LP nerve called the inferior calcaneal nerve aka the baxter's nerve is almost to the normal range now. I just had a repeat ncv test last week to confirm this. This was with 10 months of conservative treatment.

I'm sure when they do the ncv test they will test not only the nerves in your feet, but will also make sure the source is not coming from a higher course along the Posterior tibial nerve.

Good luck, and please keep me posted if you can. If you have any other questions don't hesitate to ask.

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 13:05 (075395)

Unfortunately, yes, several of those 'conservative measures' have already been tried. I've been on Vioxx 25 mg every day for 5 months; the Dr. tried upping it to 50 mg but that gave me too many stomach problems. I don't want addictive pain relievers -- not for a chronic problem. I do use Tylenol sometimes but I don't like the potential for liver damage, and anyway Tylenol doesn't help at all when I start getting those shooting pains! I have custom orthotics -- I can't really tell how much they help, if at all. I also have compression hose, because the MRI showed the compression in the TT is due to a swollen (varicose) vein. I've had steroid injections twice; that helps FAR more than anything else, but it also raises my blood pressure -- and I've had high blood pressure since I was 19. And it wears off after a few weeks; certainly not a long-term solution. As for Neurontin -- I already asked my pod about that; she says I can start it AFTER I get the nerve conduction studies done, that she doesn't want anything interfering with the results. So that's where I am right now. Thanks for responding -- I've visited this site several times but this is the first time I've posted anything. I am worried that the nerve conduction studies will show something distressing -- and worried that they WON'T... which would make me look like I'm faking this, or exaggerating, and I'm not. I'm also worried about what will happen, pain-wise, after the neurologist stimulates those nerves...

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 14:17 (075408)

Hi Sharon,

I've had a physiatrist MD treating me for this, and he didn't feel it was necessary to stop taking the meds before the test, but I did anyway. He also performed my ncv test, and does these test all the time. I would think vioxx more than anything would possibly affect it, because it reduces swelling, but a medication like neurontin is just controlling the nerve pain. It only stays in the system a very short time maybe 4-5 hours.

If there is any demylination, or any other damage to the nerve body itself, that will still show regardless of medications like neurontin. The only thing that could have a possible affect on a ncv test is a recent injection of cortisone. If it makes you feel better than just stop them a week to a few days before the test. Even the day before should be enough. Also, a low dose of narcotic drugs in a short period of time will not cause addiction, especially when you are in pain, and in the long run the results of chronic pain can be worse then the affects of taking these drugs, because there is literally pathological changes to the nervous system when you are constantly exposed to pain.

I've read that cortisone didn't help many people in the long run, so I never tried it. Also traditional PT for 6 months prior to the current treatments I had to didn't help me at all. I'm not familiar with swollen varicose veins, and TTS. I am seeing my chiropractor today who performed the ART on me which released the tight tissue on my nerves, and my physiatrist next week who did the acupuncture. I'll ask them both if they have ever treated anyone sucessfully in a case like yours with the treatments I had.

If you are not going to take these meds before the test than keep them around for immediately after the ncv test. When my nerves were really entrapped the ncv test seemed to irritate them more for a couple of weeks. This doesn't happen to everyone. After having the most recent test when my nerves were better the test didn't bother me at all.

There are many people that have TTS, and other problems that don't show on diagnostic testing, so don't worry that anyone will think that you are faking, or imagining it. Have you seen any other doctors other than your podiatrist like a neurologist, physiatrist, or even possibly a vascular specialist in regards to this?

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 16:20 (075419)

Dear Donna,
What's a physiatrist?
I never heard of ART (active release technique) before; what does it do?
No, the only doctors I've been to about this are our family practicioner she's the one who scripped the Vioxx and the Ambien, to help me sleep)and the pod. But once I go to the neurologist for NCV tests, I suppose I'll have a neurologist...
It's nice to communicate with someone else who has BOTH TTS and PF; it really doesn't seem to be that common a combination so there aren't a lot of people out there who know what I'm going through. And in spite of your reassurances, I DO sense that a lot of people are thinking, 'What's with all the whining about sore feet? EVERYBODY gets sore feet sometimes, i'ts no big deal...' I even have the impression, sometimes, that my pod thinks I'm faking it because MOST of the time I don't have anything worse than a slight limp and some tingling, and mild soreness, and she has never seen me when I happened to be having a cluster of shooting pains.
Anyway, thanks for your help.

Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/01/02 at 16:46 (075421)

Hi Sharon,

A physiatrist is a doctor of physical medicine, and rehab. They are also good at diagnosing soft tissue, nerve injuries, etc., and treating them. They also conduct ncv test. I'm getting ready to run out door, but will try to write more either tonight or tommorrow. In the interim you can look at the postings on this board I did around April, and after that on ART. You should find the info using the search function, and my name.

Donna

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 19:47 (075425)

Donna,
I did a search using your name & learned quite a bit about ART (and other things) before my web connection timed out. I was very interested to find your postings about that first NCV study and how your foot responded to it. Being in pain for a couple of weeks after the test is more or less what I expected, because EVERY time my pod presses on those nerves during a routine clinical assessment, the rest of the day is painful for me. Actually, while the pod is doing her assessment, all I usually feel is some mildly painful tingling; it isn't until a couple of hours later that the real pain begins. I don't understand why, but my nerves seem to respond to that stimulation by firing off random pain signals for 12-48 hours afterward. So I figure the aftermath of the NCV is bound to be much WORSE...
I really don't know what symptoms you've experienced or whether they are much like mine at all. But, judging by your comments about ART, it sounds like you probably aren't as affected by mild pressure on those nerves as I am. Still, I'm very encouraged by the fact that you're doing so well with your treatment and even talking about being 'cured' eventually! I had finally resigned myself to the idea that my foot problems will probably never go away and that my focus needs to be on MANAGING the problem, not trying to cure it. After all, I HAVEN'T responded very well to the treatments that have been tried so far, and I certainly haven't gotten any encouragement from doctors about my prognosis. I thought my discouraging responses to treatment were probably because I have two problems going on at the same time. But here you are, writing about how much better you feel now and anticipating a 'cure'!
About the varicose vein in my tarsal tunnel: What happens with varicose veins is that the valves (in the veins) that ordinarily prevent blood from flowing back toward the feet due to the force of gravity are malfunctioning in my leg, causing the damaged veins to swell and leading to inflammation in the surrounding tissues. My pod says it's very unusual for this to occur with the vein that runs through the tarsal tunnel. She says that if she were to perform surgery she would strip the vein (remove it completely) from the tarsal tunnel so that it can't cause any more trouble. In doing that, she would (of course) have to cut the flexor retinaculum, which is the typical 'decompression' procedure for TTS. But she doesn't want to operate; she says I'm not a good candidate for surgery and she won't even consider it unless ALL other treatment options are exhausted first.

Re: Nerve conduction studies There are lots of things to try

wendyn on 3/01/02 at 21:21 (075432)

Sharon, I thought that a vericose vein (in the tunnel)was a fairly frequent (relatively) cause of TTS.

Have you had an MRI?

Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/01/02 at 22:15 (075437)

Wendyn,
You may be right; my podiatrist said it was rare but I don't think she's had all THAT much experience with TTS. (She definitely looks like she's under 35, which means she can't possibly have that many years of experience.) And as for me, I'd never even HEARD of TTS until about 6 months ago, so...
-- Sharon

Re: Nerve conduction studies There are lots of things to try

wendyn on 3/01/02 at 22:56 (075438)

I think TTS itself is relatively uncommon...but if you look at causes of it, a vericose vein seems to be a common one, and I thought a fairly treatable one too.

Might be wise to get a second opinion...just to be sure.

Re: Varisose vein in TT rare?

Sharon W on 3/02/02 at 09:08 (075459)

Wendyn,
Yes, that's probably it. Obviously, plantar fascaetis and peripheral neuropathy are far more common than TTS, and I doubt if a pod sees TTS all that frequently. Mine commented that she'd done 2 TTS 'decompression' surgeries in the past 2 years.
It was my impression that inflammation itself was the most common cause, which is why MRIs often don't show up an obvious CAUSE for TTS. (They do show PF, though.) Oh -- and to answer your earlier question -- yes, the varicose vein showed up on the MRI, so it's been confirmed.
Yes, although I like my pod, I've been thinking of asking my family Dr. for a referral to another pod for a second opinion. At this point I'm not enthusiastic about the idea of surgery, anyway (although the family Dr. keeps talking about it) but if I do reach that point, I think I would want someone else to operate. It's clear that my pod is very uncomfortable with the idea and I see no sense in trying to 'talk her into it'.
-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/03/02 at 13:45 (075553)

Hi Sharon,

I only had a quick chance to ask my chiropractor about the varicose vein issue, but he said ART could be performed if there was no thrombophlebitis. I'm guessing if there is just phlebitis, and the vein is just being entrapped by soft tissue adhesions, fibrosis, etc. than the ART would probably be ok. That's why it's important to see a vascular specialist to find out why this vein in inflamed, and there aren't other vascular problems. They may have ways of treating the vein problem. From what I've read it is a rare condition in the ankle area. If you discuss ART with one of these doctors, and they are not familiar with it just say is it's a form of gentle myofascial tissue release, and they will understand.

There are so many factors that could be causing your pain, and sometimes conditions can overlap one another, and it gets confusing to what is causing each symptom. A lot of people start out with just PF, and then start to compensate in their gait, and the tissues become tight around the ankles calves, etc., and problems like tendonitis, tendinosis, fibrosis, etc., can develop around the TT area, causing pressure on the nerves. This compensatory walk can sometimes affect the back too, which happened in my case, which than can add to more complications by affecting the nerves in the back that travel to the feet. Then that has to be treated too. It can become a viscous cycle, and the best thing is to slowly un-do the many areas that have been affected. Every case is different, and the original cause could have been of a different nature. It takes the proper form of PT, and a lot of time, and patience to correct this conservatively along with right team of professionals.

Most nerve entrapment, or compression is due to some type of swelling on the nerves from tight tissue which causes the nerves to slow, and pain to result. Once the swelling is reduced, then the nerves will improve. A lot of the times the proper methods of reducing this swelling are not applied, and the person fails traditional conservative methods, or doesn't give alternative methods enough time, and ends up having unnecessary surgery which can make things worse by causing new trauma, and more scar tissue. Statically 90% of TTS should resolve with conservative care. On the other hand there are cases when people have had some type of lesion taking up space in the tunnel, and when it was removed their symptoms resolved. That may be the situation with your varicose vein. I''ve read that these types of cases have the greatest chance of succeeding in surgery Even in cases like this additional PT would help the surrounding structures that were affected. You could always try these conservative methods first before attempting surgery.

In your case you could have coexisting PF complicated by this inflamed vein that is causing all your symptoms. Or maybe none of the symptoms in
your feet are from the PF, and it is all because of the entrapment in the TTS area. The inflamed varicose vein may, or may not be what's even causing your symptoms. There are so many gray areas.

As far as increasing pain the intention of ART is not to inflame the nerve, but to move adhesions off of tissue, and chiropractors are very careful when working on nerve paths. My nerves were irritated in a fashion similar to yours when the pod palpated the trouble spots, but I only had some mild inflammation with the first couple of ART sessions. ART practitioners can tell by feeling your tissue if it feels normal or not, and will only work on the abnormal tissue, and are very aware of any existing medical conditions that might not be appropriate for ART. That's why with any form of nerve entrapment I would only trust a licensed medical practitioner like a chiropractor, because they do have medical training vs a massage therapist doing some sort of myofascial release. To take the ART course you have to be either a certified PT, MD, DO, chiropractor, or podiatrist. My chiropractor said at the most recent ART seminar there were several MD's and DPM's taking the course. If you decided on acupuncture treatment too, I would only recommend a certified medical acupuncturist. http://www.medicalacupuncture.com/

Also, I had mentioned that chronic pain syndrome can occur, and some of your symptoms may be due to that as the nerves become more irritable.
There is lot information on the web on this subject, but the most important thing to understand is the concept of wind-up pain that occurs in chronic pain situations which could be causing some of the intensity of your symptoms. Below are a couple of good articles that explain this. This has to be addressed, so a more serious condition like RSD doesn't develop.

http://www.hosppract.com/issues/2000/07/brook.htm
http://www.helpforpain.com/articles/understand-neuropathic-pain/understanding.htm
http://www.hosppract.com/issues/1998/10/bennett.htm

a good web site with animations
http://www.bayareapainmedical.com/

I'm not completely familiar with all your symptoms, but I had all kinds of horrendous pains throughout my feet, heels, ankles, etc., that ranged from dull aches, burning, stabbing electrical pains,etc. I got to the point where I couldn't stand for more than around 10 minutes before the symptoms began. After a while it took less and less outside stimulus to cause pain, which also kept increasing in intensity. Some of this may have been due to chronic pain syndrome, that's why you need to consider proper treatment for this too. I have little to none of the nerve pain most days now. I get some mild flare ups, and set backs from time to time, but in general I've been consistently improving from week to week. This week for example I've been out every single day on my feet between 3 and 4 hours, before I noticed any pain, and that is really only in the rims of the heels now, and it's a much lower pain level. Also, I have very rigid high arched feet which don't absorb shock very well. Getting out of orthotics for now helped too. I had to do it gradually with tape, but now I don't even use that. The muscles in your feet and legs will eventually get stronger, and that will put less strain on the fascia, etc.

If it is decided that you need surgery, and you choose a podiatrist for this make sure they are member of the American Board of Podiatric surgery, and have extensive experience in this area. I've read that the American podiatric medical association (APMA) recognizes only the American Board of Podiatric Surgery (ABPS) for certifying competency in performing ankle and foot surgery. Only about 3,700 podiatrists are certified by this board, and only about 2,500 of those are certified in both ankle and foot surgery. You can get the pods qualifications by looking on the APMA web site http://www.apma.org and then look under 'find a podiatrist'. The ABPS board charges $25.00 for 4 podiatrist name, that's why I recommend looking under the APMA board for no charge. Also, depending on what's going on with your foot, a vascular, or neurosurgeon may be the right choice. You need to use the same careful selection criteria no matter what type of doctor you choose. De. Lee Dellon specializes in nerve entrapment syndromes, and is supposed to be excellent. He's in Baltimore. http://www.dellon.com

You shouldn't be concerned if people don't understand your foot pain. I've had similar reactions even from MD's that didn't understand the intensity of the pain. If you say you have some type of neuropathy, or neuralgia, you'll be surprised how their expressions change. That they understand, and know that is a painful condition, and will have more empathy.

Donna

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 08:45 (075604)

My pod just called it a 'varicose vein,' although I suppose any swollen vein would technically qualify as phlebitis. I don't think mine is ALWAYS swollen, though; it seems to swell as the day wears on and I've been on my feet somewhat, and it gets really bad if I'm constantly on my feet for a couple of hours. And I probably have more than ONE varicose vein, although I don't have the problem as much as my mother or my sister. So yes, seeing a vascular specialist would be a good idea; I think there's only one in town though. (There are limited specialists available locally, and our medical insurance makes it VERY clear that they won't pay if we go to a someone outside the immediate area unless they specifically authorize it.)
My TTS is in the right foot; I don't think I have it in the left. At least the last time the pod palated the left side, she didn't get + Tinel's sign. My left foot wasn't viewed by the MRI, so this is unconfirmed, but I do think I have PF on that side; it's been bothering me quite a bit recently.
I'm going to send this before my internet connection times out and then send you a summary of my history with this foot in the next message.
-- Sharon
P.S: why did you stop the orthotics?

Why did you stop the orthotics?

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 12:22 (075626)

Donna,

This is my history: I'd been working as a hospital nurse (8 hrs on my feet). I kept telling myself that sore feet were an oppupational hazard and I just had to 'get used to it'. But those 'sore feet' would throb so painfully at night that I couldn't get to sleep for hours, and I usually woke up repeatedly at night because my feet were burning. I was constantly exhausted, and in SOME level of pain 24/7, even on my days off. The numbness and painful tingles SHOULD have set off alarms for me, but I was in denial. I didn't talk about sore feet to other nurses; I didn't want to be known as a 'whiner'. I didn't even tell my family Dr. I had a foot problem until mid-September 2001, when the pain got so bad I could no longer block it from my thoughts when I needed to focus on work. It was the pulsing, throbbing heel and the shooting pains all over my right foot that finally forced me to acknowledge I had a problem. My Dr. suspected PF, so she immediately started me on anti-inflammatories and made an appointment with the pod. But I think I'd already had TTS for a couple of months by then, and I might have had PF for as much as a year.

Two weeks later, early last October, I quit my job. I had assumed that if I got off my feet and followed medical advice, they would immediately begin to heal. I was taking Vioxx by then, and the pod started me on taping my foot. She asked me questions, did X-rays, found a + Tinel's sign in my right ankle, and detected some numbness in my right foot with the safety pin test. That's when she diagnosed TTS in my right foot. And based on my complaint of terrible (but temporary) arch pain first thing in the morning, she also said I had PD. She scheduled me to be fitted for custom orthotics, and I got them at the end of November. (I'm not really sure if they help at all; I really hated them at first, but now I've gotten comfortable with them and I still use them.)

I'm going to break here and start a new message, so my net connection won't time out on me...

-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Sharon W on 3/04/02 at 12:40 (075633)

Donna,

Continuing the history:
Actually, some of the pain DID get better after all of that; I no longer had low-level pain 24/7,and the heel throbbing improved quite a bit. But all my problems reappeared whenever I'd been on my feet for a couple of hours. And the shooting pains, which HAD been limited to my foot, expanded to include sharp 'electric shock' pains that zapped up my ankle past the medial malleolus. Those 'shooting ankle pains' (as I call them) grew much more frequent with the passage of time and became a bit slower, no longer 'zapping'. And then, at the beginning of December (AFTER I had my new orthotics), they began occurring in clusters occasionally. (By 'cluster' I mean when the next nerve fires its pain impulse before the first one is complete, and they build on each other, each time increasing the pain level.)

I think my PF has improved in the past 5 months, but the nerve pain in my right foot has definitely grown in intensity with the passage of time. Perhaps this is because the damage to my posterior tibial nerve is increasing and/or becoming permanent. Perhaps it is because that varicose vein is getting worse. Or perhaps it is because of chronic pain syndrome -- although I don't really think I've developed that yet. But the TTS seems to be getting steadily worse in spite of treatments. Fortunately, those 'clusters' of 'shooting ankle pains' are still rare -- they only happen a couple of times a month,and they've always begun to calm down within half an hour or so. And so far, I've always had enough warning to get off the road and to a safe place before it gets that bad. But I do worry about whether I could control the car if one hit me out of the blue, with no warning, and I couldn't easily pull of to the side of the road. It's a scary thought!

Thanks for all the info you sent; I found out that there IS a local podiatrist certified by the American Board of Podiatric surgery, and he has four DECADES of experience.

-- Sharon

Re: Sharon - Re: Nerve conduction studies There are lots of things to try

Donna SL on 3/04/02 at 14:35 (075641)

Hi Sharon,

You have a lot of things to do now, but the first priority is to get on nerve medications asap. It's not good in any case for your system be exposed to the pains you are feeling. If you have pain as long as you have you are in a chronic pain situation if you realize it, or not. If the doctors you know are not familiar with the proper meds ask them for the name of a good pain mgt clinic, or psychopharmacologist. (yes another new speciality) You need to be on meds until you figure out what's going on. My doc even had a great topical cream made up by a compound pharmacist.

I'm so glad you found the new pod. When are you going to see him? Hopefully he'll be able to give you a clear diagnosis of your problem. Bring your Mri's. Also it's critical to see the vascular specialist asap. You also need to make sure your orthotics aren't pressing on any nerves in the foot, or causing additional stress on the foot structures. ie. if you are over or under corrected this will put additional stress on everything. Also, you need to find out if anything else systemically is causing this problem, but it does sound like it's a local one. Believe it or not, it's hard to find a specialist that takes interest in the foot. I don't know why, it is a part of the body. I've gone to neurologists, orthopedic doctors, md's etc. that were totally ignorant on this subject. You sometimes have to keep digging until you find the proper one.

I stopped wearing orthotics, because I couldn't find a correction that didn't irritate some part of my foot especially the arch, or cause some other type of problem, once I developed these foot problems. I realized that my feet started to improve with nothing on them. One of the nerves that were entrapped (baxter's nerve) was being compressed more with the orthotics. (near the insertion point). Also, they restricted my motion even more which put additional stress on my feet. I had worn orthotics prior to this, and was fine. A prior pod gave me the wrong correction which caused most of these injuries. The new pod said I never really needed them in the first place, and was in the wrong correction anyway. At my insistance he attempted over a long period to to make many pairs, but I couldn't really tolerate them, and if he fixed one thing, then they caused another problem. My right foot had become severely unstable, because some of the nerves got affected in my back from all this, but the entire situation is improving now. I have a high arched foot which is tough to fit for orthotics anyway. Now that I'm feeling better, and not as sensitive, I could give them a try again. If I can continue to do without them I'd prefer that. They are sometimes more trouble then they are worth.

Sometimes people only a need stretching routine, foot strengthening program for the intrinsic foot muscles, PTT area, etc., or some other type of lower extremity program rather than orthotics, but a lot of pods have a tendency to over prescribe them. Sometimes they are needed until the injury is resolved.

Once you find out what's going on with your feet then you can determine the best course of action to take. If it's PTT for example then you need to get in rehab program for that. Usually a good set of prescribed exercises will help. Also find out about the varicose vein. It that's not a major problem then hopefully you could also get started on ART. At least start your other foot now, and the rest of the lower extremities, so things don't get worse. They can work not only on your feet, but your calves, legs, etc., which when tight contribute to all these problems. Acupuncture would also help with pain control, reduce additional swelling, and increase healing.

Keep me posted.

Donna

Re: NCV tests -- will they answer my questions?

Sharon W on 3/04/02 at 18:10 (075663)

Donna,

As for pain meds, I have a cream form of the anti-inflammatory medication, Voltaren. I bought it in Mexico, with the approval of my pod; if bought in THIS country it has to be specially formulated & is very expensive (although I had THAT done once, too). It does carry a slight risk of harming the liver but, in the topical form, that risk is MUCH lower than taking pills. And it helps with pain a LOT -- soaks right in exactly wehre you need it and helps with pain & inflammation a LOT. I will use it more often now, during this time before the NCV tests, but I will respect my pod's decision not to start me on it until after those tests have been done.

The NCV tests may help to answer some of the questions I have about all of this. And hopefully, it will also help to answer the one my pod is asking, which you also touched upon in your latest message: is there nerve damage in my spine, or in the sciatic nerve? She thinks she may have detected something, and it's an important qquestion to answer. Perhaps, like you, I may have damage the nerves in my back while compensating for my injured foot. I'm hoping that the NCV tests will show it, if there's anything wrong.

But I AM a little worried that if something IS found in my spine, my pod will decide I don't really have a foot problem, after all! And I don't see why it would have to be an either/or thing. I mean, it the problem were ONLY in my spine, how could those 2 steroid injections in my FOOT have given me so much relief -- albeit temporarily? And what about the plantar fascaetis that could so clearly be seen on the MRI? What about that swollen vein in the tarsal tunnel, and the positive Tinel's sign? Do you get all of those things from a spinal injury?

Would an NCV test even show the effects of nerve compression from a varicose vein if that vein were not really engorged at the time of the test? Common sense says, probably NOT!

Re: Correction

Sharon W on 3/04/02 at 18:34 (075666)

I was unable to edit my most recent message directly so I need to correct it.
The last sentence in the first paragraph of my recent message should read: 'I will use it [Voltaren cream] more often now, during this month before the NCV test, but I will respect my pod's decision not to start me on NEURONTIN until after those tests have been done.'

Re: NCV tests -- will they answer my questions?

Donna SL on 3/04/02 at 19:49 (075682)

Hi Sharon,

As I mentioned before you can have several things going on at once, and it's hard to know what's affecting what. Even if something else was going on it doesn't mean there is not local inflammation. That's why the cortisone shot helped you. It was found that I had 3 lumbar bulged disc, stenosis, and DDD. and also slight scoliosis, which I never knew. I had a Lumbar MRI, and x-ray. Also, I had a past radiculopathy determined by the emg/ncv test specifically for that. Yet I didn't have severe back pain, but had some, and it was getting worse way after the foot problems started. I also had peroneal nerve entrapment/injury in my right leg. It's hard to know how much was affecting what, but it seems like I'm improving from having 'All' areas treated. It's the chicken and the egg thing, and it's hard to know what came first. You may not have anything wrong with your back at all, and nothing else is related to your foot problem. Or it could be vascular. It's just good to have everything checked out. Also various blood test need to be done.

Sharon please don't be so concerned, and worried about what your pod thinks about you having, or not having a foot problem which you do. She at least seems very conservative, cautious, and caring enough to make sure nothing else is causing this. Even if it is, it doesn't mean she, or any other pod will not treat any concurrent foot problems which you can still have. I still think it's very important to see the more experienced pod, to clarify what's going on. with your feet though.

A good physiatrist is probably the best person to investigate any radiculopathy, and determine the source of your problems. Some things don't even show on NCV test, Mri's, etc, but it doesn't mean there isn't a problem. There's other criteria like a good exam used to determine things. Also, the ncv test may only be on your feet if they don't suspect back problems. It depends what the doctor is looking for, and orders. You need someone skilled enough to know what to look for, and what test to order. People can have bulged disc not pressing on nerves in the spine, yet an experienced professional will tell you that the disc can emit chemicals that irritates the entire nerve path. I hate to use the phrase double crush syndrome, because this is not exactly what it is, but it's the closest analogy I have.

I still think the first thing you need investigated is your vascular system. You may, or not have a vascular problem, but if it was me that would be the first place I would be if I was told I had an enlarged vein in my TTS.

Regardless if there is local swelling, and inflammation in the TTS area and foot, that needs to be taken care of as a seperate matter no matter what caused it. I don't just think being under a care of a podiatrist is enough for the multiple problems that you are having, and you need someone else to direct your medical care. Many doctors need to be involved. If your family doctor is not a good interist familiar with these areas, he/she will be no real help at all.

NCV test will show if there is any nerve damge. That's why there could be pressure, but not enough to register on a ncv test. From the amount of pain you are having I doubt if anything will not show up, but it could happen. None of the test are gold standards that's why you need a good doctor to look at other aspects.

The cream I had made consist of a combo of anti-inflammatories, and nerve pain meds. It consistes of 10% ketamine, ketoprophen, gabapentin, (neurontin), clonidine, all in a plo gel ibupropen base. This is a stronger PLO base to drive the meds throught thicker foot skin. The regular plo's are not always powerful enough. These not only stops pain, but prohibits the wind-up pain I had mentioned. Also some of the meds are substance p inhibitors. These have to be prescribed by someone who knows what they are doing. Voltaren cream will do nothing to stop the wind-up pain.

I must go, and do some exercise, but will check back later.

Donna

Re: NCV tests -- will they answer my questions?

Sharon W on 3/04/02 at 22:54 (075695)

Donna,
I have an interesting relationship with our family Dr. She knows better than to patronize me, and she listens with an open mind if I suggest a possibility to her. She knows that before I bring something up I have always done some research on my own. Usually she will say, 'Yes, let's test for that...' She is not an expert on feet but she doesn't BS; if she doesn't know something, she'll say so, and send me on to someone who WILL. When tests are done on me, I always ask them to fax her a copy or a report on the results. I trust her to keep on top of it. Which is fortunate, because I need HER referral or the insurance won't pay for specialists! Next time I see her I do intend to ask about a vascular specialist.

Re: To Sharon - re backs and feet

Julie on 3/05/02 at 01:50 (075703)

Sharon, problems with the feet can and do arise from spinal problems. A bulging disc intruding on the sciatic nerve is a very common cause. It's what happened to me: two weeks after a minor back injury, my PF started. When I saw the podiatrist recommended by my osteopath who suspected a connection, he said yes, that was almost certainly what had tipped me into heel pain, though I also had other predisposing factors (flat feet, over-pronation, advancing age). His view is that many, if not most, cases of PF have spinal involvement.

So please don't worry about what your pod thinks. He will know about the connection, he will know that very little goes on in the human body that isn't related to something else, and he certainly won't think you don't have a foot problem, as you obviously do. Even if your plantar fasciitis was directly caused by a spinal problem, it doesn't mean the the others were: they may have been knock-on effects of the PF. The important thing is to get the tests so that if there IS something going on in your spine, it can be treated too.

Re: To Sharon - re backs and feet

Sharon W on 3/05/02 at 08:33 (075716)

Julie,
I've seen references on the message board to PF 'causing' or 'leading to' TTS. How would that happen, do you know?
-- Sharon

Re: To Sharon - re backs and feet

Julie on 3/05/02 at 09:14 (075720)

Sharon, sorry, I can't answer that and will have to leave it to one our our multi-problem experts who've had both. I do know that the factors that predispose one to PF also predispose one to the various tendonitises and probably to TTS as well. But I hope someone who knows more than I do can answer this for you.

Re: To Sharon - re backs and feet

Sharon W on 3/05/02 at 11:23 (075737)

Julie,

Thanks for responding, anyway.

Concerning what you said before about DRs: I wish I shared your confidence that they all realize the body is a single entity and thus one part or system affects the others. I've heard that European DRs do tend to have that wholistic orientation, much more than Americans, but here in the U.S. I do not think one can simply ASSUME that a Dr. has that point of view. I really wish it were.

-- Sharon

Re: Varisose vein in TT rare?

Ed Davis, DPM on 3/09/02 at 16:12 (076057)

Surgical treatment of TTS is more successful when there is a confirmed structure such as a varicose vein pressing on the nerve. See a doctor with more experience in the area.
Ed