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TTS

Posted by Jane T on 8/25/02 at 17:39 (093496)

I have had terrible PF for 2 years, but a recent disabling flare-up in the R. foot since March.
Since July I have developed TTS. I am on neurontin 2400/day. I had ESWT in Toronto (Siemons low intensity) early August.
Does anyone know what the prognosis of TTS is? The best treatment? I went to see Dr Roger Mann (well-known foot and ankle orthopedic specialist) last week and he said that he did not know what was wrong with me. He recommended a bone scan and EMG. I still think that it is TTS.
I am an emergency physician but I am also trained as a psychiatrist. I am just trying to decide how long I should give this neuropathic pain before giving up my emergency job (and living on savings). I can't stand for more than 5 minutes currently due to the neuropathic pain.

Re: TTS

Sharon W on 8/26/02 at 10:54 (093551)

Jane,

I think some people may be a bit embarrassed or inbibited about answering you, because you're a physician, and Dr. Ed (the podiatrist who sometimes answers questions on this board) is on vacation. Perhaps others feel as I do -- a bit in awe of doctors who dedicate themselves to helping others in health emergencies, as you do.

But, I'll take a stab at it.

Have you had an NCV test for TTS?

This link from the Curtin Podiatry encyclopedia is a good one for overall information about TTS. It covers anatomy, aetiology, diagnosis (both subjective, objective, and differential), and treatments (conservative modalities, TTS release, and re-surgery).

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

The article above does not, however, address prognosis. None of the research I've done has unearthed that information. (Elliott and Wendy and Donna SL have probably all done more research than I have, and perhaps one of them will respond to your post.) But from what I've learned so far, it appears that the prognosis for TTS varies depending on the CAUSE of your TTS and the length of time TTS is present before appropriate treatment is underway.

The cause of your TTS is also a factor in which treatment is likely to be most effective. If you're a pronator, or have a very low arch (pes planus), orthotics may be indicated. If your problem is varicose veins, compression hose might be an effective treatment. If you have a space-occupying lesion (which would hopefully show up on an MRI with illumination of the foot and ankle, or on a diagnostic ultrasound such as those used in conjunction with the Dornier EPOs), surgery has is more likely to be successful. If you have developed adhesions, sometimes PT and/or specialized massage techniques such as ART can be very effective. If the problem is tenosynovitis, or some sort of more generalized inflammatory condition, then of course it is very important to address the inflammation problem. (But, you probably knew all of that.)

I do understand about neuropathic pain, how excruciating and how disabling it can be. And I know how much worse it can feel when you have to be on your feet a lot, standing and walking on the brutal tile-covered concrete floors of a hospital. Unfortunately, I know of nothing that will SOLVE that dilemma for you. I'm sure you have already been looking for ways to catch a moment to sit down and rest your feet -- every moment helps a little -- but I'm sure sometimes that's impossible with a job like yours.

Concerning pain control: Ed Davis, DPM recently posted the following, on this TTS board. The post title is 'Re: 1200 mg Neurontin the first day? Wild!'
'The combination of Ultram or Ultracet (ultram with tylenol) with Neurontin is becoming very popular for neurogenic pain. The primary side effect of high doses of ultram is seizures but neurontin is an anti-seizure drug (official FDA 'on label' use).'

Sharon

Re: TTS

Missy B on 8/26/02 at 16:40 (093595)

Jane,
I am not sure what the best treatment may be for TT and I have seen wide percentage rates for success from both the non-invasive treatments such as ESWT and the surgical release. Sharon has passed on to you some very helpful information and I am sure, being a doctor, you have many resources available to you. I can only relate to you my own personal experience with TT/PF and my successful (so far) outcome.
I am a medical technologist in a very busy hospital laboratory and spend almost my entire shift on my feet. I put up with foot pain on and off for 6 years, but last year, the pain became so intense in my right foot that by the end of my shift, I was dragging my leg so I did not have to pick up my foot and step down on it. I went to a very good Pod. who tried all the non-invasive treatments - stretching, taping, cortisone shots, orthotics, night splints, and drugs (unfortunately, I developed an allergy to neurontin, so I could not stay on it). After all of these failed to give me any substantial relief, he sent me to a neurologist to have a NCV test, which came back a glaring positive for TT nerve entrapment. He gave me several choices - basically, learn to manage the pain, quit my job and change my lifestyle, or try the surgery.
I could not afford to quit my job, and after 32 years in the medical field, I was not really trained for anything else, so I opted for the surgery. I was able to speak with some patients who had had successful release surgery and I got lots of tips on how to manage my recovery. My Pod had a good success rate with this surgery and he is very conservative, so I felt my chances were a little better than average.
I had my surgery last January and was off work for 9 weeks. I started back part-time for 2 weeks and then went full-time again. I had 4 weeks of physical therapy and I continue to curtail my outside activities, so that I do not over-stress my foot, as he said it could take up to one year for total healing. I am now 7+ months post-op and happy to say that I am 90%+ improved over my presurgery pain. I go thru my whole day at work, often with no or just minor discomfort. I ride my horses several times a week and exercise 3 days a week (no high impact aerobics). I wear custom made orthotics in my athletic shoes at work, and around the house, I usually have a pair of Birkenstocks on.
You will read many stories on this board of unsuccessful surgeries that have left people in worse condition than before the surgery. What makes the difference between success and crippling pain, I am not sure, but just as each individual is unique, each person suffering from foot pain must make up their own mind as to what course is best for them. But whatever your choice, do as much research as you can, seek the opinion of several doctors, and try to talk with some patients who have been treated for TT if possible.
Sorry I have rambled on so long, but I wanted you to know that there are success stories on this board, for both non-invasive and surgical treatment - you just have to look for them. I wish you good luck and hope that you are able to find relief from your foot pain.
Missy B.

Re: TTS

Jane T on 9/10/02 at 22:49 (094972)

What was the origin of your TTS? Was it biomechanical, mass, venous. . . ?

Re: TTS

Sharon W on 8/26/02 at 10:54 (093551)

Jane,

I think some people may be a bit embarrassed or inbibited about answering you, because you're a physician, and Dr. Ed (the podiatrist who sometimes answers questions on this board) is on vacation. Perhaps others feel as I do -- a bit in awe of doctors who dedicate themselves to helping others in health emergencies, as you do.

But, I'll take a stab at it.

Have you had an NCV test for TTS?

This link from the Curtin Podiatry encyclopedia is a good one for overall information about TTS. It covers anatomy, aetiology, diagnosis (both subjective, objective, and differential), and treatments (conservative modalities, TTS release, and re-surgery).

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

The article above does not, however, address prognosis. None of the research I've done has unearthed that information. (Elliott and Wendy and Donna SL have probably all done more research than I have, and perhaps one of them will respond to your post.) But from what I've learned so far, it appears that the prognosis for TTS varies depending on the CAUSE of your TTS and the length of time TTS is present before appropriate treatment is underway.

The cause of your TTS is also a factor in which treatment is likely to be most effective. If you're a pronator, or have a very low arch (pes planus), orthotics may be indicated. If your problem is varicose veins, compression hose might be an effective treatment. If you have a space-occupying lesion (which would hopefully show up on an MRI with illumination of the foot and ankle, or on a diagnostic ultrasound such as those used in conjunction with the Dornier EPOs), surgery has is more likely to be successful. If you have developed adhesions, sometimes PT and/or specialized massage techniques such as ART can be very effective. If the problem is tenosynovitis, or some sort of more generalized inflammatory condition, then of course it is very important to address the inflammation problem. (But, you probably knew all of that.)

I do understand about neuropathic pain, how excruciating and how disabling it can be. And I know how much worse it can feel when you have to be on your feet a lot, standing and walking on the brutal tile-covered concrete floors of a hospital. Unfortunately, I know of nothing that will SOLVE that dilemma for you. I'm sure you have already been looking for ways to catch a moment to sit down and rest your feet -- every moment helps a little -- but I'm sure sometimes that's impossible with a job like yours.

Concerning pain control: Ed Davis, DPM recently posted the following, on this TTS board. The post title is 'Re: 1200 mg Neurontin the first day? Wild!'
'The combination of Ultram or Ultracet (ultram with tylenol) with Neurontin is becoming very popular for neurogenic pain. The primary side effect of high doses of ultram is seizures but neurontin is an anti-seizure drug (official FDA 'on label' use).'

Sharon

Re: TTS

Missy B on 8/26/02 at 16:40 (093595)

Jane,
I am not sure what the best treatment may be for TT and I have seen wide percentage rates for success from both the non-invasive treatments such as ESWT and the surgical release. Sharon has passed on to you some very helpful information and I am sure, being a doctor, you have many resources available to you. I can only relate to you my own personal experience with TT/PF and my successful (so far) outcome.
I am a medical technologist in a very busy hospital laboratory and spend almost my entire shift on my feet. I put up with foot pain on and off for 6 years, but last year, the pain became so intense in my right foot that by the end of my shift, I was dragging my leg so I did not have to pick up my foot and step down on it. I went to a very good Pod. who tried all the non-invasive treatments - stretching, taping, cortisone shots, orthotics, night splints, and drugs (unfortunately, I developed an allergy to neurontin, so I could not stay on it). After all of these failed to give me any substantial relief, he sent me to a neurologist to have a NCV test, which came back a glaring positive for TT nerve entrapment. He gave me several choices - basically, learn to manage the pain, quit my job and change my lifestyle, or try the surgery.
I could not afford to quit my job, and after 32 years in the medical field, I was not really trained for anything else, so I opted for the surgery. I was able to speak with some patients who had had successful release surgery and I got lots of tips on how to manage my recovery. My Pod had a good success rate with this surgery and he is very conservative, so I felt my chances were a little better than average.
I had my surgery last January and was off work for 9 weeks. I started back part-time for 2 weeks and then went full-time again. I had 4 weeks of physical therapy and I continue to curtail my outside activities, so that I do not over-stress my foot, as he said it could take up to one year for total healing. I am now 7+ months post-op and happy to say that I am 90%+ improved over my presurgery pain. I go thru my whole day at work, often with no or just minor discomfort. I ride my horses several times a week and exercise 3 days a week (no high impact aerobics). I wear custom made orthotics in my athletic shoes at work, and around the house, I usually have a pair of Birkenstocks on.
You will read many stories on this board of unsuccessful surgeries that have left people in worse condition than before the surgery. What makes the difference between success and crippling pain, I am not sure, but just as each individual is unique, each person suffering from foot pain must make up their own mind as to what course is best for them. But whatever your choice, do as much research as you can, seek the opinion of several doctors, and try to talk with some patients who have been treated for TT if possible.
Sorry I have rambled on so long, but I wanted you to know that there are success stories on this board, for both non-invasive and surgical treatment - you just have to look for them. I wish you good luck and hope that you are able to find relief from your foot pain.
Missy B.

Re: TTS

Jane T on 9/10/02 at 22:49 (094972)

What was the origin of your TTS? Was it biomechanical, mass, venous. . . ?