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TTS following P.F. surgery

Posted by Pauline on 7/17/02 at 09:22 (089864)

Has anyone ever gone back to count the number of postings on this site from people who had P.F. surgery and the next thing we hear is continued pain and a TTS diagnosis?

It seems like an awful lot to me.

Re: TTS following P.F. surgery

Steve B. on 7/17/02 at 12:24 (089877)

Tarsal Tunnel Syndrome is a myth

Re: TTS following P.F. surgery

Pauline on 7/17/02 at 13:12 (089881)

If that's the case why are these patients getting this diagnosis and in a great deal of pain. They don't go around making it up.

Re: TTS following P.F. surgery

kay f on 7/17/02 at 15:14 (089883)

steve please explain yourself. isn't tarsel tunnel like carpal tunnel only its in the foot/ankle? do you also think carpal tunnel is a myth also?
kat

Re: TTS following P.F. surgery

mary p on 7/17/02 at 17:03 (089893)

12 weeks ago i had sergery on both my feet.physio is not doing much good can anybody tell me how long recovery takes.i have started getting pain in my lower back which starts the pain in my feet.

Re: TTS following P.F. surgery

Barbara G. on 7/17/02 at 18:28 (089899)

Following up on Kay - What exactly is TTS???? Thanks.

Re: TTS following P.F. surgery

kay f on 7/17/02 at 18:50 (089902)

tarsel tunnel syndrom. its like carpal tunnel in the wrist only this is in the feet/ankle area. i still want to know why steve thinks its a myth.
kay

Re: TTS following P.F. surgery

wendyn on 7/17/02 at 19:35 (089907)

Kay, people who come into a web site and make statements like that (without any reason given) are looking for attention.

People with legitimate opinions generally explain 'why' they are making a statement.

Re: TTS following P.F. surgery

Joe S on 7/17/02 at 20:50 (089916)

Actually, I read Steve B's post. Some physicians believe TTS or tarsal tunnel syndrome may not truly exist. Please do not get me wrong. I see patient's with retromalleolar (tarsal tunnel region) pain fairly often. There are some classic signs and symptoms which are nerve related. First of all, the nerve involved in 'tarsal tunnel syndrome' is the posteior tibial nerve. This nerve lies in what we call the flexor retinaculum. Enclosed in the flexor retinaculum is the tibialis posterior muscle, the flexor digitorum longus muscle, the flexor hallucis longus muscle and the posterior tibial nerve, artery and vein. The theory behind TTS is that the posterior tibial nerve becomes compressed in this compartment. Once the nerve is compressed, impulses are slowed or even blocked. This will create some of the symptoms associated with TTS. Swelling of the lower legs can cause much of the same sensation. The diagnostic test to perform is a therapeutic nerve block which usually is a plain local anesthetic. If you still have pain after the block, then you do not have TTS. My rationale for this is if I block that nerve (make it numb), the entire plantar surface of the foot should go numb or at least most of it. One other test is to have a nerve conduction velocity. These may or may not be helpful. I will tell you that many docs throw out the diagnosis of TTS as a diagnosis of exclusion meaning that they really don't know what is going on. Alot of docs are sued for TTS Surgery as well. I believe there is a podiartist / attorney on this website who no longer practices podiatry that solicits patients who have undergone foot surgery in an attempt to sue foot and ankle surgeons for 'questionable surgery'. Anyway, my take on TTS is to make sure you get an accurate diagnosis. If a TTS release helps then so be it. If not, then you probably don't have TTS.

Re: TTS following P.F. surgery

wendyn on 7/17/02 at 23:03 (089924)

Joe, I think you are absolutely right. I think that TTS in the true sense of the word is very rare. There are many of us who have problems with that nerve, and all of the same symptoms. Therefore, the diagnosis is TTS. It's probably really separate problems all lumped incorrectly under one name.

Re: TTS following P.F. surgery

Sharon W on 7/18/02 at 07:31 (089942)

Wendyn, Joe,
That's why it's called tarsal tunnel SYNDROME; it's not a DISEASE. According to Merriam Webster's Medical Dictionary, a 'syndrome' is 'a group of signs and symptoms that occur together and characterize a particular abnormality'. There are many syndromes used as diagnoses in medicine. When a SYNDROME is diagnosed, it does not refer to any particular cause or etiology, only to a group of signs and symptoms that occur together, and that's what TTS is. The fact that it is a syndrome does NOT make it an illegitimate diagnosis!!!

But it's true, the CAUSE or SOURCE of this diagnosis is often very difficult to define.

-- Sharon

Re: TTS following P.F. surgery

Chris on 7/18/02 at 08:40 (089949)

Wow, some very interesting comments here. To get back to Pauline's post...I'm have never counted or really taken notice before. I do know that when I was first dx with PF and referred for surgery, the surgeon wanted me to try non-surgical methods again! During the second round of non-surgical treatments the surgeon decided to have me tested for TTS which was positive. I had surgery for both PF and TTS and wonder if I hadn't had both if I would still be in pain.

Chris -- pain free still after 18 months

Re: TTS following P.F. surgery

Joyce F. on 7/18/02 at 13:09 (089971)

I had lived with P.F. Dec. '02 will be 5 years. I have tried everything.
Cortisone shots, exercises, sleeping in a boot at night, rolling my foot on
a coke bottle I keep in the freezer, 2 sets of $200.00 Orthotics, wearing
special shoes.

My Dr. (Orthopedic Surgeon) is giving me onla a 50-50 chance with surgery. A 50% chance it will be better, a 50% chance it will be worse. That is why
I have not had surgery. I could not live if my pain was worse.

My questionis to you all, how do you know when to have the surgery? And then, you need to factor in the TSS? Any sugggestions? My life is is not much of a life, gained 70#s in 5 years, due to lack of activity. The activity level is almost 0, hurtts to do anything.......PLEASE HELP!!!!!

Re: Did you try ESWT? (nm)

elliott on 7/18/02 at 13:15 (089973)

.

Re: TTS following P.F. surgery

kay on 7/18/02 at 13:27 (089974)

joyce i know your pain. the only advice i can offer is do not have the endoscopic surgery. in my opinion it is a waste of time. i have met so many people who had this surgery and was not helped one bit by it, including me.
the eswt is something to consider before major surgery like open release surgery. i didn't do it as my insurance would not cover it. they consider it experimental still.
i had come to the point that i couldn't work any longer without some relief of my pain. my doctor did an open foot partial release and a tarsel tunnel release as well as cleaning up scar tissue around the nerve area. he is a orthopedic that my pod sent me to. its been over 4 weeks and i am just now starting to use my foot a bit. keep coming here and read. you will learn alot. i will keep everyone posted on my progress.
good luck
kay

Re: Did you try ESWT? (nm)

Joyce F. on 7/18/02 at 13:32 (089977)

No, I have not. Today is the first time I have ever heard of it. But, for myself, It will more than likely not be an option, if insurance does not pay.Have been to 3 dirrerent podiatrist, and 4 different ortho surgeons

Re: TTS following P.F. surgery

Chris on 7/18/02 at 13:34 (089978)

I did not find this site until after I had surgery. I think I was very lucky. I trusted the doctor and when he said surgery, I said 'when'. Of course by this time I was in so much pain I would have preferred to have had my foot cut off. I would say that that was when I decided I was ready for surgery. Actually, I was ready for surgery with just the pf dx. I do wonder if I had only had pf surgery if I would still be in pain.

Re: I'm with you on this one

elliott on 7/18/02 at 13:44 (089981)

I also don't think entrapment, stretching, or crushing of a nerve is that hard to understand. The fact that there are many possible causes leading to the above is not that unusal either. Same with cancer. If a doc doesn't get it, let me snip his nerve and he'll see if it's all in the head. I think at least a great part of it is that the syndrome is rare, certainly a lot rarer than PF, so many docs don't get enough exposure to it and don't know enough about it. I've read so much about it that I don't really find it that mysterious anymore; still disappointed that I should know more than a doc I see (for crying out loud, can't he spend a few hours reading about it?). It may also be in part because you can't usually see the damage to the nerve itself (positive NCV does not count in their eyes). Many docs can't even name the three main branches of the posterior tibial nerve as it passes through the tunnel (if they could and knew where they traversed, they might have a bit more of a clue as to how symptoms are what they are. I think things are slowly changing with time, though (better exposure and awareness). I think RSD has much more of a difficult problem than TTS; its cause is still far less understood.

Of course, some TTS cases are more clearcut than others. The hardest case is where there is no obvious contributory cause, no supporting evidence, patient has surgery by competent doc and gets no relief. But hey, even with supporting evidence, I don't think my relatives and friends believe me either. And they and even many docs think there's something wrong with you when the surgery doesn't go well.

----

Re: how 'bout aggressive stretching? :-)

elliott on 7/18/02 at 13:57 (089984)

There's a few threads about it on the Treatments board.

If ESWT really would cure you for sure, wouldn't that be worth $3000? I'd borrow that to get rid of something ruining my life. The problem, of course, is you don't know for sure. Some are going to Canada where they get that for half the price. Go to the board here of that name and read up on it.

You tried 2 pairs of $200 orthotics. How about one pair of $400 orthotics? I posted about such a pair on the treatments board; check it out. Some co-workers with PF got the same kind and it's helping them.

So you haven't yet tried everything; I've just listed three. And yes, when you've exhausted other possibilities and you just can't take it anymore, surgery is a viable but not risk-free option.

----

Re: I'm with you on this one

Sharon W on 7/18/02 at 14:17 (089986)

Elliott,

Just a couple of weeks ago, I was explaining to my cardiologist WHAT TTS WAS. I told him I was having surgery soon (next week) and that my pod would be doing a TTS release. I used to work with him, so I guess he was comfortable enough with me to ask me questions. He could figure out from the name, that it was similar to carpal tunnel syndrome, but in the foot/ankle. I had to explain to him, though, exactly what the surgery was -- about cutting the flexor retinaculum, what nerves were affected, etc. etc.

At least my cardiologist knew more about TTS than that PT they sent me to! I had to explain all about it to her... She had never had a patient before with a diagnosis of TTS, and other than knowing it was somewhere in the ankle she really had no idea what it WAS. (And SHE was supposed to be TREATING me for it??!!)

I DO agree with Wendyn that sometimes the nerve damage diagnosed as TTS is probably CAUSED by errors during PF surgery, especially when an EPF is done (the doctors say they can't really see what they're doing very well with that one). And a nerve that has been nicked by a scalpel may NEVER completely heal... but even in a case like that, perhaps steroid injections into the area, or even a tarsal tunnel release, could help to prevent ADDITIONAL damage do do inflammation within that very limited space (the tarsal tunnel) putting so much pressure on the (already damaged) posterior tibial nerve that it continues to get worse & cannot even BEGIN to heal. So even when something like that happens, it is probably legitimate to call the problem TTS and to treat it as such.

-- Sharon

Re: I'm with you on this one

elliott on 7/18/02 at 14:44 (089988)

Good luck on next week's surgery. Hope things go well. What caused yours? I've had bilateral TTS releases; hope I don't need any more.

Funny, but I talked recently to a world-famous cardiologist; he never heard of TTS! Maybe these guys are all way too specialized. At the least, they need some core lectures or reading on things that can go wrong with the body. I'd bet there's some overlap to their area that they never imagined.

Are you implying you alone agree with Wendyn? No beef from me there. PF surgical error (a doc would probably rather word it as a risk of the surgery rather than an outright error, but of course the risk is greater with a less-skilled surgeon) causing a TTS-type problem is understandable too: there's a branch of the lateral plantar nerve that runs right into the arch there; tug it the wrong way, do a little injudicious snipping, maybe even unlucky scar tissue formation, and one can be left with a nerve problem, but not the classic TTS originating at the medial malleolus. Of couse, there can in general be entrapment of a single nerve branch. Does one want to call this TTS, or not? Doesn't matter that much (I'd rather it be called entrapment of whatever nerve, and TTS be left for entrapment originating at or at least including the area of the medial malleolus), as long as the problem is addressed properly. But why am I telling you all this anyway? I think you already know it.

The PF-to-TTS thing may be a little more unclear, though, as often the new pain is nonnervy pain, and they're not sure if it's that nerve branch causing it or something else.

----

Re: TTS Surgery

Sharon W on 7/18/02 at 15:01 (089996)

Elliott,

No, I certainly didn't think I was the only one who agreed with Wendyn! Wendyn is a very smart lady, and most of what she says makes a LOT of sense to me... It's just that I did a lot of posting about my belief that in many cases, the reason a person whose PF surgery was a failure then ends up with a diagnosis of TTS, is because they had undiagnosed TTS in the first place! And I didn't want to leave the impression that I believed doctors could never make mistakes, or nick the posterior tibial nerve during PF surgery and cause TTS.

Didn't you say that you had a nerve cut during one of your surgeries? Was that the calcaneal branch of the posterior tibial nerve, by any chance? If so, what was your experience with that?

My TTS is probably caused by a combination of two things: (1) over-pronation & poor biomechanics (combined with working a constant standing/walking job on tile-covered concrete floors) and (2) My posterior tibial vein (the biggest vein that goes through the tarsal tunnel) is varicose, and when it swells up it causes inflammation and puts enough pressure on the nerve to cause TTS. The biomechancis factor has, I think, been successfully addressed by the use of orthotics, but the varicose vein has to be removed surgically.

-- Sharon

Re: TTS following P.F. surgery

Joe S on 7/18/02 at 21:20 (090018)

Sharon, before screaming at me you should really understand that most docs (orthopedists, podiatrists, neurosurgeons, physiatrists) don't believe that TTS exists. Tarsal tunnel syndrome is not a catch all diagnosis for wrist pain. TTS is a catch all diagnosis for unexplained retromalleolar pain. Just like fibromyalgia (I'm sure I'm going to offend a ton of people with this). Most doc's when they can't find anything wrong with you other than a type A personality that complains of pain for no apparent reason other than having pain they diagnose you with fibromyalgia. That's a catch all diagnosis. I see it day in and day out. It's always women, typically in their 40's, on some psych meds, comes in wearing braces on both wrists and ankles and complains of pain without any antecedent trauma or injury. I'm not saying that there is not something causing their pain. I'm saying that their primary care physician have given up on them and basically diagnosed them with fibromyalgia. And, I will tell you, when 99% of most doctors see that in the patient's history they already have a preconceived assumption of what this person or patient is about. Anyway, getting back to TTS, my point is that people with 'TTS' who undergoe a Tarsal Tunnel Release without relief of their symptoms probably don't have anything wrong with their tarsal tunnel. The tarsal tunnel is an anatomic structure. It is not the cause of every bit of retromalleolar pain.

Re: I'm with you on this one

Joe S on 7/18/02 at 21:31 (090019)

Actually Elliot, the laciniate ligament houses more than the '3'nerves. It is divided into 4 compartments. The compartments (from anterior to posterior)contain the the Tibialis posterior tendon (comp 1), FDL tendon (comp 2), The posterior tibial nerve, artery and vein (comp 3), and finally the flexor hallucis longus tendon. As the posterior tibial nerve exits the laciniate ligament it divides itself into three branches...the lateral plantar nerve, the medial plantar nerve and the medial calcaneal nerve which actually pierce the distal end of the laciniate ligament. I do know my anatomy. I do know my surgery. I know that most tarsal tunnel releases do not work. I repeat, do not work. I've reviewed too many charts concerning this condition and the postop sequelae that happen. Once again, I'm not doubting that there is pain, what I doubt is that it is coming from the 'tarsal tunnel'. It very well could be coming from higher up. Say from your lumbosacral region (L4, L5, S1,2,3). You could have some unilateral disk problems in your back affecting these spinal nerves causing your symptoms. That's my point. Get the right diagnosis.

Re: I'm with you on this one

Joe S on 7/18/02 at 21:35 (090021)

The condition you speak of is called Baxter's neuritis. The first branch of the lateral plantar nerve is called Baxter's nerve. It is one source of nonresponsive heel pain. I've posted an article pertaining to this syndrome on here before.

Re: TTS following P.F. surgery

Sharon W on 7/18/02 at 21:36 (090022)

Joe,

I am old enough to remember when many doctors didn't 'believe' in CARPAL tunnel syndrome, either. The fact that there were MANY of them, didn't make them RIGHT.

And you are undoubtedly right about TTS being used, at least sometimes, as a 'catch all' diagnosis (or to be more precise, a diagnosis of exclusion). I'm sure there are many cases of inaccurate diagnosis that occur as a result of that practice. That DOESN'T make the diagnosis invalid, however; it just makes the doctors who used it inappropriately, WRONG.

-- Sharon

Re: TTS Surgery

Pauline on 7/18/02 at 21:37 (090024)

Sharon,
I personally find this TTS discussion very valuable. The question I pose about your possible surgery is why not have a Vascular Surgeon address this varicose vein which you think is causing the problem before you go ahead with surgery? Maybe you did get an opinion from one already.

One of the things I find hardest to believe is the misdiagnosis of TTS when it seems like it presents with a pretty definate set of symptoms.

I'm more inclined to believe it's cause is a direct relationship to P.F. or other heel surgery.

Re: TTS Surgery

Joe S on 7/18/02 at 21:37 (090025)

The posterior tibial vein is the only vein running through the tarsal tunnel.

Re: Baxter's neurtitis

Sharon W on 7/18/02 at 21:38 (090026)

Joe,

I read that article, and it is EXCELLENT.

-- Sharon

Re: Baxter's neuritis

Sharon W on 7/18/02 at 21:43 (090027)

Joe,

My last post seems to have gotten mixed up with one by Scott. I wanted to say that I read that article you posted earlier, and it was excellent.

-- Sharon

Re: I'm with you on this one

scott r on 7/18/02 at 21:45 (090028)

For some reason, a post Sharon W just made got assigned the name of a post i made at the exact same time (i thought my flocking programming had fixed that) so that her post disappeared into the nether world. Here's a copy of it:

Joe,

I read that article, and it is EXCELLENT.

-- Sharon

Re: I'm with you on this one

Sharon W on 7/18/02 at 21:47 (090029)

First my post got tangled up with one by Scott, then it happened AGAIN!

Joe, I wanted to say that I read the article on Baxter's neuritis and it was very interesting. Thank you for posting it.

-- Sharon

Re: TTS following P.F. surgery

Joe S on 7/18/02 at 21:47 (090030)

I never said the diagnosis is invalid. I just think that too many docs throw that diagnosis around when they know good and well that if the patient doesn't have 'nerve symptoms' (numbness, tingling, 'electrical shocks') etc, they don't have TTS. I believe that there are certain compression neuropathies that affect the tarsal tunnel. Swelling can cause this, surgery can cause constriction of the neurovascular structures of the tarsal tunnel. There are a host of reasons that can cause true neurological symptoms around the tarsal tunnel. I saw a patient the other day who actually had a positive tinels sign at the tarsal tunnel. She has no risk factors other than she works as a scrub assistant in the O.R. and is on her feet 8-10 hours per day. No PF. My question is what is causing the symptoms. She does have some low back problems. Could be a radiculopathy of the L4, L5, S1,S2 or S3. These are the dermatomal levels which are affected by these spinal nerves. Could be that. SHould I order a Lumbar MRI. Probably so. I bet this is the root of her problem. As far as surgery goes, when you incise any structure it heals by scar tissue. My belief is that when you release the laciniate ligament, it has to heal or fibrose in somewhat. Well, that puts additional pressure on the remaining structures. I've seen way too many failures of this procedure. I've also seen a fair amount of RSD resulting from these surgeries. Some docs when they diagnose you with PF and TTS, they want to do two procedures on you in an attempt to maximize their reimbursement. That's another thing. That one I see all the time too. It's really a shame. These are not just podiatrists either.

Re: TTS Surgery

Pauline on 7/18/02 at 21:48 (090031)

Then a Vascular Surgeon shouldn't have any problem finding it. It really bothers me the amount of surgery constantly offered to cure a TTS diagnosis when the stats already show it does not work.

Doctors wanting to go in and cut out everything just in case it might produce a cure has got to stop.

Re: I'm with you on this one

scott r on 7/18/02 at 21:49 (090032)

This is pretty strange, everytime sharon makes a post, it gets assigned a number of whoever makes a post right before or after her. The one below got mixde up with Wendys. Sharon, maybe it's becuase of the '--' you're using near your name.

Joe,

My last post seems to have gotten mixed up with one by **scott**. I wanted to say that I read that article you posted earlier, and it was excellent.

-- Sharon

Re: I'm with you on this one

Joe S on 7/18/02 at 21:53 (090033)

Maybe that article should be available for everyone to read. It is a very good article. I do believe these discussions are beneficial for both patients and doctors. I personally can see how patients get frustrated with their care. I hope that the people who read my posts see that I try to truly say what symptoms are what and so on. I am not trying to argue with anyone on here. I do not discount anyone's symptoms either. I also do not post on here to market my practice. I do it because I enjoy the interaction. The friendly debates as well. Plus, it keeps me on top of everything. I found out about this website from one of my patients. It's a great resource.

Re: TTS Surgery

Joe S on 7/18/02 at 21:56 (090034)

Actually, any surgeon who performs ankle surgery frequently would not have a problem finding it. The posterior tibial vein and artery as well as nerve run right along with each other. You just have to know your landmarks. I'm waiting for someone to come up with an endoscopic tarsal tunnel decompression like the endoscopic carpal tunnel decompression. Their are some hand doc that do those in like 7 minutes.

Re: most docs don't believe TTS exists?

elliott on 7/18/02 at 22:36 (090040)

Not sure you're right on that.

Re: I'm with you on this one

wendyn on 7/18/02 at 22:37 (090041)

Joe, I think you make a great contribution here and it's always nice to have a doctor's perspective.

Thanks!

Re: endoscopic for TTS

elliott on 7/18/02 at 22:40 (090042)

It already exists, used by a few fringe podiatrists who claimed phenomenal success (like 100%), but considered flawed and too risky by mainstream docs. One person here had it done, and the results were not pretty.

Re: TTS Surgery

elliott on 7/18/02 at 22:56 (090043)

Pauline, I don't agree with you (sorry, but that's OK, isn't it?). A varicose vein *is* a cause of TTS (it presses on the nerve), a rather common one, in fact. That's not a misdiagnosis of TTS at all. And apparently it would be better to have an orthopedic surgeon or podiatrist familiar with TTS to handle the surgery than a vascular surgeon who, believe it or not, may know little about TTS and the delicate nerves there. Ligating a vein if necessary is relatively routine; TTS release and associated issues are not. Dr. Ed has stated such an opinion about varicose veins associated with TTS as well. I saw the best vascular guy in my state and got the impression he knew next to nothing about TTS; even said the enlarged vein there would not be giving me my symptoms. Great. Anyway, while in there, it would almost certainly be appropriate to do the standard TTS release (e.g. cut the flexor retinaculum, or laciniate ligament, as Joe calls it), since the tightness with it in there may well be contributing to the nervy pain (how would you know for sure it's not?), and doing so may well be less risky than not doing so. The last thing one wants is to increase the chances of a failed surgery. So no scandal here.

----

Re: Vascular Surgeons and TTS

Sharon W on 7/18/02 at 23:02 (090044)

Pauline,

The answer to that is, I tried. I couldn't find a vascular surgeon who was willing to work on my tarsal tunnel and was available to me on my medical plan.

Sharon

Re: endoscopic for TTS

Joe S on 7/18/02 at 23:19 (090045)

Exactly. Not many people who have had endoscopic carpal tunnel releases are satisfied either.

Re: most docs don't believe TTS exists?

Joe S on 7/18/02 at 23:22 (090046)

Actually, you may not be too sure. I'm pretty sure. I 'm pretty sure that they think something is happening in the retromalleolar region. Tarsal Tunnel Syndrome is not the cause of 100% of retromalleolar pain. Why do so many tts releases fail? Because the patient doesn't have TTS without the appropriate symptoms. Just because a doctor checks a diagnosis on his superbill doesn't actually mean that you clinically have tarsal tunnel syndrome.

Re: PF and TTS

Sharon W on 7/18/02 at 23:24 (090047)

Joe,

I do have PF as well as TTS -- or at least, there was inflammation visible around my plantar fascia when the MRI (with illumination) was done. That MRI also showed that the posterior tibial vein was varicose. A nerve block was done and the pain disappeared. I have a positive Tinel's sign, too. And the NCV showed that my lateral plantar nerve in that foot is slowed.

I trust my pod and I am glad she will be performing the surgery. She is always inclined to err on the side of CAUTION, and I like that. She was concerned that I might have a problem with the nerves in my spine and sent me to a neurologist to rule that possibility in or out. (It was normal.) She gathers as much information as she possibly can rather than jumping to a diagnosis, and I think I am VERY lucky about that.

Sharon

Re: PS

Sharon W on 7/18/02 at 23:34 (090049)

My pod will NOT be doing any kind of PF surgery on me; we both feel it isn't necessary at this point. And she certainly DIDN'T 'push' me to have the surgery -- quite the opposite, in fact; she thinks TTS surgery is too risky in most cases, and she wouldn't even CONSIDER it until all the usual 'conservative measures' had been attempted. Even then, I had to talk her into it. I guess I was able to make an adequate argument.

Sharon

Re: PF and TTS

Joe S on 7/18/02 at 23:40 (090052)

She worked you up the right way. My point exactly. Hopefully you will have a successful outcome. Your therapeutic nerve block worked. That's also an indication of a nerve problem. The most important thing you said was that 'I trust my pod'.

Re: where's the 4th branch?

elliott on 7/19/02 at 00:09 (090054)

I said there were three main branches, you said there's more, but I don't see you listing another. In addition, I believe it is quite common for the first branch of the medial calcaneal nerve to also pierce the proximal end of the laciniate ligament.

Joe, I appreciate your comments, especially as a doctor, but the more you speak on this, the more I think you're going too far out on a limb. It sounds like you're one of those who doesn't believe in the TTS diagnosis at all either. No, the odds of favorable TTS surgery are not as high as we would like (the lowest in a detailed study with appropriate followup was 44%; most claim well over 50%, knocking out your 'most', but of course you have to pick and choose which study to believe). I think one main reason for the poorer results is that many docs, not as familiar with it, don't perform it as well. Another is they don't figure out the root cause of the problem. Furthermore, success rates are much higher when there is a visible obstruction in the tunnel, something you may wish to ponder as to why. Yet another reason is that there are sometimes unpredictable nerve reactions to surgery, such as a neuroma, increasing the risks of different post-surgical comlications. Yet another (often leading to recurrence after intial relief) is because scar tissue forms over the very area released and may cause re-entrapment, not surprising given how teensy-weensy the nerves are. But these don't negate the fact that there was compression of a nerve in or near the tarsal tunnel, contrary to your general feelings.

I had bilateral release. I've had some complications which, if you're really interested, I can discuss, as well as the pre- and post-surgical findings, and had I the opportunity with hindsight to do things somewhat differently (different doc, try some other things first before surgery), I would have (hindsight is 100%) but I did get complete relief of nervy symptoms in first foot (why?), and almost complete relief, although somewhat temporary, in second foot (why?), and, after some vigorous massage and stretching, this foot seems to be making somewhat of a comeback. BTW, there were observed obstructions at surgery in the tunnel.

Oh yes, I also had an MRI for sciatica (right-sided only) which developed after right-sided TTS surgery (I believe due to a very weakened right foot post-op, but I can't be sure, no one can). Showed nothing on left side, L4-L5 bulging disc and dessicated L5-S1 on right side. Sure, not enough is known about the relationship between sciatica and TTS, if any. Theories such as double-crush phenomenon do leave many holes. But--and you may not believe this--most patients can tell the difference between pain originating from their spine and that from their ankle, especially if they've had both. I've esperience it all firsthand; bet you haven't. When my sciatica is bad, I can feel it running from my back and dropping into my foot when sitting. I don't call that TTS. In any case, my MRI would not explain the TTS symptoms I had (in right foot, numbness and burning in medial and back heel and ankle radiating up calf, mainly after exercise such as running, tingling in left foot at medial malleolus and radiating into the four medial toes). For example, I had no pain or nervy symptoms at all in the lateral toes of my right foot, where L4-L5 ends.

Tarsal tunnel surgery is risky, no doubt about that. But sometimes, many times, in fact, someone actually has entrapment of a nerve in or near the tarsal tunnel, and, given unresolved and often unbearable pain, surgery is definitely an option.

----

Re: I mean your claim that *most* docs don't believe it exists (nm)

elliott on 7/19/02 at 00:10 (090055)

.

Re: then maybe...

elliott on 7/19/02 at 00:13 (090056)

we shouldn't be waiting for someone to come up with an endoscopic tarsal tunnel decompression like the endoscopic carpal tunnel decompression.

---

Re: Sharon

elliott on 7/19/02 at 00:32 (090060)

No, it wasn't I who had a nerve cut during surgery, thank God.

I too had (1) and (2) in right foot, just (2) in left. I believe (1) can cause (2), especially if exaggerated through things like running. I'm feeling a bit uneasy about some parts of your surgery. Maybe I can offer some advice. Can you describe/answer

1. your exact symptoms (type, location)
2. whether they're continuous or only after standing/walking/exercise
3. how long since onset of symptoms
4. what you've tried
5. did you have an Xray?
6. any previous surgery on that foot?
7. how does the doc know it's a neuroma, separate from your TTS symptoms?
8. when she says cut it, what's she planning to do (just cut, or resect)?
9. has she done this sort of thing before?
10. did you get a second opinion, especially about the neuroma?
11. where do you live?

---

Re: the informed ones, anyway (nm)

elliott on 7/19/02 at 00:37 (090061)

.

Re: Baxter

elliott on 7/19/02 at 00:51 (090062)

There are a couple of issues that seem to have got garbled into one in this thread: 1) whether Baxter's nerve often gets injured when performing a PF release 2) whether Baxter's nerve should be released as part of any TTS surgery especially since (according to Baxter, anyway) PF may likely be a contributory cause of problems in that nerve.

The problem with a nerve being named after someone is that the someone became famous by claiming that this nerve's problems appear anywhere and everywhere (otherwise it wouldn't be named after him). The story with this nerve is still somewhat unclear, although it's probably safer to release it in a TTS surgery than not (mine were), especially if there's any arch pain. Time will tell for sure.

Anyone know if it's also safer to do so as a matter of course in PF even without nervy symptoms?

-----

Re: Baxter

Joe S on 7/19/02 at 01:04 (090064)

Baxter's nerve is the first branch of the lateral plantar nerve. I'm not much for naming structures after people but whatever. I've never confused Baxter's Neuritis with TTS. Read the article I posted on Baxter's neuritis and heel pain. Scott R should have it somewhere.

Re: where's the 4th branch?

Joe S on 7/19/02 at 01:21 (090065)

Listen pal, evidently you've only skimmed my postings. I never once said I didn't believe in TTS. If you want to get picky, only one nerve runs through the laciniate ligament. As it exits the flexor retinaculum it becomes the medial and lateral plantar nerves. This is well documented in anatomical literature as well as cadaveric studies. The medial calcaneal branch pierce the laciniate ligament. I basically agree that any space occupying mass be it a hypertrophic muscle belly, varicose vein, or whatever that compresses the posterior tibial nerve will give you the symptoms you discuss. But to call all pain that is retromalleolar (behind the medial malleolus) TTS is absurd. I never once stated that sciatica can mimic TTS. A radiculopathy of say L4 could mimick this condition. That's why the appropriate workup is necessary prior to proceeding with surgery. I believe a misdiagnosis which proceeds to surgery often fails. It is those with true neurological symptoms that do much better.

I challenge you my friend to pull out an anatomy book. Look up the dermatomal distribution of the your lumbosacral plexus. L4 basically provides sensation to the anterior and posterior medial aspect of your leg. L5 provides sensory to the posterior lateral and anterior central aspect of the leg including toes 1-3. S1 provides sensation to the dorsal lateral aspect of your foot (toes 4/5) and the plantar lateral aspect of the foot. S2 provides sensory information to the posterior central aspect of your thigh and leg.

Anyway, I've wasted way too much time on this suject.

Re: where's the 4th branch?

Joe S on 7/19/02 at 01:23 (090066)

Elliot,

I believe if you reread my post you will realize that I said there are 4 compartments to the lacinitate ligament. Not 4 branches to the nerve. You really need to learn to read these posts better before criticizing.

Re: I mean your claim that *most* docs don't believe it exists (nm)

Joe S on 7/19/02 at 01:24 (090067)

you're an idiot.

Re: most docs don't believe TTS exists?

Joe S on 7/19/02 at 01:26 (090068)

your post doesn't make sense?

Re: thanks; very professional (nm)

elliott on 7/19/02 at 06:48 (090075)

.

Re: where's the 4th branch?

elliott on 7/19/02 at 07:07 (090077)

How do you explain the quotes around the 3 in your first sentence, 'Actually Elliot, the laciniate ligament houses more than the '3'nerves'? Sorry for taking yout posts at face value.

---

Re: That didn't take long

wendyn on 7/19/02 at 07:24 (090078)

You'll have to pardon my friend Elliott. He's a bright guy, but he seems to have a little thing about him being right and therefore everyone else being wrong.

Elliot, is it _possible_ for you to debate without pissing people off?

Re: Elliott

Sharon W on 7/19/02 at 07:41 (090079)

Elliott,

No, I have never had foot surgery before. And thanks for your offer to help; I do appreciate it. But (please don't take offense) the reason I didn't post a thread about my upcoming surgery was that my decision is now made.

If you are interested in the history of my symptoms and everything we've tried in the past, that information is detailed in a series of threads (most of them with Donna SL) back in March. Since then I have gone through PT (unsuccessfully) and started using Neurontin (what a relief!) but I have stopped posting about my own foot problems in any detail.

In fact, I had not even intended to mention my surgery next week, until after it was over -- but I was hoping you could tell me what it's like to get a nerve cut. I don't know who I confused you with that mentioned having a (sensory-only) nerve cut, but sorry. The part about cutting the nerve probably won't even happen; it will only happen if my pod goes in and sees that that nerve branch looks extremely abnormal.

I live in Central Texas.

Sharon

Re: funny

elliott on 7/19/02 at 08:15 (090086)

When I saw your post title, I actually thought you were going to defend me this time. Anyway, thanks for your kind thoughts.

----

Re: Thanks

Sharon W on 7/19/02 at 10:14 (090099)

Joe,

Thank you. I agree that trusting one's surgeon is very important, assuming that trust is deserved and not simply based on a blind faith in doctors.

Sharon

Re: I'm with you on this one

Pauline on 7/19/02 at 11:47 (090113)

Dr. Joe,
Your correct about not marketing your practice. I've never seen you do this. We haven't heard about all the crutches left hanging on your walls.
I for one greatly appreciate your marketing free posting and sincerity. I think others do too. Thanks for being here.

Re: Vascular Surgeons and TTS

Pauline on 7/19/02 at 12:12 (090116)

Sharon,
I think not having a doctor available on a specific medical plan has probably cause many people a great deal more suffering because they were then forced or chose perhaps a doctor less qualified.

Not everyone is in a position to pay to go out of network for treatment and I understand that, but if I thought there was one doctor that could provide me with a better chance to live pain free, I'd go to see him regardless of what I had to pay out of pocket.

A lot of people would never consider this. I have personal friends who would never see a doctor they have to pay out of pocket. Some won't go any one that doesn't offer them personal courtsey and they can well afford to do so.

My belief is one visit usually won't break the bank and it's worth the risk of money it it can truly offer a better outcome. At least you know you've exhausted all your options.

Like Elliot said maybe Vascular Surgeons don't do this work, but if one indicated he had experience in this area and was out of network, I go to see him.

Personally I find writing a letter to a specialist listing history and symptoms and things that were tried always brings a response without
any need for insurance. They either call or write back making suggestions and tell you if they think they can help your situation.

Sometimes I think we forget to use this method of communication to our advantage. I've had many physicians respond to letters for various medical problems. Some tell you they can help, others refer you elsewhere, but you always get a response from a good doctor.

Just my opinion before you offer your foot for surgery.

Re: Vascular Surgeons and TTS

Sharon W on 7/19/02 at 13:36 (090124)

Pauline,

I said I had checked into the vascular surgeon thing first, a couple of months ago -- I DIDN'T say I was frustrated because I had learned of an infinitely superior vascular surgeon out there who would be willing to do the surgery but was OUTSIDE the range of my POS 'network' and therefore unavailable to me. In fact, noone I talked to around here had ever heard of a vascular surgeon removing a posterior tibial vein from the TT.

I am satisfied with the decision I have made, and I am no longer focused on whether to have TTS surgery to remove that vein or on finding a good surgeon to perform it. I confident in my decision and I think I HAVE a good surgeon. My focus now is on making plans for a safe and successful recovery period. Any tips on how best to handle life in a wheelchair for a month would be greatly appreciated.

Sharon

Re: TTS Surgery

Donna SL on 7/19/02 at 13:52 (090127)

Hi Sharon,

Is the pod that's been treating your for while doing your surgery? If so, I thought you said she didn't have that much experience with this type of surgery. I'm just curious what happened with the pod who had more experience, and was certified by the ABPS. Did you ever see him, or someone with similiar experience, and credentials?

Donna

Re: Vascular Surgeons and TTS

Pauline on 7/19/02 at 13:59 (090128)

Sharon,
I'm sure others who have spent time in a wheel chair will be better at offering tips to you. Best of luck with your surgery and I hope your recovery time speeds along leaving you without pain.

If I were to suggest anything it would be to surround yourself with friends. Ask for their support if and when you feel down during your recovery.

Re: where's the 4th branch?

Joe S on 7/19/02 at 14:53 (090133)

You're correct. The 1st sentence should have read the laciniate ligament is made up of 4 compartments. I stand corrected.

Re: That didn't take long

Joe S on 7/19/02 at 14:56 (090134)

The funny thing is that I never disagreed with him. He only wants me to disagree with him. No harm done.

Re: Thanks

Joe S on 7/19/02 at 15:00 (090135)

Actually, I attempt to develop a very good relationship with my patients. I do not haphazardly push surgeries on my patient's. We all lose in the end. I am able to come home and go to sleep at night knowing that I have not screwed little Mrs. Jones over by promising her that I can fix her foot with surgery. I guess it's the way you're brought up. I have a very busy practice too. I have a large referral base from other MD's who trust me even to the point of sending their mother's daughter's and wives to me. If I don't think a problem will be fixed by surgery, I don't recommend it. I know alot of doctors do. They have to live with themselves. I rest easy at night.

Re: Thanks

Sharon W on 7/19/02 at 15:13 (090138)

Joe,

I'm sure you do. And I think that if I were referred to you for surgery, I would probably rather quickly determine that you were being honest with me, and I definitely would respect that (even if I didn't like everything you had to say). And I bet I would have considerable respect for your REPUTATION, too. But when someone is referred to you specificaly for surgery, how much TIME do you usually have to develop a relationship with them? That's all I'm saying.

Sharon

Re: Pauline

Sharon W on 7/19/02 at 15:13 (090139)

Thank you.

Sharon

Re: TTS Surgery

Sharon W on 7/19/02 at 15:29 (090142)

Donna,

I checked into it. He had retired and, in fact, he DIED recently. There are no foot & ankle orthos around here. There's another pod in town who apparently doesn't even DO surgery, and then there are my pod's PARTNERS, two of whom have more years of experience but none of them are board certified for podiatric surgery, either. So I had a very long conversation with my pod and, in the end, I decided she really was the best person available for the job. She told me the story of the TTS surgery that went wrong. She is the kind of person who demands a LOT of herself, and I think it hit her pretty hard. But for that same reason, I don't think I could find a more CAREFUL surgeon...

As I said, I have already made my decision.

Sharon

Re: TTS Surgery

Donna SL on 7/19/02 at 17:07 (090149)

Sharon,

Don't get mad at me, but of course I'm not happy you choose her to do your surgery, and all the 'carfulness', in the world won't make up for the skill required to do this kind of job. That requires years of training, and experience in this area., no matter how self demanding she is. Did she do any type of surgical residency? If so why isn't she board certified? Not that it matters if she's not really experienced in TTS surgery. I'm just curious. Would you have surgery on any other part of your body, buy a non board certified surgeon?

I would think that if there wasn't a surgeon in your area qualified to do this that your ins co would pay for someone else out of network. This is a risky enough surgery under the best of circumstances with the best surgeon, so it only seems logical to find the most qualified doctor, along with a clear surgical plan. Also, a board certified surgeon would hopefully offer better follow up care, which can be just as important as the surgery.

At this point after all you know, and have read about on this board about these surgeries, the complications that can occur, etc., and are still pursuing this with her I know all the convincing that I may try to do is not going to make you change your mind, and seek out another surgeon somewhere. I'll just keep my fingers crossed, and you are lucky, and everything comes out ok for you.

Donna

Re: most docs don't believe TTS exists?

A MANOLI MD on 7/19/02 at 20:06 (090169)

maybe time for a little science here, rather than name calling.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8056802&dopt=Abstract

this study of tts shows poor surgical results, in general, with the best results in those with a space occupying lesion. in the article itself, many of the patients eventually had spinal nerve problems, diabetes, or other problems which surfaced after some time.

i don't know about 'most' docs, but we never find patients without a space occupying lesion, or sciatica-type complaints who we think are true nerve compressions at the tarsal tunnel. i just don't see them, perhaps they see me.

as i tell my fellows/residents, just because a lot of people DO something, doesn't mean it is correct.

i guess i'm in joes's camp, so let the flogging begin.

am2

Re: TTS Surgery

Joe S on 7/19/02 at 21:32 (090179)

It's an interesting fact that back in the old days of podiatry (70's -80's and up into the early 90's) that all pods could sit for the only recognized surgical board (american board of podiatric surgery). This has changed. I completed a 3 year surgical residency. I am board qualified by the ABPS. They give you 7 years after becoming qualified to sit for the board certification exam. I have all of my cases for the forefoot portion of my boards. I am currently working on rearfoot, ankle, and leg trauma to complete my certification for board certification in reconstructive rearfoot and ankle surgery. It is a very long and hard process. It's well worth it in the end too. While in my residency I performed well over a thousand procedures ranging from simple hammertoe corrections to reconstructive surgery of the ankle and leg. As an aside, there are many good surgeons who are not board certified or even qualified for one reason or the next. They should really attempt to become certified. Hospitals and insurance companies look at this when credentialling you for their plan or for hospital privileges. For example, the medical staff office contacted me the other day asking for me to check over the application and requests for certain surgical procedures for another pod in town applying to our hospital (I'm a pod that works with 3 orthopedic surgeons in a hospital based clinic). Most of this pods requests were straightforward procedures. There were about ten or 12 procedures she threw in there that I had to question. The orthopedists questioned me when I applied for them. I was able to prove from my surgical logs from my residency that I was more than experienced enough to perform these more complicated procedures. Anyway, after questioning these procedures and requesting proof of performance of these procedures she became very mad at me for making the request that she be proctored for these certain procedures and to also prove that she's actually performed them in the past. I personally believe we need to hold ourselves accountable for our actions. If I let this podiatrist have carte blanche privileges then if something went wrong with one of her more advanced requested procedures, I could be held accountable. Anyway, it's usually a good call to ask your doc how many of these procedures they've done in the past. Hopefully they will be truthful.

Re: Thanks

Joe S on 7/19/02 at 21:46 (090181)

My concern is that when someone comes in for surgery on visit number one I have to ask why? Is it because all of the standard conservative measures have failed? Is it because Ms. Jones down the street said that he or she's a great doc and will fix you? If it's truly a surgical problem and you present to me only one time my first question is usually why not let your previous doctor operate? Is there some reason for that? I have been called by another surgeon not too long ago about fixing a fracture of the 1st metatarsal. He sent the patient to me. I felt that the patient needed the fracture fixed. I called the referring pod to tell him what I had planned and discussed with the patient. I asked him if he would like to scrub the case with me. This type of situation is a little different than our present conservation though. I believe you can get a feel for the patient as well as the doc in usually one visit. If he or she comes in the room looks at your chart and says 'Sharon, I've read your chart from Dr. Sims and you've got TTS. Let's operate. I can do it next week at 2 pm and this is what we are going to do...' I'd be very wary about this guy. If he comes in and examines you discusses your previous treatments and why they failed or were not successful and then states that all conservative efforts were attempted the next step is surgery and these are the options.... then I think my trust would be much higher. I used to work with both types of these doctors in my residency. I believe I learned more about treating patients from the one that never really informed his patients about their conditions. I actually learned what not to do. Believe me, my patient's who undergo surgery from me understand the procedure. I discuss it with them, I have a drawn schematic. I discuss the possible complications. I write the consent right there in front of them. I discuss my expectations of postop care for certain procedures. This may take a little longer but that's why my receptionist schedules a block time for surgery consults. I want my patients to be clear and understand that foot surgery is MAJOR Surgery. Postop complications do happen. ANyway, another longwinded post. Sorry

Re: most docs don't believe TTS exists?

Joe S on 7/19/02 at 21:50 (090182)

I believe Lee Dellon, MD who is a plastic and reconstructive surgeon has done a fair amount of work on TTS as well. He also does alot with diabetic peripheral neuropathy. He has some very interesting thoughts on TTS and compression neuropathies about the tarsal tunnel region.

I whole heartedly agree with your statement that 'just because a lot of people DO something, doesn't mean it is correct'.

Re: TTS Surgery

Pauline on 7/20/02 at 18:56 (090236)

Dr. Joe,
You are the exception not the norm. Many new Podiatry graduates are not even getting into residency programs, and I guess they don't have to in order to join a practice and operate.

If they can earn a good living without taking advance training and it's not a requirement for them to practice why should they spend the money and the time? The learn as you practice seems like the norm today.

Re: To Dr. Manoli

Pauline on 7/20/02 at 19:11 (090239)

Congratulations on your listing in 'America's TOP Doctors'.

Re: TTS Surgery

Pauline on 7/20/02 at 19:32 (090242)

Sharon,
Everyone must come to their own decision about having a surgical procedure and who is going to do it. You seem satisfied with your decision and I respect that, but I've got to tell you I've traveled out of state on three different occasions for various surgeries.

We are only limited by the limitiations we put upon ourselves and the priorities we set.

I have to say that I'm with Donna on this one because of all the postings and medical studies that have been done. Dr. Manoli just posted one abstract that gives medical evidence to this surgery.

Personal opinion do ALL your homework ahead of time. Don't take your feet for granted because they are complex. If you were dealing with eye surgery you'd want the very best, some how feet seem to get a lesser ranking in importance.

Your feet, your pain, your decision, your surgery. The saying 'Act in Hast, Repent in Leisure' certainly has it's application when it comes to TTS surgery.

I hope this isn't true in your case. Once again wishing you the very best outcome.

Re: TTS Surgery

DR Zuckerman on 7/20/02 at 22:55 (090248)

Pauline,

In order to understand podiatry profession you have to make the comparison to denistry. There are generalists in denistry who clean teeth, treat infections and do very minor surgery. This would be the podiatrist who didn't do a residency ( which is very rare) Then you have the orthodonist. This would be the podiatrist who is a specialist in orthosis. You have diabetic foot specialists. You have sport medicine podiatrist. and on and on . The oral surgeon could be compared to the foot surgeon who did the 2 and 3 year additional training. One is not better then then the other just different.

I can't remember the last time I met a podiatrist who did have at least a one year surgical residency. In my practice we even have a four year surgical trained foot and ankle specialists. Where does it stop.

Re: TTS Surgery

Joe S on 7/20/02 at 22:56 (090249)

Actually, for the last 2 or 3 years residencies are in abundance. There's no excuse for new graduates not being able to get a good quality residency. The application pool to podiatry schools this year is WAY DOWN. The one's who don't pursue a residency typically are the ones cutting toenails in nursing homes day in and day out.

Re: Thanks

Sharon W on 7/20/02 at 23:09 (090251)

Joe,

I would have imagined that the usual reason patients are referred to you for surgery on visit 1, is that you have a reputation as a good surgeon and perhaps the patient's 'regular' podiatrist is younger and has less experience, or they have not achieved board certification, at least, not at this point in their career. Perhaps this is because the podiatrist himself (or herself) recognized that you are a better or more experienced surgeon, as in the case you described where you invited the other guy to scrub with you (that was a nice thing to do, by the way). My bet is, most of the time it is probably at the patient's instigation. 'Everybody' wants the doctor with the best reputation, the best credentials, the most experience. I suspect that most patients know at least ONE doctor willing to give them a referral to a more renowned surgeon, if they ask for it. I think the truth is, most of it comes down to money, to what a given patient can afford. Perhaps if (irrespective of insurance coverage) EVERY potential surgery patient could AFFORD the surgeon with the best reputation, best credentials, most experience, then no younger surgeon would ever be given a CHANCE to prove themselves or to develop an equivallent level of skill and experience. Perhaps in that case the ONLY cases that a talented and promising and conscientious young surgeon would ever have an opportunity to operate on, would be the ones in which all the REPUTABLE surgeons have already refused to attempt surgical intervention.

I don't know. Just a thought. But, doesn't every surgeon have to endure being new, for their first ten years or so?

Sharon

Re: more science

elliott on 7/21/02 at 10:04 (090276)

Thank you for your comments. You have an eminent reputation, and I respect what you say. I hope, therefore, you don't find me an 'idiot' or 'know-it-all' for responding to your post. Check out this link:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8714673&dopt=Abstract

This study seems to have been aware of the study you quote (I too quoted the 44% in an earlier post in this thread), yet this study comes up with 71%. The lead author is Mahan, very respected among podiatrists.

Concerning sciatica and the like, I agree docs don't seem to know enough about the connection with TTS, nor even exactly what to do once a patient has both. I would like to know a lot more about that. And yes, misdiagnoses are possible. I will say, though, that developing a bulging disc and sciatica two years after altering one's gait due to TTS nervy pain is not necessarily that surprising, nor does it necessarily mean the initial TTS surgery was inappropriate. Check out this link:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8384154&dopt=Abstract

There the authors claimed TTS success on 6 out of 7 patients who had sciatic or other similar conditions accompanying their TTS. The chief author, Sammarco, is a renowned orthopedist, one of three direct TTS disciples of Baxter, and past president of the AOFAS. Sure, studies are of varying quality, but which study does one believe?

Someone I know who went to Baxter for TTS told me that he told her that there are only a handful of people (his three disciples included, of course) who really know what they're doing with TTS. Maybe that's a bit self-serving and overblown, but maybe there's a point there too, that your run-of-the-mill [ortho]pod may not be quite up to the task percentagewise. Even for a correct diagnosis and an appropriate candidate for surgery, there's so much that can go wrong with peripheral nerve surgery in general (scar tissue, insufficient release, strange nerve flareup, etc.) that maybe the best surgeons are needed to produce the best results.

---

Re: Elliot: I've always liked this link

Sharon W on 7/21/02 at 13:26 (090291)

Elliott,

Good post. I think part of the problem in identifying 'success rates' for TTS surgery is that exactly how to define 'success' is defined in many different ways. I note that the 44% figure in Dr. Manoli's post said that while 44% 'benefitted markedly' from TTS surgery, an additional 19% had their 'pain decreased'. (I really LIKE the idea of a decrease in pain...)

This link is for the Curtin Podiatry Encyclopedia, in an article written by Pricilla Benzie:

http://www.curtin.edu.au/curtin/dept/physio/podiatry/encyclopedia/tarsaltunnel/

Benzie identified 3 different surgical procedures performed for TTS, and I would imagine that there could be differences in the 'success' rates depending on which procedures, or which COMBINATION of procedures, are performed to correct TTS. Below are quotes from her article:

'Mahan, Rock and Hillstrom (1996, p.84) report on the three most common types of surgical procedures performed. The first is the surgical incision and release of the flexor retinaculum. The second is the release of the abductor fascia in the opening of the abductor hallucis muscle (the region where the posterior tibial nerves and vessels enter the plantar aspect of the foot). The third is the release of the posterior tibial nerve and/or its branches from 'surrounding entrapments' (eg, variscosities). Alternative documented procedures include; '…excision of bony or soft tissue masses, epineural release, and excision of the posterior tibial nerve with or without the associated plantar branches' (Mahan, Rock and Hillstrom, 1996, p.84). '

Mahan, Rock and Hillstrom (1996) conducted a retrospective study and documented 71.7% of the patients studied demonstrated at least a moderate improvement in symptoms following surgical intervention. Pfieffer and Cracchiolo (1994) reported only 44% of their patients had a an excellent or good result following surgical intervention...'

Sharon

Re: A. Manoli's article -- workup

Ed Davis, DPM on 8/11/02 at 12:31 (092203)

I cannot emphasize enough the importance of a good workup. Electrodiagnostic studies should be performed as proximally as possible. One problem is the variability of training of those performing the studies.
Ed

Re: A. Manoli's article -- workup

elliott on 8/12/02 at 10:49 (092288)

Dr. Manoli happened to select the article having the lowest published success rates anywhere (44%). I just wonder if that is fairly representative or not. In response I gave links to articles showing much higher success rates when done by doctors specializing in this stuff.

The study Manoli refers to was indeed a carefully-crafted study, both with good workup/selection and appropriate followup, and has been cited in other journals. But I can't help but wonder if maybe the authors are just not as skilled in TTS surgery as some others. Or is it that everyone else is inflating their figures?

---

Re: Thanks

Vicky M on 10/31/02 at 18:46 (098841)

Wow, this is my first experience with the message board. It is also my first experience with any type of medical problem. I have been so scared, frustrated and confused about my foot condition. But your message, Joe, made me feel much at ease and more confident with my new 'foot doctor'. He seems to be taking his time and trying conservative treatments before surgery and it sounds like he has the same philosphy of you. I am 37 years old and feel that I am too young to live with such pain. I woke up one night in severe pain, I described it worse than labor pains. I did not sleep for six nights straight and yet I never felt tired. I don't remember much about those six days, except for the pain. I took two percocents every three hours, yeap I cheated, but many times I thought I was going to pass out from the pain. My foot had swollen 4 times its normal size. Between the getting into see my primary physician and then getting an MRI scheduled, it took me just over a week to finally get in to see a specialist. That was the worse week of my life. Its been about 10 days and the pain is subdued and the swelling down. The doc says I have a cyst on my ankle that is causing tarsel tunnel sydrome. All the messages that I have read do NOT report any cysts as part of their condition. So Joe how am I different as far as treatment. My doc is trying some conservative treatments, cortazone shots, Vioxx, and a boot. I have felt everything imaginable on my foot, toes and ankle: shocks, pinches, aches, burning,numbness,shooting pain, you name it I have felt it. Remember I just woke up one night in pain, no signs beforehand. Right now my skin is so sensitive and I have a pain right across the middle of the bottom of my foot. Is this cyst going to deflate and go away,will it reaccure, or will it definately need to removed. I must mention that my doctor seemed a bit puzzled as to what to do. Let me know if you have any info., advise or research. THANKS for sharing your knowlege.
Vicky

Re: To Vicky

Julie on 11/01/02 at 02:19 (098864)

Hi Vicky

You posted your post at the end of a thread that began in July, and I'm afraid no-one will see it if they don't read 'All messages posted since your last visit'. Many people don't.

I suggest you go to the home page, click on 'Message Board' and then on the 'Ask the Foot Doctors' board and post a new message there. Joe hasn't posted here for a few months, so he may not see your new message either, but I'm sure one of the other doctors will answer you.

Re: TTS following P.F. surgery

Steve B. on 7/17/02 at 12:24 (089877)

Tarsal Tunnel Syndrome is a myth

Re: TTS following P.F. surgery

Pauline on 7/17/02 at 13:12 (089881)

If that's the case why are these patients getting this diagnosis and in a great deal of pain. They don't go around making it up.

Re: TTS following P.F. surgery

kay f on 7/17/02 at 15:14 (089883)

steve please explain yourself. isn't tarsel tunnel like carpal tunnel only its in the foot/ankle? do you also think carpal tunnel is a myth also?
kat

Re: TTS following P.F. surgery

mary p on 7/17/02 at 17:03 (089893)

12 weeks ago i had sergery on both my feet.physio is not doing much good can anybody tell me how long recovery takes.i have started getting pain in my lower back which starts the pain in my feet.

Re: TTS following P.F. surgery

Barbara G. on 7/17/02 at 18:28 (089899)

Following up on Kay - What exactly is TTS???? Thanks.

Re: TTS following P.F. surgery

kay f on 7/17/02 at 18:50 (089902)

tarsel tunnel syndrom. its like carpal tunnel in the wrist only this is in the feet/ankle area. i still want to know why steve thinks its a myth.
kay

Re: TTS following P.F. surgery

wendyn on 7/17/02 at 19:35 (089907)

Kay, people who come into a web site and make statements like that (without any reason given) are looking for attention.

People with legitimate opinions generally explain 'why' they are making a statement.

Re: TTS following P.F. surgery

Joe S on 7/17/02 at 20:50 (089916)

Actually, I read Steve B's post. Some physicians believe TTS or tarsal tunnel syndrome may not truly exist. Please do not get me wrong. I see patient's with retromalleolar (tarsal tunnel region) pain fairly often. There are some classic signs and symptoms which are nerve related. First of all, the nerve involved in 'tarsal tunnel syndrome' is the posteior tibial nerve. This nerve lies in what we call the flexor retinaculum. Enclosed in the flexor retinaculum is the tibialis posterior muscle, the flexor digitorum longus muscle, the flexor hallucis longus muscle and the posterior tibial nerve, artery and vein. The theory behind TTS is that the posterior tibial nerve becomes compressed in this compartment. Once the nerve is compressed, impulses are slowed or even blocked. This will create some of the symptoms associated with TTS. Swelling of the lower legs can cause much of the same sensation. The diagnostic test to perform is a therapeutic nerve block which usually is a plain local anesthetic. If you still have pain after the block, then you do not have TTS. My rationale for this is if I block that nerve (make it numb), the entire plantar surface of the foot should go numb or at least most of it. One other test is to have a nerve conduction velocity. These may or may not be helpful. I will tell you that many docs throw out the diagnosis of TTS as a diagnosis of exclusion meaning that they really don't know what is going on. Alot of docs are sued for TTS Surgery as well. I believe there is a podiartist / attorney on this website who no longer practices podiatry that solicits patients who have undergone foot surgery in an attempt to sue foot and ankle surgeons for 'questionable surgery'. Anyway, my take on TTS is to make sure you get an accurate diagnosis. If a TTS release helps then so be it. If not, then you probably don't have TTS.

Re: TTS following P.F. surgery

wendyn on 7/17/02 at 23:03 (089924)

Joe, I think you are absolutely right. I think that TTS in the true sense of the word is very rare. There are many of us who have problems with that nerve, and all of the same symptoms. Therefore, the diagnosis is TTS. It's probably really separate problems all lumped incorrectly under one name.

Re: TTS following P.F. surgery

Sharon W on 7/18/02 at 07:31 (089942)

Wendyn, Joe,
That's why it's called tarsal tunnel SYNDROME; it's not a DISEASE. According to Merriam Webster's Medical Dictionary, a 'syndrome' is 'a group of signs and symptoms that occur together and characterize a particular abnormality'. There are many syndromes used as diagnoses in medicine. When a SYNDROME is diagnosed, it does not refer to any particular cause or etiology, only to a group of signs and symptoms that occur together, and that's what TTS is. The fact that it is a syndrome does NOT make it an illegitimate diagnosis!!!

But it's true, the CAUSE or SOURCE of this diagnosis is often very difficult to define.

-- Sharon

Re: TTS following P.F. surgery

Chris on 7/18/02 at 08:40 (089949)

Wow, some very interesting comments here. To get back to Pauline's post...I'm have never counted or really taken notice before. I do know that when I was first dx with PF and referred for surgery, the surgeon wanted me to try non-surgical methods again! During the second round of non-surgical treatments the surgeon decided to have me tested for TTS which was positive. I had surgery for both PF and TTS and wonder if I hadn't had both if I would still be in pain.

Chris -- pain free still after 18 months

Re: TTS following P.F. surgery

Joyce F. on 7/18/02 at 13:09 (089971)

I had lived with P.F. Dec. '02 will be 5 years. I have tried everything.
Cortisone shots, exercises, sleeping in a boot at night, rolling my foot on
a coke bottle I keep in the freezer, 2 sets of $200.00 Orthotics, wearing
special shoes.

My Dr. (Orthopedic Surgeon) is giving me onla a 50-50 chance with surgery. A 50% chance it will be better, a 50% chance it will be worse. That is why
I have not had surgery. I could not live if my pain was worse.

My questionis to you all, how do you know when to have the surgery? And then, you need to factor in the TSS? Any sugggestions? My life is is not much of a life, gained 70#s in 5 years, due to lack of activity. The activity level is almost 0, hurtts to do anything.......PLEASE HELP!!!!!

Re: Did you try ESWT? (nm)

elliott on 7/18/02 at 13:15 (089973)

.

Re: TTS following P.F. surgery

kay on 7/18/02 at 13:27 (089974)

joyce i know your pain. the only advice i can offer is do not have the endoscopic surgery. in my opinion it is a waste of time. i have met so many people who had this surgery and was not helped one bit by it, including me.
the eswt is something to consider before major surgery like open release surgery. i didn't do it as my insurance would not cover it. they consider it experimental still.
i had come to the point that i couldn't work any longer without some relief of my pain. my doctor did an open foot partial release and a tarsel tunnel release as well as cleaning up scar tissue around the nerve area. he is a orthopedic that my pod sent me to. its been over 4 weeks and i am just now starting to use my foot a bit. keep coming here and read. you will learn alot. i will keep everyone posted on my progress.
good luck
kay

Re: Did you try ESWT? (nm)

Joyce F. on 7/18/02 at 13:32 (089977)

No, I have not. Today is the first time I have ever heard of it. But, for myself, It will more than likely not be an option, if insurance does not pay.Have been to 3 dirrerent podiatrist, and 4 different ortho surgeons

Re: TTS following P.F. surgery

Chris on 7/18/02 at 13:34 (089978)

I did not find this site until after I had surgery. I think I was very lucky. I trusted the doctor and when he said surgery, I said 'when'. Of course by this time I was in so much pain I would have preferred to have had my foot cut off. I would say that that was when I decided I was ready for surgery. Actually, I was ready for surgery with just the pf dx. I do wonder if I had only had pf surgery if I would still be in pain.

Re: I'm with you on this one

elliott on 7/18/02 at 13:44 (089981)

I also don't think entrapment, stretching, or crushing of a nerve is that hard to understand. The fact that there are many possible causes leading to the above is not that unusal either. Same with cancer. If a doc doesn't get it, let me snip his nerve and he'll see if it's all in the head. I think at least a great part of it is that the syndrome is rare, certainly a lot rarer than PF, so many docs don't get enough exposure to it and don't know enough about it. I've read so much about it that I don't really find it that mysterious anymore; still disappointed that I should know more than a doc I see (for crying out loud, can't he spend a few hours reading about it?). It may also be in part because you can't usually see the damage to the nerve itself (positive NCV does not count in their eyes). Many docs can't even name the three main branches of the posterior tibial nerve as it passes through the tunnel (if they could and knew where they traversed, they might have a bit more of a clue as to how symptoms are what they are. I think things are slowly changing with time, though (better exposure and awareness). I think RSD has much more of a difficult problem than TTS; its cause is still far less understood.

Of course, some TTS cases are more clearcut than others. The hardest case is where there is no obvious contributory cause, no supporting evidence, patient has surgery by competent doc and gets no relief. But hey, even with supporting evidence, I don't think my relatives and friends believe me either. And they and even many docs think there's something wrong with you when the surgery doesn't go well.

----

Re: how 'bout aggressive stretching? :-)

elliott on 7/18/02 at 13:57 (089984)

There's a few threads about it on the Treatments board.

If ESWT really would cure you for sure, wouldn't that be worth $3000? I'd borrow that to get rid of something ruining my life. The problem, of course, is you don't know for sure. Some are going to Canada where they get that for half the price. Go to the board here of that name and read up on it.

You tried 2 pairs of $200 orthotics. How about one pair of $400 orthotics? I posted about such a pair on the treatments board; check it out. Some co-workers with PF got the same kind and it's helping them.

So you haven't yet tried everything; I've just listed three. And yes, when you've exhausted other possibilities and you just can't take it anymore, surgery is a viable but not risk-free option.

----

Re: I'm with you on this one

Sharon W on 7/18/02 at 14:17 (089986)

Elliott,

Just a couple of weeks ago, I was explaining to my cardiologist WHAT TTS WAS. I told him I was having surgery soon (next week) and that my pod would be doing a TTS release. I used to work with him, so I guess he was comfortable enough with me to ask me questions. He could figure out from the name, that it was similar to carpal tunnel syndrome, but in the foot/ankle. I had to explain to him, though, exactly what the surgery was -- about cutting the flexor retinaculum, what nerves were affected, etc. etc.

At least my cardiologist knew more about TTS than that PT they sent me to! I had to explain all about it to her... She had never had a patient before with a diagnosis of TTS, and other than knowing it was somewhere in the ankle she really had no idea what it WAS. (And SHE was supposed to be TREATING me for it??!!)

I DO agree with Wendyn that sometimes the nerve damage diagnosed as TTS is probably CAUSED by errors during PF surgery, especially when an EPF is done (the doctors say they can't really see what they're doing very well with that one). And a nerve that has been nicked by a scalpel may NEVER completely heal... but even in a case like that, perhaps steroid injections into the area, or even a tarsal tunnel release, could help to prevent ADDITIONAL damage do do inflammation within that very limited space (the tarsal tunnel) putting so much pressure on the (already damaged) posterior tibial nerve that it continues to get worse & cannot even BEGIN to heal. So even when something like that happens, it is probably legitimate to call the problem TTS and to treat it as such.

-- Sharon

Re: I'm with you on this one

elliott on 7/18/02 at 14:44 (089988)

Good luck on next week's surgery. Hope things go well. What caused yours? I've had bilateral TTS releases; hope I don't need any more.

Funny, but I talked recently to a world-famous cardiologist; he never heard of TTS! Maybe these guys are all way too specialized. At the least, they need some core lectures or reading on things that can go wrong with the body. I'd bet there's some overlap to their area that they never imagined.

Are you implying you alone agree with Wendyn? No beef from me there. PF surgical error (a doc would probably rather word it as a risk of the surgery rather than an outright error, but of course the risk is greater with a less-skilled surgeon) causing a TTS-type problem is understandable too: there's a branch of the lateral plantar nerve that runs right into the arch there; tug it the wrong way, do a little injudicious snipping, maybe even unlucky scar tissue formation, and one can be left with a nerve problem, but not the classic TTS originating at the medial malleolus. Of couse, there can in general be entrapment of a single nerve branch. Does one want to call this TTS, or not? Doesn't matter that much (I'd rather it be called entrapment of whatever nerve, and TTS be left for entrapment originating at or at least including the area of the medial malleolus), as long as the problem is addressed properly. But why am I telling you all this anyway? I think you already know it.

The PF-to-TTS thing may be a little more unclear, though, as often the new pain is nonnervy pain, and they're not sure if it's that nerve branch causing it or something else.

----

Re: TTS Surgery

Sharon W on 7/18/02 at 15:01 (089996)

Elliott,

No, I certainly didn't think I was the only one who agreed with Wendyn! Wendyn is a very smart lady, and most of what she says makes a LOT of sense to me... It's just that I did a lot of posting about my belief that in many cases, the reason a person whose PF surgery was a failure then ends up with a diagnosis of TTS, is because they had undiagnosed TTS in the first place! And I didn't want to leave the impression that I believed doctors could never make mistakes, or nick the posterior tibial nerve during PF surgery and cause TTS.

Didn't you say that you had a nerve cut during one of your surgeries? Was that the calcaneal branch of the posterior tibial nerve, by any chance? If so, what was your experience with that?

My TTS is probably caused by a combination of two things: (1) over-pronation & poor biomechanics (combined with working a constant standing/walking job on tile-covered concrete floors) and (2) My posterior tibial vein (the biggest vein that goes through the tarsal tunnel) is varicose, and when it swells up it causes inflammation and puts enough pressure on the nerve to cause TTS. The biomechancis factor has, I think, been successfully addressed by the use of orthotics, but the varicose vein has to be removed surgically.

-- Sharon

Re: TTS following P.F. surgery

Joe S on 7/18/02 at 21:20 (090018)

Sharon, before screaming at me you should really understand that most docs (orthopedists, podiatrists, neurosurgeons, physiatrists) don't believe that TTS exists. Tarsal tunnel syndrome is not a catch all diagnosis for wrist pain. TTS is a catch all diagnosis for unexplained retromalleolar pain. Just like fibromyalgia (I'm sure I'm going to offend a ton of people with this). Most doc's when they can't find anything wrong with you other than a type A personality that complains of pain for no apparent reason other than having pain they diagnose you with fibromyalgia. That's a catch all diagnosis. I see it day in and day out. It's always women, typically in their 40's, on some psych meds, comes in wearing braces on both wrists and ankles and complains of pain without any antecedent trauma or injury. I'm not saying that there is not something causing their pain. I'm saying that their primary care physician have given up on them and basically diagnosed them with fibromyalgia. And, I will tell you, when 99% of most doctors see that in the patient's history they already have a preconceived assumption of what this person or patient is about. Anyway, getting back to TTS, my point is that people with 'TTS' who undergoe a Tarsal Tunnel Release without relief of their symptoms probably don't have anything wrong with their tarsal tunnel. The tarsal tunnel is an anatomic structure. It is not the cause of every bit of retromalleolar pain.

Re: I'm with you on this one

Joe S on 7/18/02 at 21:31 (090019)

Actually Elliot, the laciniate ligament houses more than the '3'nerves. It is divided into 4 compartments. The compartments (from anterior to posterior)contain the the Tibialis posterior tendon (comp 1), FDL tendon (comp 2), The posterior tibial nerve, artery and vein (comp 3), and finally the flexor hallucis longus tendon. As the posterior tibial nerve exits the laciniate ligament it divides itself into three branches...the lateral plantar nerve, the medial plantar nerve and the medial calcaneal nerve which actually pierce the distal end of the laciniate ligament. I do know my anatomy. I do know my surgery. I know that most tarsal tunnel releases do not work. I repeat, do not work. I've reviewed too many charts concerning this condition and the postop sequelae that happen. Once again, I'm not doubting that there is pain, what I doubt is that it is coming from the 'tarsal tunnel'. It very well could be coming from higher up. Say from your lumbosacral region (L4, L5, S1,2,3). You could have some unilateral disk problems in your back affecting these spinal nerves causing your symptoms. That's my point. Get the right diagnosis.

Re: I'm with you on this one

Joe S on 7/18/02 at 21:35 (090021)

The condition you speak of is called Baxter's neuritis. The first branch of the lateral plantar nerve is called Baxter's nerve. It is one source of nonresponsive heel pain. I've posted an article pertaining to this syndrome on here before.

Re: TTS following P.F. surgery

Sharon W on 7/18/02 at 21:36 (090022)

Joe,

I am old enough to remember when many doctors didn't 'believe' in CARPAL tunnel syndrome, either. The fact that there were MANY of them, didn't make them RIGHT.

And you are undoubtedly right about TTS being used, at least sometimes, as a 'catch all' diagnosis (or to be more precise, a diagnosis of exclusion). I'm sure there are many cases of inaccurate diagnosis that occur as a result of that practice. That DOESN'T make the diagnosis invalid, however; it just makes the doctors who used it inappropriately, WRONG.

-- Sharon

Re: TTS Surgery

Pauline on 7/18/02 at 21:37 (090024)

Sharon,
I personally find this TTS discussion very valuable. The question I pose about your possible surgery is why not have a Vascular Surgeon address this varicose vein which you think is causing the problem before you go ahead with surgery? Maybe you did get an opinion from one already.

One of the things I find hardest to believe is the misdiagnosis of TTS when it seems like it presents with a pretty definate set of symptoms.

I'm more inclined to believe it's cause is a direct relationship to P.F. or other heel surgery.

Re: TTS Surgery

Joe S on 7/18/02 at 21:37 (090025)

The posterior tibial vein is the only vein running through the tarsal tunnel.

Re: Baxter's neurtitis

Sharon W on 7/18/02 at 21:38 (090026)

Joe,

I read that article, and it is EXCELLENT.

-- Sharon

Re: Baxter's neuritis

Sharon W on 7/18/02 at 21:43 (090027)

Joe,

My last post seems to have gotten mixed up with one by Scott. I wanted to say that I read that article you posted earlier, and it was excellent.

-- Sharon

Re: I'm with you on this one

scott r on 7/18/02 at 21:45 (090028)

For some reason, a post Sharon W just made got assigned the name of a post i made at the exact same time (i thought my flocking programming had fixed that) so that her post disappeared into the nether world. Here's a copy of it:

Joe,

I read that article, and it is EXCELLENT.

-- Sharon

Re: I'm with you on this one

Sharon W on 7/18/02 at 21:47 (090029)

First my post got tangled up with one by Scott, then it happened AGAIN!

Joe, I wanted to say that I read the article on Baxter's neuritis and it was very interesting. Thank you for posting it.

-- Sharon

Re: TTS following P.F. surgery

Joe S on 7/18/02 at 21:47 (090030)

I never said the diagnosis is invalid. I just think that too many docs throw that diagnosis around when they know good and well that if the patient doesn't have 'nerve symptoms' (numbness, tingling, 'electrical shocks') etc, they don't have TTS. I believe that there are certain compression neuropathies that affect the tarsal tunnel. Swelling can cause this, surgery can cause constriction of the neurovascular structures of the tarsal tunnel. There are a host of reasons that can cause true neurological symptoms around the tarsal tunnel. I saw a patient the other day who actually had a positive tinels sign at the tarsal tunnel. She has no risk factors other than she works as a scrub assistant in the O.R. and is on her feet 8-10 hours per day. No PF. My question is what is causing the symptoms. She does have some low back problems. Could be a radiculopathy of the L4, L5, S1,S2 or S3. These are the dermatomal levels which are affected by these spinal nerves. Could be that. SHould I order a Lumbar MRI. Probably so. I bet this is the root of her problem. As far as surgery goes, when you incise any structure it heals by scar tissue. My belief is that when you release the laciniate ligament, it has to heal or fibrose in somewhat. Well, that puts additional pressure on the remaining structures. I've seen way too many failures of this procedure. I've also seen a fair amount of RSD resulting from these surgeries. Some docs when they diagnose you with PF and TTS, they want to do two procedures on you in an attempt to maximize their reimbursement. That's another thing. That one I see all the time too. It's really a shame. These are not just podiatrists either.

Re: TTS Surgery

Pauline on 7/18/02 at 21:48 (090031)

Then a Vascular Surgeon shouldn't have any problem finding it. It really bothers me the amount of surgery constantly offered to cure a TTS diagnosis when the stats already show it does not work.

Doctors wanting to go in and cut out everything just in case it might produce a cure has got to stop.

Re: I'm with you on this one

scott r on 7/18/02 at 21:49 (090032)

This is pretty strange, everytime sharon makes a post, it gets assigned a number of whoever makes a post right before or after her. The one below got mixde up with Wendys. Sharon, maybe it's becuase of the '--' you're using near your name.

Joe,

My last post seems to have gotten mixed up with one by **scott**. I wanted to say that I read that article you posted earlier, and it was excellent.

-- Sharon

Re: I'm with you on this one

Joe S on 7/18/02 at 21:53 (090033)

Maybe that article should be available for everyone to read. It is a very good article. I do believe these discussions are beneficial for both patients and doctors. I personally can see how patients get frustrated with their care. I hope that the people who read my posts see that I try to truly say what symptoms are what and so on. I am not trying to argue with anyone on here. I do not discount anyone's symptoms either. I also do not post on here to market my practice. I do it because I enjoy the interaction. The friendly debates as well. Plus, it keeps me on top of everything. I found out about this website from one of my patients. It's a great resource.

Re: TTS Surgery

Joe S on 7/18/02 at 21:56 (090034)

Actually, any surgeon who performs ankle surgery frequently would not have a problem finding it. The posterior tibial vein and artery as well as nerve run right along with each other. You just have to know your landmarks. I'm waiting for someone to come up with an endoscopic tarsal tunnel decompression like the endoscopic carpal tunnel decompression. Their are some hand doc that do those in like 7 minutes.

Re: most docs don't believe TTS exists?

elliott on 7/18/02 at 22:36 (090040)

Not sure you're right on that.

Re: I'm with you on this one

wendyn on 7/18/02 at 22:37 (090041)

Joe, I think you make a great contribution here and it's always nice to have a doctor's perspective.

Thanks!

Re: endoscopic for TTS

elliott on 7/18/02 at 22:40 (090042)

It already exists, used by a few fringe podiatrists who claimed phenomenal success (like 100%), but considered flawed and too risky by mainstream docs. One person here had it done, and the results were not pretty.

Re: TTS Surgery

elliott on 7/18/02 at 22:56 (090043)

Pauline, I don't agree with you (sorry, but that's OK, isn't it?). A varicose vein *is* a cause of TTS (it presses on the nerve), a rather common one, in fact. That's not a misdiagnosis of TTS at all. And apparently it would be better to have an orthopedic surgeon or podiatrist familiar with TTS to handle the surgery than a vascular surgeon who, believe it or not, may know little about TTS and the delicate nerves there. Ligating a vein if necessary is relatively routine; TTS release and associated issues are not. Dr. Ed has stated such an opinion about varicose veins associated with TTS as well. I saw the best vascular guy in my state and got the impression he knew next to nothing about TTS; even said the enlarged vein there would not be giving me my symptoms. Great. Anyway, while in there, it would almost certainly be appropriate to do the standard TTS release (e.g. cut the flexor retinaculum, or laciniate ligament, as Joe calls it), since the tightness with it in there may well be contributing to the nervy pain (how would you know for sure it's not?), and doing so may well be less risky than not doing so. The last thing one wants is to increase the chances of a failed surgery. So no scandal here.

----

Re: Vascular Surgeons and TTS

Sharon W on 7/18/02 at 23:02 (090044)

Pauline,

The answer to that is, I tried. I couldn't find a vascular surgeon who was willing to work on my tarsal tunnel and was available to me on my medical plan.

Sharon

Re: endoscopic for TTS

Joe S on 7/18/02 at 23:19 (090045)

Exactly. Not many people who have had endoscopic carpal tunnel releases are satisfied either.

Re: most docs don't believe TTS exists?

Joe S on 7/18/02 at 23:22 (090046)

Actually, you may not be too sure. I'm pretty sure. I 'm pretty sure that they think something is happening in the retromalleolar region. Tarsal Tunnel Syndrome is not the cause of 100% of retromalleolar pain. Why do so many tts releases fail? Because the patient doesn't have TTS without the appropriate symptoms. Just because a doctor checks a diagnosis on his superbill doesn't actually mean that you clinically have tarsal tunnel syndrome.

Re: PF and TTS

Sharon W on 7/18/02 at 23:24 (090047)

Joe,

I do have PF as well as TTS -- or at least, there was inflammation visible around my plantar fascia when the MRI (with illumination) was done. That MRI also showed that the posterior tibial vein was varicose. A nerve block was done and the pain disappeared. I have a positive Tinel's sign, too. And the NCV showed that my lateral plantar nerve in that foot is slowed.

I trust my pod and I am glad she will be performing the surgery. She is always inclined to err on the side of CAUTION, and I like that. She was concerned that I might have a problem with the nerves in my spine and sent me to a neurologist to rule that possibility in or out. (It was normal.) She gathers as much information as she possibly can rather than jumping to a diagnosis, and I think I am VERY lucky about that.

Sharon

Re: PS

Sharon W on 7/18/02 at 23:34 (090049)

My pod will NOT be doing any kind of PF surgery on me; we both feel it isn't necessary at this point. And she certainly DIDN'T 'push' me to have the surgery -- quite the opposite, in fact; she thinks TTS surgery is too risky in most cases, and she wouldn't even CONSIDER it until all the usual 'conservative measures' had been attempted. Even then, I had to talk her into it. I guess I was able to make an adequate argument.

Sharon

Re: PF and TTS

Joe S on 7/18/02 at 23:40 (090052)

She worked you up the right way. My point exactly. Hopefully you will have a successful outcome. Your therapeutic nerve block worked. That's also an indication of a nerve problem. The most important thing you said was that 'I trust my pod'.

Re: where's the 4th branch?

elliott on 7/19/02 at 00:09 (090054)

I said there were three main branches, you said there's more, but I don't see you listing another. In addition, I believe it is quite common for the first branch of the medial calcaneal nerve to also pierce the proximal end of the laciniate ligament.

Joe, I appreciate your comments, especially as a doctor, but the more you speak on this, the more I think you're going too far out on a limb. It sounds like you're one of those who doesn't believe in the TTS diagnosis at all either. No, the odds of favorable TTS surgery are not as high as we would like (the lowest in a detailed study with appropriate followup was 44%; most claim well over 50%, knocking out your 'most', but of course you have to pick and choose which study to believe). I think one main reason for the poorer results is that many docs, not as familiar with it, don't perform it as well. Another is they don't figure out the root cause of the problem. Furthermore, success rates are much higher when there is a visible obstruction in the tunnel, something you may wish to ponder as to why. Yet another reason is that there are sometimes unpredictable nerve reactions to surgery, such as a neuroma, increasing the risks of different post-surgical comlications. Yet another (often leading to recurrence after intial relief) is because scar tissue forms over the very area released and may cause re-entrapment, not surprising given how teensy-weensy the nerves are. But these don't negate the fact that there was compression of a nerve in or near the tarsal tunnel, contrary to your general feelings.

I had bilateral release. I've had some complications which, if you're really interested, I can discuss, as well as the pre- and post-surgical findings, and had I the opportunity with hindsight to do things somewhat differently (different doc, try some other things first before surgery), I would have (hindsight is 100%) but I did get complete relief of nervy symptoms in first foot (why?), and almost complete relief, although somewhat temporary, in second foot (why?), and, after some vigorous massage and stretching, this foot seems to be making somewhat of a comeback. BTW, there were observed obstructions at surgery in the tunnel.

Oh yes, I also had an MRI for sciatica (right-sided only) which developed after right-sided TTS surgery (I believe due to a very weakened right foot post-op, but I can't be sure, no one can). Showed nothing on left side, L4-L5 bulging disc and dessicated L5-S1 on right side. Sure, not enough is known about the relationship between sciatica and TTS, if any. Theories such as double-crush phenomenon do leave many holes. But--and you may not believe this--most patients can tell the difference between pain originating from their spine and that from their ankle, especially if they've had both. I've esperience it all firsthand; bet you haven't. When my sciatica is bad, I can feel it running from my back and dropping into my foot when sitting. I don't call that TTS. In any case, my MRI would not explain the TTS symptoms I had (in right foot, numbness and burning in medial and back heel and ankle radiating up calf, mainly after exercise such as running, tingling in left foot at medial malleolus and radiating into the four medial toes). For example, I had no pain or nervy symptoms at all in the lateral toes of my right foot, where L4-L5 ends.

Tarsal tunnel surgery is risky, no doubt about that. But sometimes, many times, in fact, someone actually has entrapment of a nerve in or near the tarsal tunnel, and, given unresolved and often unbearable pain, surgery is definitely an option.

----

Re: I mean your claim that *most* docs don't believe it exists (nm)

elliott on 7/19/02 at 00:10 (090055)

.

Re: then maybe...

elliott on 7/19/02 at 00:13 (090056)

we shouldn't be waiting for someone to come up with an endoscopic tarsal tunnel decompression like the endoscopic carpal tunnel decompression.

---

Re: Sharon

elliott on 7/19/02 at 00:32 (090060)

No, it wasn't I who had a nerve cut during surgery, thank God.

I too had (1) and (2) in right foot, just (2) in left. I believe (1) can cause (2), especially if exaggerated through things like running. I'm feeling a bit uneasy about some parts of your surgery. Maybe I can offer some advice. Can you describe/answer

1. your exact symptoms (type, location)
2. whether they're continuous or only after standing/walking/exercise
3. how long since onset of symptoms
4. what you've tried
5. did you have an Xray?
6. any previous surgery on that foot?
7. how does the doc know it's a neuroma, separate from your TTS symptoms?
8. when she says cut it, what's she planning to do (just cut, or resect)?
9. has she done this sort of thing before?
10. did you get a second opinion, especially about the neuroma?
11. where do you live?

---

Re: the informed ones, anyway (nm)

elliott on 7/19/02 at 00:37 (090061)

.

Re: Baxter

elliott on 7/19/02 at 00:51 (090062)

There are a couple of issues that seem to have got garbled into one in this thread: 1) whether Baxter's nerve often gets injured when performing a PF release 2) whether Baxter's nerve should be released as part of any TTS surgery especially since (according to Baxter, anyway) PF may likely be a contributory cause of problems in that nerve.

The problem with a nerve being named after someone is that the someone became famous by claiming that this nerve's problems appear anywhere and everywhere (otherwise it wouldn't be named after him). The story with this nerve is still somewhat unclear, although it's probably safer to release it in a TTS surgery than not (mine were), especially if there's any arch pain. Time will tell for sure.

Anyone know if it's also safer to do so as a matter of course in PF even without nervy symptoms?

-----

Re: Baxter

Joe S on 7/19/02 at 01:04 (090064)

Baxter's nerve is the first branch of the lateral plantar nerve. I'm not much for naming structures after people but whatever. I've never confused Baxter's Neuritis with TTS. Read the article I posted on Baxter's neuritis and heel pain. Scott R should have it somewhere.

Re: where's the 4th branch?

Joe S on 7/19/02 at 01:21 (090065)

Listen pal, evidently you've only skimmed my postings. I never once said I didn't believe in TTS. If you want to get picky, only one nerve runs through the laciniate ligament. As it exits the flexor retinaculum it becomes the medial and lateral plantar nerves. This is well documented in anatomical literature as well as cadaveric studies. The medial calcaneal branch pierce the laciniate ligament. I basically agree that any space occupying mass be it a hypertrophic muscle belly, varicose vein, or whatever that compresses the posterior tibial nerve will give you the symptoms you discuss. But to call all pain that is retromalleolar (behind the medial malleolus) TTS is absurd. I never once stated that sciatica can mimic TTS. A radiculopathy of say L4 could mimick this condition. That's why the appropriate workup is necessary prior to proceeding with surgery. I believe a misdiagnosis which proceeds to surgery often fails. It is those with true neurological symptoms that do much better.

I challenge you my friend to pull out an anatomy book. Look up the dermatomal distribution of the your lumbosacral plexus. L4 basically provides sensation to the anterior and posterior medial aspect of your leg. L5 provides sensory to the posterior lateral and anterior central aspect of the leg including toes 1-3. S1 provides sensation to the dorsal lateral aspect of your foot (toes 4/5) and the plantar lateral aspect of the foot. S2 provides sensory information to the posterior central aspect of your thigh and leg.

Anyway, I've wasted way too much time on this suject.

Re: where's the 4th branch?

Joe S on 7/19/02 at 01:23 (090066)

Elliot,

I believe if you reread my post you will realize that I said there are 4 compartments to the lacinitate ligament. Not 4 branches to the nerve. You really need to learn to read these posts better before criticizing.

Re: I mean your claim that *most* docs don't believe it exists (nm)

Joe S on 7/19/02 at 01:24 (090067)

you're an idiot.

Re: most docs don't believe TTS exists?

Joe S on 7/19/02 at 01:26 (090068)

your post doesn't make sense?

Re: thanks; very professional (nm)

elliott on 7/19/02 at 06:48 (090075)

.

Re: where's the 4th branch?

elliott on 7/19/02 at 07:07 (090077)

How do you explain the quotes around the 3 in your first sentence, 'Actually Elliot, the laciniate ligament houses more than the '3'nerves'? Sorry for taking yout posts at face value.

---

Re: That didn't take long

wendyn on 7/19/02 at 07:24 (090078)

You'll have to pardon my friend Elliott. He's a bright guy, but he seems to have a little thing about him being right and therefore everyone else being wrong.

Elliot, is it _possible_ for you to debate without pissing people off?

Re: Elliott

Sharon W on 7/19/02 at 07:41 (090079)

Elliott,

No, I have never had foot surgery before. And thanks for your offer to help; I do appreciate it. But (please don't take offense) the reason I didn't post a thread about my upcoming surgery was that my decision is now made.

If you are interested in the history of my symptoms and everything we've tried in the past, that information is detailed in a series of threads (most of them with Donna SL) back in March. Since then I have gone through PT (unsuccessfully) and started using Neurontin (what a relief!) but I have stopped posting about my own foot problems in any detail.

In fact, I had not even intended to mention my surgery next week, until after it was over -- but I was hoping you could tell me what it's like to get a nerve cut. I don't know who I confused you with that mentioned having a (sensory-only) nerve cut, but sorry. The part about cutting the nerve probably won't even happen; it will only happen if my pod goes in and sees that that nerve branch looks extremely abnormal.

I live in Central Texas.

Sharon

Re: funny

elliott on 7/19/02 at 08:15 (090086)

When I saw your post title, I actually thought you were going to defend me this time. Anyway, thanks for your kind thoughts.

----

Re: Thanks

Sharon W on 7/19/02 at 10:14 (090099)

Joe,

Thank you. I agree that trusting one's surgeon is very important, assuming that trust is deserved and not simply based on a blind faith in doctors.

Sharon

Re: I'm with you on this one

Pauline on 7/19/02 at 11:47 (090113)

Dr. Joe,
Your correct about not marketing your practice. I've never seen you do this. We haven't heard about all the crutches left hanging on your walls.
I for one greatly appreciate your marketing free posting and sincerity. I think others do too. Thanks for being here.

Re: Vascular Surgeons and TTS

Pauline on 7/19/02 at 12:12 (090116)

Sharon,
I think not having a doctor available on a specific medical plan has probably cause many people a great deal more suffering because they were then forced or chose perhaps a doctor less qualified.

Not everyone is in a position to pay to go out of network for treatment and I understand that, but if I thought there was one doctor that could provide me with a better chance to live pain free, I'd go to see him regardless of what I had to pay out of pocket.

A lot of people would never consider this. I have personal friends who would never see a doctor they have to pay out of pocket. Some won't go any one that doesn't offer them personal courtsey and they can well afford to do so.

My belief is one visit usually won't break the bank and it's worth the risk of money it it can truly offer a better outcome. At least you know you've exhausted all your options.

Like Elliot said maybe Vascular Surgeons don't do this work, but if one indicated he had experience in this area and was out of network, I go to see him.

Personally I find writing a letter to a specialist listing history and symptoms and things that were tried always brings a response without
any need for insurance. They either call or write back making suggestions and tell you if they think they can help your situation.

Sometimes I think we forget to use this method of communication to our advantage. I've had many physicians respond to letters for various medical problems. Some tell you they can help, others refer you elsewhere, but you always get a response from a good doctor.

Just my opinion before you offer your foot for surgery.

Re: Vascular Surgeons and TTS

Sharon W on 7/19/02 at 13:36 (090124)

Pauline,

I said I had checked into the vascular surgeon thing first, a couple of months ago -- I DIDN'T say I was frustrated because I had learned of an infinitely superior vascular surgeon out there who would be willing to do the surgery but was OUTSIDE the range of my POS 'network' and therefore unavailable to me. In fact, noone I talked to around here had ever heard of a vascular surgeon removing a posterior tibial vein from the TT.

I am satisfied with the decision I have made, and I am no longer focused on whether to have TTS surgery to remove that vein or on finding a good surgeon to perform it. I confident in my decision and I think I HAVE a good surgeon. My focus now is on making plans for a safe and successful recovery period. Any tips on how best to handle life in a wheelchair for a month would be greatly appreciated.

Sharon

Re: TTS Surgery

Donna SL on 7/19/02 at 13:52 (090127)

Hi Sharon,

Is the pod that's been treating your for while doing your surgery? If so, I thought you said she didn't have that much experience with this type of surgery. I'm just curious what happened with the pod who had more experience, and was certified by the ABPS. Did you ever see him, or someone with similiar experience, and credentials?

Donna

Re: Vascular Surgeons and TTS

Pauline on 7/19/02 at 13:59 (090128)

Sharon,
I'm sure others who have spent time in a wheel chair will be better at offering tips to you. Best of luck with your surgery and I hope your recovery time speeds along leaving you without pain.

If I were to suggest anything it would be to surround yourself with friends. Ask for their support if and when you feel down during your recovery.

Re: where's the 4th branch?

Joe S on 7/19/02 at 14:53 (090133)

You're correct. The 1st sentence should have read the laciniate ligament is made up of 4 compartments. I stand corrected.

Re: That didn't take long

Joe S on 7/19/02 at 14:56 (090134)

The funny thing is that I never disagreed with him. He only wants me to disagree with him. No harm done.

Re: Thanks

Joe S on 7/19/02 at 15:00 (090135)

Actually, I attempt to develop a very good relationship with my patients. I do not haphazardly push surgeries on my patient's. We all lose in the end. I am able to come home and go to sleep at night knowing that I have not screwed little Mrs. Jones over by promising her that I can fix her foot with surgery. I guess it's the way you're brought up. I have a very busy practice too. I have a large referral base from other MD's who trust me even to the point of sending their mother's daughter's and wives to me. If I don't think a problem will be fixed by surgery, I don't recommend it. I know alot of doctors do. They have to live with themselves. I rest easy at night.

Re: Thanks

Sharon W on 7/19/02 at 15:13 (090138)

Joe,

I'm sure you do. And I think that if I were referred to you for surgery, I would probably rather quickly determine that you were being honest with me, and I definitely would respect that (even if I didn't like everything you had to say). And I bet I would have considerable respect for your REPUTATION, too. But when someone is referred to you specificaly for surgery, how much TIME do you usually have to develop a relationship with them? That's all I'm saying.

Sharon

Re: Pauline

Sharon W on 7/19/02 at 15:13 (090139)

Thank you.

Sharon

Re: TTS Surgery

Sharon W on 7/19/02 at 15:29 (090142)

Donna,

I checked into it. He had retired and, in fact, he DIED recently. There are no foot & ankle orthos around here. There's another pod in town who apparently doesn't even DO surgery, and then there are my pod's PARTNERS, two of whom have more years of experience but none of them are board certified for podiatric surgery, either. So I had a very long conversation with my pod and, in the end, I decided she really was the best person available for the job. She told me the story of the TTS surgery that went wrong. She is the kind of person who demands a LOT of herself, and I think it hit her pretty hard. But for that same reason, I don't think I could find a more CAREFUL surgeon...

As I said, I have already made my decision.

Sharon

Re: TTS Surgery

Donna SL on 7/19/02 at 17:07 (090149)

Sharon,

Don't get mad at me, but of course I'm not happy you choose her to do your surgery, and all the 'carfulness', in the world won't make up for the skill required to do this kind of job. That requires years of training, and experience in this area., no matter how self demanding she is. Did she do any type of surgical residency? If so why isn't she board certified? Not that it matters if she's not really experienced in TTS surgery. I'm just curious. Would you have surgery on any other part of your body, buy a non board certified surgeon?

I would think that if there wasn't a surgeon in your area qualified to do this that your ins co would pay for someone else out of network. This is a risky enough surgery under the best of circumstances with the best surgeon, so it only seems logical to find the most qualified doctor, along with a clear surgical plan. Also, a board certified surgeon would hopefully offer better follow up care, which can be just as important as the surgery.

At this point after all you know, and have read about on this board about these surgeries, the complications that can occur, etc., and are still pursuing this with her I know all the convincing that I may try to do is not going to make you change your mind, and seek out another surgeon somewhere. I'll just keep my fingers crossed, and you are lucky, and everything comes out ok for you.

Donna

Re: most docs don't believe TTS exists?

A MANOLI MD on 7/19/02 at 20:06 (090169)

maybe time for a little science here, rather than name calling.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8056802&dopt=Abstract

this study of tts shows poor surgical results, in general, with the best results in those with a space occupying lesion. in the article itself, many of the patients eventually had spinal nerve problems, diabetes, or other problems which surfaced after some time.

i don't know about 'most' docs, but we never find patients without a space occupying lesion, or sciatica-type complaints who we think are true nerve compressions at the tarsal tunnel. i just don't see them, perhaps they see me.

as i tell my fellows/residents, just because a lot of people DO something, doesn't mean it is correct.

i guess i'm in joes's camp, so let the flogging begin.

am2

Re: TTS Surgery

Joe S on 7/19/02 at 21:32 (090179)

It's an interesting fact that back in the old days of podiatry (70's -80's and up into the early 90's) that all pods could sit for the only recognized surgical board (american board of podiatric surgery). This has changed. I completed a 3 year surgical residency. I am board qualified by the ABPS. They give you 7 years after becoming qualified to sit for the board certification exam. I have all of my cases for the forefoot portion of my boards. I am currently working on rearfoot, ankle, and leg trauma to complete my certification for board certification in reconstructive rearfoot and ankle surgery. It is a very long and hard process. It's well worth it in the end too. While in my residency I performed well over a thousand procedures ranging from simple hammertoe corrections to reconstructive surgery of the ankle and leg. As an aside, there are many good surgeons who are not board certified or even qualified for one reason or the next. They should really attempt to become certified. Hospitals and insurance companies look at this when credentialling you for their plan or for hospital privileges. For example, the medical staff office contacted me the other day asking for me to check over the application and requests for certain surgical procedures for another pod in town applying to our hospital (I'm a pod that works with 3 orthopedic surgeons in a hospital based clinic). Most of this pods requests were straightforward procedures. There were about ten or 12 procedures she threw in there that I had to question. The orthopedists questioned me when I applied for them. I was able to prove from my surgical logs from my residency that I was more than experienced enough to perform these more complicated procedures. Anyway, after questioning these procedures and requesting proof of performance of these procedures she became very mad at me for making the request that she be proctored for these certain procedures and to also prove that she's actually performed them in the past. I personally believe we need to hold ourselves accountable for our actions. If I let this podiatrist have carte blanche privileges then if something went wrong with one of her more advanced requested procedures, I could be held accountable. Anyway, it's usually a good call to ask your doc how many of these procedures they've done in the past. Hopefully they will be truthful.

Re: Thanks

Joe S on 7/19/02 at 21:46 (090181)

My concern is that when someone comes in for surgery on visit number one I have to ask why? Is it because all of the standard conservative measures have failed? Is it because Ms. Jones down the street said that he or she's a great doc and will fix you? If it's truly a surgical problem and you present to me only one time my first question is usually why not let your previous doctor operate? Is there some reason for that? I have been called by another surgeon not too long ago about fixing a fracture of the 1st metatarsal. He sent the patient to me. I felt that the patient needed the fracture fixed. I called the referring pod to tell him what I had planned and discussed with the patient. I asked him if he would like to scrub the case with me. This type of situation is a little different than our present conservation though. I believe you can get a feel for the patient as well as the doc in usually one visit. If he or she comes in the room looks at your chart and says 'Sharon, I've read your chart from Dr. Sims and you've got TTS. Let's operate. I can do it next week at 2 pm and this is what we are going to do...' I'd be very wary about this guy. If he comes in and examines you discusses your previous treatments and why they failed or were not successful and then states that all conservative efforts were attempted the next step is surgery and these are the options.... then I think my trust would be much higher. I used to work with both types of these doctors in my residency. I believe I learned more about treating patients from the one that never really informed his patients about their conditions. I actually learned what not to do. Believe me, my patient's who undergo surgery from me understand the procedure. I discuss it with them, I have a drawn schematic. I discuss the possible complications. I write the consent right there in front of them. I discuss my expectations of postop care for certain procedures. This may take a little longer but that's why my receptionist schedules a block time for surgery consults. I want my patients to be clear and understand that foot surgery is MAJOR Surgery. Postop complications do happen. ANyway, another longwinded post. Sorry

Re: most docs don't believe TTS exists?

Joe S on 7/19/02 at 21:50 (090182)

I believe Lee Dellon, MD who is a plastic and reconstructive surgeon has done a fair amount of work on TTS as well. He also does alot with diabetic peripheral neuropathy. He has some very interesting thoughts on TTS and compression neuropathies about the tarsal tunnel region.

I whole heartedly agree with your statement that 'just because a lot of people DO something, doesn't mean it is correct'.

Re: TTS Surgery

Pauline on 7/20/02 at 18:56 (090236)

Dr. Joe,
You are the exception not the norm. Many new Podiatry graduates are not even getting into residency programs, and I guess they don't have to in order to join a practice and operate.

If they can earn a good living without taking advance training and it's not a requirement for them to practice why should they spend the money and the time? The learn as you practice seems like the norm today.

Re: To Dr. Manoli

Pauline on 7/20/02 at 19:11 (090239)

Congratulations on your listing in 'America's TOP Doctors'.

Re: TTS Surgery

Pauline on 7/20/02 at 19:32 (090242)

Sharon,
Everyone must come to their own decision about having a surgical procedure and who is going to do it. You seem satisfied with your decision and I respect that, but I've got to tell you I've traveled out of state on three different occasions for various surgeries.

We are only limited by the limitiations we put upon ourselves and the priorities we set.

I have to say that I'm with Donna on this one because of all the postings and medical studies that have been done. Dr. Manoli just posted one abstract that gives medical evidence to this surgery.

Personal opinion do ALL your homework ahead of time. Don't take your feet for granted because they are complex. If you were dealing with eye surgery you'd want the very best, some how feet seem to get a lesser ranking in importance.

Your feet, your pain, your decision, your surgery. The saying 'Act in Hast, Repent in Leisure' certainly has it's application when it comes to TTS surgery.

I hope this isn't true in your case. Once again wishing you the very best outcome.

Re: TTS Surgery

DR Zuckerman on 7/20/02 at 22:55 (090248)

Pauline,

In order to understand podiatry profession you have to make the comparison to denistry. There are generalists in denistry who clean teeth, treat infections and do very minor surgery. This would be the podiatrist who didn't do a residency ( which is very rare) Then you have the orthodonist. This would be the podiatrist who is a specialist in orthosis. You have diabetic foot specialists. You have sport medicine podiatrist. and on and on . The oral surgeon could be compared to the foot surgeon who did the 2 and 3 year additional training. One is not better then then the other just different.

I can't remember the last time I met a podiatrist who did have at least a one year surgical residency. In my practice we even have a four year surgical trained foot and ankle specialists. Where does it stop.

Re: TTS Surgery

Joe S on 7/20/02 at 22:56 (090249)

Actually, for the last 2 or 3 years residencies are in abundance. There's no excuse for new graduates not being able to get a good quality residency. The application pool to podiatry schools this year is WAY DOWN. The one's who don't pursue a residency typically are the ones cutting toenails in nursing homes day in and day out.

Re: Thanks

Sharon W on 7/20/02 at 23:09 (090251)

Joe,

I would have imagined that the usual reason patients are referred to you for surgery on visit 1, is that you have a reputation as a good surgeon and perhaps the patient's 'regular' podiatrist is younger and has less experience, or they have not achieved board certification, at least, not at this point in their career. Perhaps this is because the podiatrist himself (or herself) recognized that you are a better or more experienced surgeon, as in the case you described where you invited the other guy to scrub with you (that was a nice thing to do, by the way). My bet is, most of the time it is probably at the patient's instigation. 'Everybody' wants the doctor with the best reputation, the best credentials, the most experience. I suspect that most patients know at least ONE doctor willing to give them a referral to a more renowned surgeon, if they ask for it. I think the truth is, most of it comes down to money, to what a given patient can afford. Perhaps if (irrespective of insurance coverage) EVERY potential surgery patient could AFFORD the surgeon with the best reputation, best credentials, most experience, then no younger surgeon would ever be given a CHANCE to prove themselves or to develop an equivallent level of skill and experience. Perhaps in that case the ONLY cases that a talented and promising and conscientious young surgeon would ever have an opportunity to operate on, would be the ones in which all the REPUTABLE surgeons have already refused to attempt surgical intervention.

I don't know. Just a thought. But, doesn't every surgeon have to endure being new, for their first ten years or so?

Sharon

Re: more science

elliott on 7/21/02 at 10:04 (090276)

Thank you for your comments. You have an eminent reputation, and I respect what you say. I hope, therefore, you don't find me an 'idiot' or 'know-it-all' for responding to your post. Check out this link:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8714673&dopt=Abstract

This study seems to have been aware of the study you quote (I too quoted the 44% in an earlier post in this thread), yet this study comes up with 71%. The lead author is Mahan, very respected among podiatrists.

Concerning sciatica and the like, I agree docs don't seem to know enough about the connection with TTS, nor even exactly what to do once a patient has both. I would like to know a lot more about that. And yes, misdiagnoses are possible. I will say, though, that developing a bulging disc and sciatica two years after altering one's gait due to TTS nervy pain is not necessarily that surprising, nor does it necessarily mean the initial TTS surgery was inappropriate. Check out this link:

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8384154&dopt=Abstract

There the authors claimed TTS success on 6 out of 7 patients who had sciatic or other similar conditions accompanying their TTS. The chief author, Sammarco, is a renowned orthopedist, one of three direct TTS disciples of Baxter, and past president of the AOFAS. Sure, studies are of varying quality, but which study does one believe?

Someone I know who went to Baxter for TTS told me that he told her that there are only a handful of people (his three disciples included, of course) who really know what they're doing with TTS. Maybe that's a bit self-serving and overblown, but maybe there's a point there too, that your run-of-the-mill [ortho]pod may not be quite up to the task percentagewise. Even for a correct diagnosis and an appropriate candidate for surgery, there's so much that can go wrong with peripheral nerve surgery in general (scar tissue, insufficient release, strange nerve flareup, etc.) that maybe the best surgeons are needed to produce the best results.

---

Re: Elliot: I've always liked this link

Sharon W on 7/21/02 at 13:26 (090291)

Elliott,

Good post. I think part of the problem in identifying 'success rates' for TTS surgery is that exactly how to define 'success' is defined in many different ways. I note that the 44% figure in Dr. Manoli's post said that while 44% 'benefitted markedly' from TTS surgery, an additional 19% had their 'pain decreased'. (I really LIKE the idea of a decrease in pain...)

This link is for the Curtin Podiatry Encyclopedia, in an article written by Pricilla Benzie:

http://www.curtin.edu.au/curtin/dept/physio/podiatry/encyclopedia/tarsaltunnel/

Benzie identified 3 different surgical procedures performed for TTS, and I would imagine that there could be differences in the 'success' rates depending on which procedures, or which COMBINATION of procedures, are performed to correct TTS. Below are quotes from her article:

'Mahan, Rock and Hillstrom (1996, p.84) report on the three most common types of surgical procedures performed. The first is the surgical incision and release of the flexor retinaculum. The second is the release of the abductor fascia in the opening of the abductor hallucis muscle (the region where the posterior tibial nerves and vessels enter the plantar aspect of the foot). The third is the release of the posterior tibial nerve and/or its branches from 'surrounding entrapments' (eg, variscosities). Alternative documented procedures include; '…excision of bony or soft tissue masses, epineural release, and excision of the posterior tibial nerve with or without the associated plantar branches' (Mahan, Rock and Hillstrom, 1996, p.84). '

Mahan, Rock and Hillstrom (1996) conducted a retrospective study and documented 71.7% of the patients studied demonstrated at least a moderate improvement in symptoms following surgical intervention. Pfieffer and Cracchiolo (1994) reported only 44% of their patients had a an excellent or good result following surgical intervention...'

Sharon

Re: A. Manoli's article -- workup

Ed Davis, DPM on 8/11/02 at 12:31 (092203)

I cannot emphasize enough the importance of a good workup. Electrodiagnostic studies should be performed as proximally as possible. One problem is the variability of training of those performing the studies.
Ed

Re: A. Manoli's article -- workup

elliott on 8/12/02 at 10:49 (092288)

Dr. Manoli happened to select the article having the lowest published success rates anywhere (44%). I just wonder if that is fairly representative or not. In response I gave links to articles showing much higher success rates when done by doctors specializing in this stuff.

The study Manoli refers to was indeed a carefully-crafted study, both with good workup/selection and appropriate followup, and has been cited in other journals. But I can't help but wonder if maybe the authors are just not as skilled in TTS surgery as some others. Or is it that everyone else is inflating their figures?

---

Re: Thanks

Vicky M on 10/31/02 at 18:46 (098841)

Wow, this is my first experience with the message board. It is also my first experience with any type of medical problem. I have been so scared, frustrated and confused about my foot condition. But your message, Joe, made me feel much at ease and more confident with my new 'foot doctor'. He seems to be taking his time and trying conservative treatments before surgery and it sounds like he has the same philosphy of you. I am 37 years old and feel that I am too young to live with such pain. I woke up one night in severe pain, I described it worse than labor pains. I did not sleep for six nights straight and yet I never felt tired. I don't remember much about those six days, except for the pain. I took two percocents every three hours, yeap I cheated, but many times I thought I was going to pass out from the pain. My foot had swollen 4 times its normal size. Between the getting into see my primary physician and then getting an MRI scheduled, it took me just over a week to finally get in to see a specialist. That was the worse week of my life. Its been about 10 days and the pain is subdued and the swelling down. The doc says I have a cyst on my ankle that is causing tarsel tunnel sydrome. All the messages that I have read do NOT report any cysts as part of their condition. So Joe how am I different as far as treatment. My doc is trying some conservative treatments, cortazone shots, Vioxx, and a boot. I have felt everything imaginable on my foot, toes and ankle: shocks, pinches, aches, burning,numbness,shooting pain, you name it I have felt it. Remember I just woke up one night in pain, no signs beforehand. Right now my skin is so sensitive and I have a pain right across the middle of the bottom of my foot. Is this cyst going to deflate and go away,will it reaccure, or will it definately need to removed. I must mention that my doctor seemed a bit puzzled as to what to do. Let me know if you have any info., advise or research. THANKS for sharing your knowlege.
Vicky

Re: To Vicky

Julie on 11/01/02 at 02:19 (098864)

Hi Vicky

You posted your post at the end of a thread that began in July, and I'm afraid no-one will see it if they don't read 'All messages posted since your last visit'. Many people don't.

I suggest you go to the home page, click on 'Message Board' and then on the 'Ask the Foot Doctors' board and post a new message there. Joe hasn't posted here for a few months, so he may not see your new message either, but I'm sure one of the other doctors will answer you.