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Another Article on Nerve Entrapment

Posted by DJ on 8/22/02 at 11:13 (093209)

I have scanned in another article in its entirety called 'Nerve Entrapment of the foot and Ankle in Runners' by Paul C. Murphy MD and Baxter. If anyone would like this article ind PDF format, send me an email at (email removed). For any track and field historians, the elite runner he mentions in his case study on Medial Nerve Entrapment is Rudy Chapa, the great High School and later University of Oregon distance runner. Rudy ran around 28:45 for 10K in high school and was a many time all-american for the Ducks. Baxter diagnosed him with Jogger's Foot after 2 years of injury. After Surgery, Rudy went on to place 4th at the New York City Marathon.

Re: Another Article on Nerve Entrapment

elliott on 8/22/02 at 13:40 (093228)

The first article in your earlier post refers to a major league baseball player batting .324 who had a successful release of the Baxter nerve (first branch of the lateral plantar nerve) and was back to full playing 8 weeks later, continuing to be one of the top batters in the majors. Then there was an NBA player who had a successful TTS release and resumed play. (Do you know who they were? The article is 10 years old.) My reservation about such cases is that they leave the impression that this is what one should typically expect, when the truth may be far from it. I'm not saying every author should heavily highlight his failures, but at the least, such success stories should be intermingled with the author's observed success rates.

------

Re: Operative Results

DJ on 8/22/02 at 15:45 (093238)

I'm not sure who that baseball player was. Mark MacGuire wasn't treated until three years after this was written. Percy Snow is the only basketball player I know thats been treated by Baxter and that was recently. I feel the same way you do about these articles making these procedures seem so simple and without risk. A search on Baxter on this message board comes up with some patients of his that weren't so lucky. How do you find out about the negative operative results? Also, does the Doctor come up with his own ideas of what a positive result is or does an outsider perform follow up surveys. I'm gonna do as much research as I can at the about operative results but I have a feeling that this message board is the only place I'll be able to find out what happens when the surgery doesn't go so well.

Re: Operative Results

john h on 8/22/02 at 18:15 (093260)

DJ: I had the Baxter procedure 3 years ago and it did not cure me but most importantly it did not make me worse. I looked at all the options and types of surgery available at the time and it seemed clear there was no surgical procedure safer than the Baxter Procedure. This is for a very simple and understandable reason. They barely cut the fascia so your foot remains stable. Probably as stable as before surgery. Traditional PF surgeries release 50% or more of the fasia often leading to foot instability, pain on the opposite side of the foot and perhaps a collapsing arch. With Baxter a very small wedge of fascia (perhaps a 1/4' moon shaped) is removed. This in fact does release some tension on the fascia but not near the release of a conventional PF release. My greatest concern was to be made worse. I asked my Doctor who was an orthopedic foot and ankle surgeon who trained under Baxter how many of his patients had been worse after surgery and he said one and that was a person who had diabetes. He has performed many of the procedures. Although it did not cure me I am certainly glad I chose that procedure because I am certainly no worse and perhaps a little better. If you observe the fascia on my foot that was operated on while stretching it you will see that it is as prominent as the foot that did not have surgery. Not so with someone who has had a 50% plus release. I think I am the only one on the board that I have seen post who has actually had the procedure. Small incision, little pain, little swelling, back in shoes in 2 weeks, stitches out in 10 days. About a 25 minute procedure. Again my reason for choosing Baxter was the far less likely possibilty of making the foot worse after surger. If Carl Lewis choose this procedure and ran again I guessed he must have researched it also.

Re: Operative Results

elliott on 8/22/02 at 21:49 (093276)

You've said all this before. I'll reiterate, you're not the only one on this board to have had this procedure. The current thinking in TTS is to do this as part of the standard TTS release; I've had it done bilaterally.

I'd agree that Baxter's or a Baxter-trained doc's success rate on the nerve named after him might be higher than for others. Of course, you're a sample size of one. Just because you came out unscathed (and still not a success) doesn't mean another would have been so lucky. In any case, we're not talking in this thread so much about a release of this nerve as part of a PF surgery, as you keep bringing up, but rather nerve releases in general (this being one of them), some more risky or in more sensitive locations, for which the article gave numerous prominent cases all successes, perhaps leaving one with an inflated sense of security. If a doc tells you that failure is a rarity for these, well, that's disingenuous.

----

Re: PS--the pods win!!!

elliott on 8/22/02 at 22:40 (093279)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1600660&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10881458&dopt=Abstract

---------------

Re: Elliott

Pete on 8/23/02 at 05:42 (093288)

So what's the surgical procedure for releasing the medial calcaneal nerve ?
What other nerves could be trapped other than Baxter's and mcn ?

Are you likely to have both feet affected with nerve problems and what are the symptoms ?

Both my feet are affected but I'm not convinced I have pf...no morning pain etc

Re: TTS 101

elliott on 8/23/02 at 08:12 (093298)

I'm only going to dicuss the TTS nerves. There are other main nerves on the middle and other side of your foot, but they would produce different locations for pain.

The posterior tibial nerve runs down your leg and, as it enters the tarsal tunnel located near your medial (inner) ankle, it splits into three main branches: the medial calcaneal nerve(s) (a person can have anywhere between 1 and 4 of these, with 2 and 3 by far the most common), the lateral plantar nerve, and the medial plantar nerve. It is important to consider symptoms, e.g. where is the discomfort, where does it radiate (e.g. to various toe combinations), etc. to determine which if any nerve is entrapped (the signs aren't always so clear). If one has nervy pain at medial ankle radiating to arch, heel, and toes, that sounds like classical TTS, possibly warranting the classical TTS release at the ankle area only. If one has tingling only in the lateral two toes, it could be just the lpn. If pain just in the arch, it could be just the first branch of the lpn. If the only toes affected are the 4 medial toes or sometimes 2 of them or mainly the big toe, it could be just mpn. If just the medial heel it could be just mcn. You can have combinations too. Isolating exactly where the problem is can be difficult; insufficient release is a standard reason for failure. But they can't just cut up your whole foot, for then you'll have nothing left. They should listen very carefully to your symptoms. What's causing it is real important too. I can't say what's causing yours; have you posted the details on these boards? Maybe someone can help. When it's bilateral you always have to be especially cautious as to systemic causes (bloodwork may help for this), gait and back problems.

There's a small thread still on the first page of the TTS board where Dr. Ed describes what he would do for mcn only. If mcn entrapment is originating near the medial ball of the foot, I believe they would make an incision there.

---

Re: Operative Results

DJ on 8/23/02 at 08:49 (093306)

The procedure for releasing the medial plantar nerve at the midfoot does not seem as risky as some surgical procedures either. If I were to have this procedure, I would definitely have it done by Baxter himself.
Because my symptoms are completely different than the case studies he writes about for Jogger's Foot, it makes me alittle more doubtful. Especially after another dr that trained under Baxter said he didn't think I had jogger's foot and that he would not recommend messing with the nerves. He told me he has seen bad results and he wouldn't want me to be one of them.

Re: Operative Results

john h on 8/23/02 at 09:21 (093310)

I believe Dr. Weil is the team foot doctor for the Chicago White Sox and has provided ESWT treatment to some of the team members. There are several former players for the Arkansas Razorbacks who went to Canada for ESWT one being Lee Maybury (NBA) I talk to Corliss Williamson on occason and several other NBA players (Scottie Pippin, Darrell Walker, Sydney Moncrief, Joe Klein, Derrick Fisher) who work out at the health club I attend. They tell me PF is fairly common in the NBA and that most players wear orthotics. They also said players typically try to hide their injuries from management and other players for obvious reasons

Re: Operative Results

john h on 8/23/02 at 09:55 (093313)

Elliott: I am not really sure the Baxter Procedure is considered a PF Release. If it is it is probably a misnomer as the removal of the section of fascia is to remove pressure off of the nerve and any resulting release of any fascia is just coincidental.

I have read so much on the subject that I no longer read the journals as I see nothing new coming out. We are all left with very simple choices if we have PF type pain. (1) Do all of the endless but sometimes effective methods you read about on this board (2) Do ESWT (3) Have a PF Release with either an open, MIS, or endoscope (4) Decide you may have a compressed nerve and go for TTS surgery of which you also have a choice of types of surgery. Dr. Gordon who is well known in PF and ESWT circles told me there are a group of people who will never get over PF no matter what is done. Hope I am not one of those.

Elliott you have a style of writting where by intent or accidental can be offensive. That is acceptable but it is also very true..

All of these endless articles and studies will often disagree. A point comes when you just have to make a decision based on your information and gut feeling. You can read yourself into oblivion but until you take action nothing happens.

After 8-9 years of bi-laterial life altering PF I have my personal opinion that there are multiple causes of PF Pain. PF is a medical term much like Degenerative Disc Disease which is a catch all for many problems. There is no one cure all for PF. We all got PF through various life styles and if we are to be cured or at least manage our PF it will be with what works for us as individuals. At my pain levels I have never reached the point where an open PF release was a viable treatment. If my pain level as some on this board I might reconsider but since I have not walked in their shoes I do not know what I would do. The only thing really new in the 8 years plus that has emerged is ESWT. I had 4 treatments with the old Orby and it did help and I will at some point go for the treatment with one of the new machines

Re: Elliott

john h on 8/23/02 at 10:13 (093315)

Pete: Having bi-laterial PF and having bi-laterial trapped nerves would in my mind defy all odds and that is exactly what happened to me. Especially if they start at the same time. My test for nerve entrapment came back positive but as the Doctor said there is no gold standard test that will positively confirm TTS. The Doctor told me it was my call whether to go for the TTS surgery. I went for it and all he found was a vericose vein in the tarsal tunnel which he removed but that was not the problem. What I accomplished is eliminating TTS as a probable cause of my pain. I still think that if you have had PF for a year and tried conservative treatments that ESWT is the best alternative available. Every once in a while I read a post from someone like Mohez who had very bad PF for a long time and he had 11 ESWT tretments in Canada with all three machines and reports that he is 'cured' and back to running and doing all the things he always did. Mohez was one of the original Ossatron 6 that went to Canada. He did not give up but pressed on. I also have come across a couple of other long time PF patients who found a way out of their misery. This board helped all of those people. The board should remain a positive place and a place to give hope and comfort. On occasion, disagreements errupt and the board is not an inspiring place to visit. We should all aspire to provide good information and inspiration when posting.

Re: Operative Results

john h on 8/25/02 at 10:36 (093471)

I read this week that Shaq of the Lakers had a Cheilectomy and hopes to be back rather quick. Shaq buddy I had one and to come back and play at the level you play at your size will take more than a couple of months depending on how much bone they removed. My lady Orthopedic Surgeon had one on her toe and she told me the day after surgery she placed her foot against a object and bent the toe upwards about 40 degrees. ouch ouch! she said other than the pain she knew she would do no damage and the quicker your start bending that toe the more flex you will have in it. I used a small rope to tie around my great toe and would pull on it sevral times a day to flex the toe up as much as my pain level would allow.

Re: Another Article on Nerve Entrapment

elliott on 8/22/02 at 13:40 (093228)

The first article in your earlier post refers to a major league baseball player batting .324 who had a successful release of the Baxter nerve (first branch of the lateral plantar nerve) and was back to full playing 8 weeks later, continuing to be one of the top batters in the majors. Then there was an NBA player who had a successful TTS release and resumed play. (Do you know who they were? The article is 10 years old.) My reservation about such cases is that they leave the impression that this is what one should typically expect, when the truth may be far from it. I'm not saying every author should heavily highlight his failures, but at the least, such success stories should be intermingled with the author's observed success rates.

------

Re: Operative Results

DJ on 8/22/02 at 15:45 (093238)

I'm not sure who that baseball player was. Mark MacGuire wasn't treated until three years after this was written. Percy Snow is the only basketball player I know thats been treated by Baxter and that was recently. I feel the same way you do about these articles making these procedures seem so simple and without risk. A search on Baxter on this message board comes up with some patients of his that weren't so lucky. How do you find out about the negative operative results? Also, does the Doctor come up with his own ideas of what a positive result is or does an outsider perform follow up surveys. I'm gonna do as much research as I can at the about operative results but I have a feeling that this message board is the only place I'll be able to find out what happens when the surgery doesn't go so well.

Re: Operative Results

john h on 8/22/02 at 18:15 (093260)

DJ: I had the Baxter procedure 3 years ago and it did not cure me but most importantly it did not make me worse. I looked at all the options and types of surgery available at the time and it seemed clear there was no surgical procedure safer than the Baxter Procedure. This is for a very simple and understandable reason. They barely cut the fascia so your foot remains stable. Probably as stable as before surgery. Traditional PF surgeries release 50% or more of the fasia often leading to foot instability, pain on the opposite side of the foot and perhaps a collapsing arch. With Baxter a very small wedge of fascia (perhaps a 1/4' moon shaped) is removed. This in fact does release some tension on the fascia but not near the release of a conventional PF release. My greatest concern was to be made worse. I asked my Doctor who was an orthopedic foot and ankle surgeon who trained under Baxter how many of his patients had been worse after surgery and he said one and that was a person who had diabetes. He has performed many of the procedures. Although it did not cure me I am certainly glad I chose that procedure because I am certainly no worse and perhaps a little better. If you observe the fascia on my foot that was operated on while stretching it you will see that it is as prominent as the foot that did not have surgery. Not so with someone who has had a 50% plus release. I think I am the only one on the board that I have seen post who has actually had the procedure. Small incision, little pain, little swelling, back in shoes in 2 weeks, stitches out in 10 days. About a 25 minute procedure. Again my reason for choosing Baxter was the far less likely possibilty of making the foot worse after surger. If Carl Lewis choose this procedure and ran again I guessed he must have researched it also.

Re: Operative Results

elliott on 8/22/02 at 21:49 (093276)

You've said all this before. I'll reiterate, you're not the only one on this board to have had this procedure. The current thinking in TTS is to do this as part of the standard TTS release; I've had it done bilaterally.

I'd agree that Baxter's or a Baxter-trained doc's success rate on the nerve named after him might be higher than for others. Of course, you're a sample size of one. Just because you came out unscathed (and still not a success) doesn't mean another would have been so lucky. In any case, we're not talking in this thread so much about a release of this nerve as part of a PF surgery, as you keep bringing up, but rather nerve releases in general (this being one of them), some more risky or in more sensitive locations, for which the article gave numerous prominent cases all successes, perhaps leaving one with an inflated sense of security. If a doc tells you that failure is a rarity for these, well, that's disingenuous.

----

Re: PS--the pods win!!!

elliott on 8/22/02 at 22:40 (093279)

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1600660&dopt=Abstract

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10881458&dopt=Abstract

---------------

Re: Elliott

Pete on 8/23/02 at 05:42 (093288)

So what's the surgical procedure for releasing the medial calcaneal nerve ?
What other nerves could be trapped other than Baxter's and mcn ?

Are you likely to have both feet affected with nerve problems and what are the symptoms ?

Both my feet are affected but I'm not convinced I have pf...no morning pain etc

Re: TTS 101

elliott on 8/23/02 at 08:12 (093298)

I'm only going to dicuss the TTS nerves. There are other main nerves on the middle and other side of your foot, but they would produce different locations for pain.

The posterior tibial nerve runs down your leg and, as it enters the tarsal tunnel located near your medial (inner) ankle, it splits into three main branches: the medial calcaneal nerve(s) (a person can have anywhere between 1 and 4 of these, with 2 and 3 by far the most common), the lateral plantar nerve, and the medial plantar nerve. It is important to consider symptoms, e.g. where is the discomfort, where does it radiate (e.g. to various toe combinations), etc. to determine which if any nerve is entrapped (the signs aren't always so clear). If one has nervy pain at medial ankle radiating to arch, heel, and toes, that sounds like classical TTS, possibly warranting the classical TTS release at the ankle area only. If one has tingling only in the lateral two toes, it could be just the lpn. If pain just in the arch, it could be just the first branch of the lpn. If the only toes affected are the 4 medial toes or sometimes 2 of them or mainly the big toe, it could be just mpn. If just the medial heel it could be just mcn. You can have combinations too. Isolating exactly where the problem is can be difficult; insufficient release is a standard reason for failure. But they can't just cut up your whole foot, for then you'll have nothing left. They should listen very carefully to your symptoms. What's causing it is real important too. I can't say what's causing yours; have you posted the details on these boards? Maybe someone can help. When it's bilateral you always have to be especially cautious as to systemic causes (bloodwork may help for this), gait and back problems.

There's a small thread still on the first page of the TTS board where Dr. Ed describes what he would do for mcn only. If mcn entrapment is originating near the medial ball of the foot, I believe they would make an incision there.

---

Re: Operative Results

DJ on 8/23/02 at 08:49 (093306)

The procedure for releasing the medial plantar nerve at the midfoot does not seem as risky as some surgical procedures either. If I were to have this procedure, I would definitely have it done by Baxter himself.
Because my symptoms are completely different than the case studies he writes about for Jogger's Foot, it makes me alittle more doubtful. Especially after another dr that trained under Baxter said he didn't think I had jogger's foot and that he would not recommend messing with the nerves. He told me he has seen bad results and he wouldn't want me to be one of them.

Re: Operative Results

john h on 8/23/02 at 09:21 (093310)

I believe Dr. Weil is the team foot doctor for the Chicago White Sox and has provided ESWT treatment to some of the team members. There are several former players for the Arkansas Razorbacks who went to Canada for ESWT one being Lee Maybury (NBA) I talk to Corliss Williamson on occason and several other NBA players (Scottie Pippin, Darrell Walker, Sydney Moncrief, Joe Klein, Derrick Fisher) who work out at the health club I attend. They tell me PF is fairly common in the NBA and that most players wear orthotics. They also said players typically try to hide their injuries from management and other players for obvious reasons

Re: Operative Results

john h on 8/23/02 at 09:55 (093313)

Elliott: I am not really sure the Baxter Procedure is considered a PF Release. If it is it is probably a misnomer as the removal of the section of fascia is to remove pressure off of the nerve and any resulting release of any fascia is just coincidental.

I have read so much on the subject that I no longer read the journals as I see nothing new coming out. We are all left with very simple choices if we have PF type pain. (1) Do all of the endless but sometimes effective methods you read about on this board (2) Do ESWT (3) Have a PF Release with either an open, MIS, or endoscope (4) Decide you may have a compressed nerve and go for TTS surgery of which you also have a choice of types of surgery. Dr. Gordon who is well known in PF and ESWT circles told me there are a group of people who will never get over PF no matter what is done. Hope I am not one of those.

Elliott you have a style of writting where by intent or accidental can be offensive. That is acceptable but it is also very true..

All of these endless articles and studies will often disagree. A point comes when you just have to make a decision based on your information and gut feeling. You can read yourself into oblivion but until you take action nothing happens.

After 8-9 years of bi-laterial life altering PF I have my personal opinion that there are multiple causes of PF Pain. PF is a medical term much like Degenerative Disc Disease which is a catch all for many problems. There is no one cure all for PF. We all got PF through various life styles and if we are to be cured or at least manage our PF it will be with what works for us as individuals. At my pain levels I have never reached the point where an open PF release was a viable treatment. If my pain level as some on this board I might reconsider but since I have not walked in their shoes I do not know what I would do. The only thing really new in the 8 years plus that has emerged is ESWT. I had 4 treatments with the old Orby and it did help and I will at some point go for the treatment with one of the new machines

Re: Elliott

john h on 8/23/02 at 10:13 (093315)

Pete: Having bi-laterial PF and having bi-laterial trapped nerves would in my mind defy all odds and that is exactly what happened to me. Especially if they start at the same time. My test for nerve entrapment came back positive but as the Doctor said there is no gold standard test that will positively confirm TTS. The Doctor told me it was my call whether to go for the TTS surgery. I went for it and all he found was a vericose vein in the tarsal tunnel which he removed but that was not the problem. What I accomplished is eliminating TTS as a probable cause of my pain. I still think that if you have had PF for a year and tried conservative treatments that ESWT is the best alternative available. Every once in a while I read a post from someone like Mohez who had very bad PF for a long time and he had 11 ESWT tretments in Canada with all three machines and reports that he is 'cured' and back to running and doing all the things he always did. Mohez was one of the original Ossatron 6 that went to Canada. He did not give up but pressed on. I also have come across a couple of other long time PF patients who found a way out of their misery. This board helped all of those people. The board should remain a positive place and a place to give hope and comfort. On occasion, disagreements errupt and the board is not an inspiring place to visit. We should all aspire to provide good information and inspiration when posting.

Re: Operative Results

john h on 8/25/02 at 10:36 (093471)

I read this week that Shaq of the Lakers had a Cheilectomy and hopes to be back rather quick. Shaq buddy I had one and to come back and play at the level you play at your size will take more than a couple of months depending on how much bone they removed. My lady Orthopedic Surgeon had one on her toe and she told me the day after surgery she placed her foot against a object and bent the toe upwards about 40 degrees. ouch ouch! she said other than the pain she knew she would do no damage and the quicker your start bending that toe the more flex you will have in it. I used a small rope to tie around my great toe and would pull on it sevral times a day to flex the toe up as much as my pain level would allow.