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Telling The Difference Between PF and TTS

Posted by Anna on 12/10/02 at 15:18 (102590)

How can I tell if I have PF or TTS? How do the symptoms differ? I have pain when I run. The pain seems to be in the inside part of my foot.Also, if I stand too long, I get what I call 'hot heels'. My heels get warm and painful and i have to ice them. All this has started up in the past few mths for me. I took up serious running about 7 mths ago, and I am thinking that is why i have the foot pain.Is tts anything like a repetitive stress injury, like carpal tunnel can be? My wrists act up if I spend too much time on the computer, or if I lift weights that are too heavy.I get all the symptoms- the numbness and tingling in the wrists. It seems I am predisposed to repetitive stress and ligament and tendon problems since I was about 20. I started becoming athletic around that age for weight control. And now I am 27, and I feel as if all my parts are wearing out LOL. Something is always hurting or aching. I have been tested for rheumatoid arthritis. The 1st time it came up positive. But then I had the test another time and it was negative. My family dr. said I may have something called 'sero-negative rheumatoid arthritis' Has anyone ever heard of this, b/c I sure havent. Presently I dont have insurance, so I cant get to a dr. for this foot problem. How does a dr diagnose tts . How does the dr know if its tts or pf?
Thanks
Anna

Re: Telling The Difference Between PF and TTS

Sharon W on 12/10/02 at 15:54 (102595)

Anna,

Look at the top of this message board. There is a link for Steve's tarsal tunnel syndrome web site. It describes what Tinel's Sign is -- that's one of the tests that doctors use to figure out whether your problem is TTS or not. There is also a link to the FAQ that Wendy put together -- it might help you to figure out the answer to your question.

I hate to tell you this, though -- neither of these problems are the kind of thing where you can just ignore it and hope it will go away. You really need to see a podiatrist or an orthopedic foot and ankle specialist.

Sharon

Re: Telling The Difference Between PF and TTS

sheila on 12/11/02 at 00:38 (102662)

Just from personal experience, my family doc and podiatrist thought I had pf at first. I had heel pain. It was worse in the mornings and when I stood up. Then, other symptoms developed (tingling, redness, arch pain)and was sent for a nerve conduction test. The results indicated that I had tts.

Physical therapy for tts was not helpful. I am now going to try custom made orthotics. My podiatrist just had a pair made for me.

hth

Re: Telling The Difference Between PF and TTS

Lara T on 12/11/02 at 06:55 (102673)

Sharon's right that Tinel's sign is a good indication. I don't think it's necessary however (as I don't believe I have Tinel's sign, and I have had an NCV test come out positive for TTS, and fit many other of the symptoms). I believe the gold standard for determining TTS is the NCV test - which requires a neurologist - perhaps a bit pricey without insurance. Many people (but not all, don't even know if it's a majority) with TTS start out with a PF diagnosis, which makes it really hard to tell sometimes - at least initially. Based on comments from the doctors on this board, I believe the following statement is not ALWAYS true, but is frequently true. My podiatrist said that any PF that doesn't go away in a year is probably TTS. - However, that takes a year of treatment. I don't know if he refers for an NCV test earlier (I imagine it depends on the history and presenting symptoms) - I found him after 3 years of searching and being told all kinds of stuff, including it was in my head so he sent me for the NCV test immediately.

Sharon is also right, neither goes away by itself. REst is good for both (easier said than done!) NSAIDS help for both. There is someone who posted recently on how he was able to cure himself of PF. I don't believe that is even possible with TTS without surgery (although there are treatments that give people enough of a life that they decide against surgery, which has significant risks).

Re: Telling The Difference Between PF and TTS - better without surgery?

kellys on 12/11/02 at 08:14 (102680)

A quick counterpoint to Lara's comment about recovering from TTS without surgery - Although I've had battled with a relatively severe case of PF/TTS for about 2.5 years, I am finally getting better from both without surgery. Since I am young and used to be (and want to again be) quite active, I have tried to avoid surgery, and thus have pursued most of the non-surgical options. ESWT (2X), about 6 pairs of custom orthotics, NSAIDS, rest, ice (still, almost daily), stretching, PT, cortisone shots both in heel and TT area, taping, etc. This summer I had unbearable aching/burning up well into the lower legs, and out of desperation consulted a neuromuscular therapist(NMT) in my area. I believe the combination of some pretty terrific regular massage (neuromuscular) therapy and good timing after some recent cortisone shots and better orthotics have really contributed to my progress. In my opinion, the NMT helped me break the cycle of muscle tension/pain/walking funny and allowed me to _start_ (and I emphasize, just _start_) to get back to some activity which in turn increased blood flow to the area with the possible effect of promoting healing.

I'm not back to running and may never be, but I am now up and about on my feet most of the day with minimal(tolerable) if any pain. Still VERY careful with what shoes I wear and how much unnecessary walking or standing I do, but I've even been on the elliptical trainer a few times recently without pain. Cycling when possible throughout the rest of the ordeal - it was easier to get around on a bike than on foot, frankly.

The hardest part is that I want to heal faster. If nothing else, I am learning or exercising my patience in appreciating the small victories and not pushing too much.

This was no mild case, I assure you. And no, it doesn't go away by itself. I think it would never have gotten so bad if I'd gotten treated as soon as PF set in, but I waited 9 months and ran on it regularly. But being creative with the options seems to be paying off now.

The non-surgical option isn't for everyone, but nor is the surgical option. Just wanted to present one case of good progress without surgery..

Re: Telling The Difference Between PF and TTS - better without surgery?

Carl D. on 12/11/02 at 09:29 (102695)

Kelly, Thanks so much for posting your experience. I agree with you and hope people don't read Lara's and believe TTS is incurable without surgery. I have just started PT, but it definitely helped, as has acupuncture for the pain. I think you're right about not necessarily being able to get back to the activity levels many of us had prior to TTS, but I have not read many posts on this board from people who think their surgery was completely successful. In fact, many seem to regret having surgery. Please keep us posted on your progress, and anyone else who is trying these non-surgical things (successful or not) please let us know your experiences.

Carl

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 10:58 (102711)

Carl,

Whether surgery is right for someone, or not, often depends on what CAUSED the TTS. If something shows up on an MRI, if there is a THING for the surgeon to go in and REMOVE from the tarsal tunnel area, most doctors who treat this condition (and this is supported by research) say that surgery is more likely to be successful. (And conservative measures CANNOT remove something like a cyst, or varicose veins, that have built up pressure inside your tarsal tunnel.) But there is some disagreement, even among foot and ankle specialists, about whether surgery is a good idea otherwise.

There is also considerable variability in what 'conservative treatments' are available to people with TTS. Not everyone can afford accupuncture or specialized massage therapy, for example -- and most insurance plans will not pay for them. Some insurance will not even pay for physical therapy, but they WILL authorize surgery.

Especially if nothing has shown up on a diagnostic ultrasound or an MRI that can be taken out, most specialists do prefer to wait until all of the 'conservative treatments' that are available to a TTS patient have been tried before even considering surgery. If another treatment is successful, EVEN WHEN IT'S NOT 100% SUCCESS, surgery probably isn't even offered. I agree with that policy, because TTS surgery is risky and painful, and the recovery time is long. But by the time all those other treatments have been unsuccessful, the TTS is usually pretty far along! To a person still in pain and desperate for relief, who has already tried all the other treatments available to them, surgery is the only hope. And I can tell you from experience, a 70% chance of feeling 80% better after 6 months, sounds VERY good in that situation.

Kelly is not the only person to have posted that she got relief from her TTS using 'conservative measures,' In fact, if you do a search on Lara's name, you will find that she found something besides surgery that helped her, too. And there are others, who have stopped posting. MOST of the people who get better (whether they have had surgery or not) soon get bored with the foot boards and just go on with their lives.

It is appropriate for ANYONE with TTS to post about their experiences on this board, whether they have chosen surgery or not, and whether the things they have tried have worked out well for them or not. We try to help each other if we can, whether it is by providing information or by understanding someone's pain and frustration and discouragement.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Carl D. on 12/11/02 at 11:10 (102713)

Sharon, I think you are misreading my post. I was not saying surgery is to be avoided at all costs. I was merely stating a view that Lara post suggests only surgery can cure TTS. She stated: 'There is someone who posted recently on how he was able to cure himself of PF. I don't believe that is even possible with TTS without surgery (although there are treatments that give people enough of a life that they decide against surgery, which has significant risks). ' To me that suggests that surgery is the only answer to TTS. I'm sure in some cases, it is better than living with the pain. However, some people might be less willing to pursue non-surgical treatments if they read that and think surgery is the only way. Finally, please do not imply that I was trying to sensor some views on this board! I in no way suggested that.
Carl

Re: Telling The Difference Between PF and TTS - better without surgery?

Sharon W on 12/11/02 at 11:19 (102715)

Kelly,

Thanks for your comments. I hope you'll keep getting better and better without ever having to resort to surgery!

I know of someone else with a bad case of TTS who got GREAT results from specialized massage -- in her case it was ART (I believe that stands for Active Release Techniques).

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 11:51 (102724)

Carl,

Your comment, 'Please keep us posted on your progress, and anyone else who is trying these non-surgical things (successful or not) please let us know your experiences,' did not include those who have chosen surgery, or those who have HAD surgery. I simply made a point of including everyone. I did not intend to imply anything about you or your opinions. I meant no offense, and I am sorry if offense was taken.

My defense of Lara's comments was based on the fact that I know her history and I think I know what she meant. I don't believe there is ANY treatment for TTS that truly offers a 'cure,' except perhaps in a few of the cases where something is successfully removed from the tarsal tunnel. For most of us, 'successful' treatment (whether it's conservative or surgical) means that we will still have to be careful for the rest of our lives, and in many cases will have to continue wearing orthotics, or the TTS could come back. And many people will also have to live with a certain level of discomfort.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Carl D. on 12/11/02 at 12:05 (102725)

Geez Sharon, you really do read too much into my comments. You are obviously trying to support people who have had or will have surgery. I have nothing against that. I am trying to encourage those who are still trying to avoid surgery to post their experiences. That in no way suggests that anyone else should NOT post their experiences (surgical or otherwise). Keep in mind that there may be treatments in the future that will, in fact, cure TTS, but having surgery may eliminate that future for you. You didn't seem to have a problem with Kelly posting her positive experience with trying everything she could to avoid surgery. All I was doing was thanking her for taking the time to post that and to encourage others like us who are doing the same. End of story.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 13:08 (102726)

Carl,

I support EVERYONE who has TTS. And I certainly support YOU in trying to avoid surgery. You are doing the right thing. I tried to avoid surgery too, and I really hope you'll have more success than I did. If someone who hasn't tried any of the other treatments has found a gung-ho surgeon and is talking about having surgery, I try to persuade them to give other things a try first. That doesn't happen all that often because most doctors don't even OFFER surgery until other treatments have failed.

You are right, though, that I am especially interested in those who have chosen surgery -- just as you are especially interested in other people who are trying to avoid it. I don't want anyone going into TTS surgery blind to its risks and its questionable prognosis. And I do try to warn them. But I also tell them that MOST TTS surgeries are successful. Because, as you said, 'I have not read many posts on this board from people who think their surgery was completely successful. In fact, many seem to regret having surgery.'

Reading this board does tend to discourage people who are facing TTS surgery and have come here looking for help, most of whom have already tried the usual conservative treatments and surgery is their one remaining hope. So, I offer them my support.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/11/02 at 13:30 (102728)

An important point here - Sharon had something in the tunnel that was removed (if I recall correctly). This greatly increases the chances of success.

The surgical results if there is NO mass are much worse.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 15:52 (102737)

Wendy,

You're right, I did. Six varicose veins.

Sharon

Re: Telling The Difference Between PF and TTS

Lara T on 12/11/02 at 18:16 (102759)

If I'm mistaken (about their being no cure for TTS without surgery, as opposed to treatments) I will be thrilled to be corrected. What are the cures? I would love to get back on the tennis court!

Re: Telling The Difference Between PF and TTS - better without surgery?

Lara T on 12/11/02 at 18:44 (102768)

I'm curious about your diagnosis and treatment. Can you tell me more.

How do you know you have PF & TTS (I believe you, I just want to figure out how what you have is different from what I have so I can figure out how best to apply your experience making decisions for me).

I'm curious about ESWT because I considered ESWT for my TTS until one of the doctors on the board said it wasn't appropriate for TTS, although it was for PF. I live close enough to the Canadian border that it would be feasible for me, and I'd love to find a cure - or a treatment that let me play tennis.

I'm curious about massage too as I receive massage regularly, and actually printed some notes from this board for my massage therapist - and then my neck/shoulders started acting up badly so my TTS (which is under control but not cured) took a back seat to my neck problems.

Thanks for any light you can shed on these things.

Re: Telling The Difference Between PF and TTS - better without surgery?

kellys on 12/16/02 at 13:07 (103301)

Lara

If you were addressing me - I knew I had PF because I had all the classic symptoms (sharp heel pain, tending to be worst in the AM, focused at the PF attachment point, some relief from icing the heel area, etc.). I had the ESWT before I knew anything about TTS, so my decision to pursue that was solely based on the PF diagnosis. Somewhere along the line, even before the ESWT, I started to get nasty burning and tingling all through the foot and well up into the leg, bilaterally. But I just thought it was all part of the PF. Eventually, several months after my second ESWT, I realized that I was icing the inner ankle more than the heel because that's where it hurt and where the icing seemed to be more effective. And that the heel wasn't so sensitive anymore, now it was the inner ankle and up into the calf. Basically, the pain shifted both in location and in character. Finally I learned about TTS and this diagnosis was confirmed by several new podiatrists and a neurologist.

The massage is relatively intense, and she works mostly on my legs. The therapist was able to dig deep into the calf area and start to break up some very painful tightness and over time, this, coupled with everything else, seemed to help reduce the pain. She works on my feet at our discretion, and has been careful not to overstretch the PF, since I've found that overstretching can bring the PF symptoms back. The massage can be extremely painful at times. I am also careful to listen to my body regarding what she can and can't do to my feet and TT area, but overall it has helped a lot.

I'm still not sure I'd even consider tennis, though! I am reintroducing weight-bearing activity pretty slowly. Painfully slowly, it seems, but there is progress. Particularly if I look at where I was 5 months ago. But tennis, running, and many other weight-bearing aerobic activities are still a ways off. I'd be very hesitant to do anything where I had to jump around or switch directions quickly since that seems to annoy the PF. On a positive note, I've found some alternate activities and have started recently to increase the intensity and duration of those activities.

Re: Surgery AFTER conservative treatment fails for TTS

LibbyD on 12/25/02 at 08:50 (103963)

OK, I have some questions, maybe someone can direct me, as I am new to the board and don't often have alot of time to dig up the answers.
OH! Sorry, Merry Christmas to all!
OK, first, what is PF? I have seen it several times but don't know what you are talking about.
I have had TTS (if that is what it is) for several months now, 3 different DR's, 3 different diagnosis. First one said I have arthritis in my big toe joint (yeah, right!), the other said I havePlantar Fascitis, this last one is the one that says I have TTS, he is a podiatrist that specializes in diabetic foot problems, I don't have diabeties or rheumatoid, at least the tests were negative but I do have an elevated sed rate. Ok, the only thing this DR has done was a NCT and orthotics, which I love and they did help for about 3 weeks but now the pain is back, I am going next week for another nerve conduction test, this is the test where they use the 'fork' thing. From what I have been reading, it seems that everyone goes to a neurologist for this test??
I am really sensitive to NSAIDs, they all make me sick, I am now trying Bextra, don't see any diff, though.
I also have alot of lower back problems, he said that I need to have that corrected in conjunction with the foot thing. He said that maybe the orthotics are working and that in the process of my nerves healing, the pain is indicative of healing (?). Well, he also said that if not better in another month, he would elect for surgery.
What I want to know, is what is everyone trying before surgery??? And should I be having an MRI or something before jumping into surgery??
He also told me that in surgery, there would be 2 cuts in the foot area, and one cut just around the bottom of the outside of the knee (?) I haven't heard anyone mention a cut in this area?? Any ideas or comments?
A lady that I work with has had this surgery done, she is diabetic, she didn't have the severe pain that I have but she had numbness. I don't have any numbness but my pain is almost unbearable.
Should I try a cortisone injection or something?? I'm deathly afraid of steroids but am now at the point to where I'll do anything, I'm tired of the pain up my legs day in and day out.
The lady did say though, that her surgery was not painful, maybe for a day or so then she was fine.
If anyone happens to see this, please direct me into the right direction so I can see what other treatment options are for this. It's getting harder to get up and go to work everyday.
Also, I have a sit-down job, so I was wondering if it has anything to do with standing on your feet all day at a job.
I also don't recall having an injury that has caused me to have this, they just began to ache and got worse and worse.
Thanks, Libby

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/25/02 at 09:46 (103972)

PF is plantar facaetis, one of the things you said you've been diagnosed with. Many people have BOTH PF and TTS, and it is usually PF that comes first. One of the doctors who posts here has said that he believes this is because both problems are often caused by the same biomechanical faults. Did you receive any treatment(s) for plantar facaetis?

An MRI or a diagnostic ultrasound of your feet would be a very good idea, to help rule out the possiblilty that you have something IN there to take out. These tests don't ALWAYS find it if there's something unusual in your tarsal tunnel -- varicose veins inside the tarsal tunnel are not uncommon and many times an MRI doesn't 'see' them. (It did, in my case, but that's probably because I had SIX of them...)

I would certainly give both physical therapy and steroid injections (into the tarsal tunnel area) a try, before even CONSIDERING tarsal tunnel surgery. The surgery is painful and the recovery period afterward is LONG and FRUSTRATING and usually quite painful.

Wendy and I disagree, to some extent. I think it's clear that a majority of studies have shown TTS to be surgery in MOST cases where it had been correctly diagnosed in the first place, whether there was a 'space-occupying lesion' (a THING to take out) in the tarsal tunnel or not. Of course, TTS surgery will NOT help if the real problem was a pinched nerve in your back, or arthritis, or anything else besides a true entrapment/compression of your posterior tibial nerve. That's why it's absolutely MANDATORY to have the tests before ever even THINKING about surgery.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 12:00 (104030)

Sharon - I'm not sure if we disagree or not, I agree that TTS surgery can be very succesful if there is something in the tunnel to remove. I don't believe the surgery works well if there isn't anything in the tunnel to fix or remove. I'm not sure if that's what you said as well?

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 12:59 (104036)

Wendyn,

I suspect we would agree that TTS surgery is often appropriate when there is something known to be inside the tarsal tunnel that needs to be taken out. And from reading these boards, it's apparent that TTS surgery is done MUCH TOO OFTEN without all the appropriate tests being done first -- in that respect, I imagine you and I would agree as well.

But I do think we disagree about this: I'm convinced there ARE times when TTS surgery works well even though there isn't any specific space-occupying lesion in the tarsal tunnel (indicating that the CAUSE of the TTS is 'idiopathic,' or unknown).

I believe a TTS release done WITHOUT something known to be in the tunnel is appropriate ONLY AFTER all the other possible treatments have failed, and ONLY assuming that nerve conduction tests were clearly positive for TTS that the patient also shows the appropriate clinical signs -- and ONLY AFTER all applicable tests and examinations have been done to rule out systemic causes, PN, sciatica, back problems, circulation problems OTHER than varicosities in the tarsal tunnel, etc.

When TTS surgeries fail, I believe it is more common for them to do so BECAUSE THEY WERE MISDIAGNOSED (or at least incompletely diagnosed) in the first place, than because the cause was idiopathic (maybe related to swelling of unknown origin) and there was nothing IN the tarsal tunnel to take out. If most of the 'nervy' symptoms attributed to TTS were actually caused by something ELSE, it would be very unlikely for a TTS release to 'fix' the problem.

My point about varicose veins in the tarsal tunnel was that they often are not 'seen' by an MRI anyway, so swollen veins might be an example of a situation where there IS actually something in there but nothing shows up on the tests.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 14:48 (104038)

Sharon - I think we agree more than we don't. I agree that all conservative options should be tried - and then if the surgeon and the patient agree that nothing else can be done, surgery is an option (even if nothing is known to be in the tunnel). In these cases, it can be exploratory if nothing else....but patients also need to understand that the surgery can actually make them worse.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 19:43 (104068)

Wendyn,

Doctors should ALWAYS explain to their patients that TTS surgery can make them worse, when it's time to discuss the surgical option(s). Even when something is in the tarsal tunnel that can be taken out, there are risks of excessive scar tissue formation, of neuroma formation, etc. It is definitely a risky procedure, and not one to be done without all due consideration.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 19:48 (104069)

You're right Sharon, but we see an awful lot of people come through here who seem to have a 'it can't hurt' attitude.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 20:01 (104072)

I agree. Many people are used to think of surgery as a (painful and expensive) 'quick-fix solution' to medical problems, and so naturally they assume that THIS surgery is like that too. (I mean, good grief, people even think of HEART BYPASS surgery these days as 'routine'!!)

I think the same argument could be made about PF surgery. THAT one certainly isn't risk-free, either, and yet it is done all the time without exhausting conservative options first. People just do not think of surgery as something that can make them WORSE. They think that if the operation itself doesn't kill them, it will make them BETTER...

Sharon

Re: Telling The Difference Between PF and TTS

Sharon W on 12/10/02 at 15:54 (102595)

Anna,

Look at the top of this message board. There is a link for Steve's tarsal tunnel syndrome web site. It describes what Tinel's Sign is -- that's one of the tests that doctors use to figure out whether your problem is TTS or not. There is also a link to the FAQ that Wendy put together -- it might help you to figure out the answer to your question.

I hate to tell you this, though -- neither of these problems are the kind of thing where you can just ignore it and hope it will go away. You really need to see a podiatrist or an orthopedic foot and ankle specialist.

Sharon

Re: Telling The Difference Between PF and TTS

sheila on 12/11/02 at 00:38 (102662)

Just from personal experience, my family doc and podiatrist thought I had pf at first. I had heel pain. It was worse in the mornings and when I stood up. Then, other symptoms developed (tingling, redness, arch pain)and was sent for a nerve conduction test. The results indicated that I had tts.

Physical therapy for tts was not helpful. I am now going to try custom made orthotics. My podiatrist just had a pair made for me.

hth

Re: Telling The Difference Between PF and TTS

Lara T on 12/11/02 at 06:55 (102673)

Sharon's right that Tinel's sign is a good indication. I don't think it's necessary however (as I don't believe I have Tinel's sign, and I have had an NCV test come out positive for TTS, and fit many other of the symptoms). I believe the gold standard for determining TTS is the NCV test - which requires a neurologist - perhaps a bit pricey without insurance. Many people (but not all, don't even know if it's a majority) with TTS start out with a PF diagnosis, which makes it really hard to tell sometimes - at least initially. Based on comments from the doctors on this board, I believe the following statement is not ALWAYS true, but is frequently true. My podiatrist said that any PF that doesn't go away in a year is probably TTS. - However, that takes a year of treatment. I don't know if he refers for an NCV test earlier (I imagine it depends on the history and presenting symptoms) - I found him after 3 years of searching and being told all kinds of stuff, including it was in my head so he sent me for the NCV test immediately.

Sharon is also right, neither goes away by itself. REst is good for both (easier said than done!) NSAIDS help for both. There is someone who posted recently on how he was able to cure himself of PF. I don't believe that is even possible with TTS without surgery (although there are treatments that give people enough of a life that they decide against surgery, which has significant risks).

Re: Telling The Difference Between PF and TTS - better without surgery?

kellys on 12/11/02 at 08:14 (102680)

A quick counterpoint to Lara's comment about recovering from TTS without surgery - Although I've had battled with a relatively severe case of PF/TTS for about 2.5 years, I am finally getting better from both without surgery. Since I am young and used to be (and want to again be) quite active, I have tried to avoid surgery, and thus have pursued most of the non-surgical options. ESWT (2X), about 6 pairs of custom orthotics, NSAIDS, rest, ice (still, almost daily), stretching, PT, cortisone shots both in heel and TT area, taping, etc. This summer I had unbearable aching/burning up well into the lower legs, and out of desperation consulted a neuromuscular therapist(NMT) in my area. I believe the combination of some pretty terrific regular massage (neuromuscular) therapy and good timing after some recent cortisone shots and better orthotics have really contributed to my progress. In my opinion, the NMT helped me break the cycle of muscle tension/pain/walking funny and allowed me to _start_ (and I emphasize, just _start_) to get back to some activity which in turn increased blood flow to the area with the possible effect of promoting healing.

I'm not back to running and may never be, but I am now up and about on my feet most of the day with minimal(tolerable) if any pain. Still VERY careful with what shoes I wear and how much unnecessary walking or standing I do, but I've even been on the elliptical trainer a few times recently without pain. Cycling when possible throughout the rest of the ordeal - it was easier to get around on a bike than on foot, frankly.

The hardest part is that I want to heal faster. If nothing else, I am learning or exercising my patience in appreciating the small victories and not pushing too much.

This was no mild case, I assure you. And no, it doesn't go away by itself. I think it would never have gotten so bad if I'd gotten treated as soon as PF set in, but I waited 9 months and ran on it regularly. But being creative with the options seems to be paying off now.

The non-surgical option isn't for everyone, but nor is the surgical option. Just wanted to present one case of good progress without surgery..

Re: Telling The Difference Between PF and TTS - better without surgery?

Carl D. on 12/11/02 at 09:29 (102695)

Kelly, Thanks so much for posting your experience. I agree with you and hope people don't read Lara's and believe TTS is incurable without surgery. I have just started PT, but it definitely helped, as has acupuncture for the pain. I think you're right about not necessarily being able to get back to the activity levels many of us had prior to TTS, but I have not read many posts on this board from people who think their surgery was completely successful. In fact, many seem to regret having surgery. Please keep us posted on your progress, and anyone else who is trying these non-surgical things (successful or not) please let us know your experiences.

Carl

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 10:58 (102711)

Carl,

Whether surgery is right for someone, or not, often depends on what CAUSED the TTS. If something shows up on an MRI, if there is a THING for the surgeon to go in and REMOVE from the tarsal tunnel area, most doctors who treat this condition (and this is supported by research) say that surgery is more likely to be successful. (And conservative measures CANNOT remove something like a cyst, or varicose veins, that have built up pressure inside your tarsal tunnel.) But there is some disagreement, even among foot and ankle specialists, about whether surgery is a good idea otherwise.

There is also considerable variability in what 'conservative treatments' are available to people with TTS. Not everyone can afford accupuncture or specialized massage therapy, for example -- and most insurance plans will not pay for them. Some insurance will not even pay for physical therapy, but they WILL authorize surgery.

Especially if nothing has shown up on a diagnostic ultrasound or an MRI that can be taken out, most specialists do prefer to wait until all of the 'conservative treatments' that are available to a TTS patient have been tried before even considering surgery. If another treatment is successful, EVEN WHEN IT'S NOT 100% SUCCESS, surgery probably isn't even offered. I agree with that policy, because TTS surgery is risky and painful, and the recovery time is long. But by the time all those other treatments have been unsuccessful, the TTS is usually pretty far along! To a person still in pain and desperate for relief, who has already tried all the other treatments available to them, surgery is the only hope. And I can tell you from experience, a 70% chance of feeling 80% better after 6 months, sounds VERY good in that situation.

Kelly is not the only person to have posted that she got relief from her TTS using 'conservative measures,' In fact, if you do a search on Lara's name, you will find that she found something besides surgery that helped her, too. And there are others, who have stopped posting. MOST of the people who get better (whether they have had surgery or not) soon get bored with the foot boards and just go on with their lives.

It is appropriate for ANYONE with TTS to post about their experiences on this board, whether they have chosen surgery or not, and whether the things they have tried have worked out well for them or not. We try to help each other if we can, whether it is by providing information or by understanding someone's pain and frustration and discouragement.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Carl D. on 12/11/02 at 11:10 (102713)

Sharon, I think you are misreading my post. I was not saying surgery is to be avoided at all costs. I was merely stating a view that Lara post suggests only surgery can cure TTS. She stated: 'There is someone who posted recently on how he was able to cure himself of PF. I don't believe that is even possible with TTS without surgery (although there are treatments that give people enough of a life that they decide against surgery, which has significant risks). ' To me that suggests that surgery is the only answer to TTS. I'm sure in some cases, it is better than living with the pain. However, some people might be less willing to pursue non-surgical treatments if they read that and think surgery is the only way. Finally, please do not imply that I was trying to sensor some views on this board! I in no way suggested that.
Carl

Re: Telling The Difference Between PF and TTS - better without surgery?

Sharon W on 12/11/02 at 11:19 (102715)

Kelly,

Thanks for your comments. I hope you'll keep getting better and better without ever having to resort to surgery!

I know of someone else with a bad case of TTS who got GREAT results from specialized massage -- in her case it was ART (I believe that stands for Active Release Techniques).

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 11:51 (102724)

Carl,

Your comment, 'Please keep us posted on your progress, and anyone else who is trying these non-surgical things (successful or not) please let us know your experiences,' did not include those who have chosen surgery, or those who have HAD surgery. I simply made a point of including everyone. I did not intend to imply anything about you or your opinions. I meant no offense, and I am sorry if offense was taken.

My defense of Lara's comments was based on the fact that I know her history and I think I know what she meant. I don't believe there is ANY treatment for TTS that truly offers a 'cure,' except perhaps in a few of the cases where something is successfully removed from the tarsal tunnel. For most of us, 'successful' treatment (whether it's conservative or surgical) means that we will still have to be careful for the rest of our lives, and in many cases will have to continue wearing orthotics, or the TTS could come back. And many people will also have to live with a certain level of discomfort.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

Carl D. on 12/11/02 at 12:05 (102725)

Geez Sharon, you really do read too much into my comments. You are obviously trying to support people who have had or will have surgery. I have nothing against that. I am trying to encourage those who are still trying to avoid surgery to post their experiences. That in no way suggests that anyone else should NOT post their experiences (surgical or otherwise). Keep in mind that there may be treatments in the future that will, in fact, cure TTS, but having surgery may eliminate that future for you. You didn't seem to have a problem with Kelly posting her positive experience with trying everything she could to avoid surgery. All I was doing was thanking her for taking the time to post that and to encourage others like us who are doing the same. End of story.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 13:08 (102726)

Carl,

I support EVERYONE who has TTS. And I certainly support YOU in trying to avoid surgery. You are doing the right thing. I tried to avoid surgery too, and I really hope you'll have more success than I did. If someone who hasn't tried any of the other treatments has found a gung-ho surgeon and is talking about having surgery, I try to persuade them to give other things a try first. That doesn't happen all that often because most doctors don't even OFFER surgery until other treatments have failed.

You are right, though, that I am especially interested in those who have chosen surgery -- just as you are especially interested in other people who are trying to avoid it. I don't want anyone going into TTS surgery blind to its risks and its questionable prognosis. And I do try to warn them. But I also tell them that MOST TTS surgeries are successful. Because, as you said, 'I have not read many posts on this board from people who think their surgery was completely successful. In fact, many seem to regret having surgery.'

Reading this board does tend to discourage people who are facing TTS surgery and have come here looking for help, most of whom have already tried the usual conservative treatments and surgery is their one remaining hope. So, I offer them my support.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/11/02 at 13:30 (102728)

An important point here - Sharon had something in the tunnel that was removed (if I recall correctly). This greatly increases the chances of success.

The surgical results if there is NO mass are much worse.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/11/02 at 15:52 (102737)

Wendy,

You're right, I did. Six varicose veins.

Sharon

Re: Telling The Difference Between PF and TTS

Lara T on 12/11/02 at 18:16 (102759)

If I'm mistaken (about their being no cure for TTS without surgery, as opposed to treatments) I will be thrilled to be corrected. What are the cures? I would love to get back on the tennis court!

Re: Telling The Difference Between PF and TTS - better without surgery?

Lara T on 12/11/02 at 18:44 (102768)

I'm curious about your diagnosis and treatment. Can you tell me more.

How do you know you have PF & TTS (I believe you, I just want to figure out how what you have is different from what I have so I can figure out how best to apply your experience making decisions for me).

I'm curious about ESWT because I considered ESWT for my TTS until one of the doctors on the board said it wasn't appropriate for TTS, although it was for PF. I live close enough to the Canadian border that it would be feasible for me, and I'd love to find a cure - or a treatment that let me play tennis.

I'm curious about massage too as I receive massage regularly, and actually printed some notes from this board for my massage therapist - and then my neck/shoulders started acting up badly so my TTS (which is under control but not cured) took a back seat to my neck problems.

Thanks for any light you can shed on these things.

Re: Telling The Difference Between PF and TTS - better without surgery?

kellys on 12/16/02 at 13:07 (103301)

Lara

If you were addressing me - I knew I had PF because I had all the classic symptoms (sharp heel pain, tending to be worst in the AM, focused at the PF attachment point, some relief from icing the heel area, etc.). I had the ESWT before I knew anything about TTS, so my decision to pursue that was solely based on the PF diagnosis. Somewhere along the line, even before the ESWT, I started to get nasty burning and tingling all through the foot and well up into the leg, bilaterally. But I just thought it was all part of the PF. Eventually, several months after my second ESWT, I realized that I was icing the inner ankle more than the heel because that's where it hurt and where the icing seemed to be more effective. And that the heel wasn't so sensitive anymore, now it was the inner ankle and up into the calf. Basically, the pain shifted both in location and in character. Finally I learned about TTS and this diagnosis was confirmed by several new podiatrists and a neurologist.

The massage is relatively intense, and she works mostly on my legs. The therapist was able to dig deep into the calf area and start to break up some very painful tightness and over time, this, coupled with everything else, seemed to help reduce the pain. She works on my feet at our discretion, and has been careful not to overstretch the PF, since I've found that overstretching can bring the PF symptoms back. The massage can be extremely painful at times. I am also careful to listen to my body regarding what she can and can't do to my feet and TT area, but overall it has helped a lot.

I'm still not sure I'd even consider tennis, though! I am reintroducing weight-bearing activity pretty slowly. Painfully slowly, it seems, but there is progress. Particularly if I look at where I was 5 months ago. But tennis, running, and many other weight-bearing aerobic activities are still a ways off. I'd be very hesitant to do anything where I had to jump around or switch directions quickly since that seems to annoy the PF. On a positive note, I've found some alternate activities and have started recently to increase the intensity and duration of those activities.

Re: Surgery AFTER conservative treatment fails for TTS

LibbyD on 12/25/02 at 08:50 (103963)

OK, I have some questions, maybe someone can direct me, as I am new to the board and don't often have alot of time to dig up the answers.
OH! Sorry, Merry Christmas to all!
OK, first, what is PF? I have seen it several times but don't know what you are talking about.
I have had TTS (if that is what it is) for several months now, 3 different DR's, 3 different diagnosis. First one said I have arthritis in my big toe joint (yeah, right!), the other said I havePlantar Fascitis, this last one is the one that says I have TTS, he is a podiatrist that specializes in diabetic foot problems, I don't have diabeties or rheumatoid, at least the tests were negative but I do have an elevated sed rate. Ok, the only thing this DR has done was a NCT and orthotics, which I love and they did help for about 3 weeks but now the pain is back, I am going next week for another nerve conduction test, this is the test where they use the 'fork' thing. From what I have been reading, it seems that everyone goes to a neurologist for this test??
I am really sensitive to NSAIDs, they all make me sick, I am now trying Bextra, don't see any diff, though.
I also have alot of lower back problems, he said that I need to have that corrected in conjunction with the foot thing. He said that maybe the orthotics are working and that in the process of my nerves healing, the pain is indicative of healing (?). Well, he also said that if not better in another month, he would elect for surgery.
What I want to know, is what is everyone trying before surgery??? And should I be having an MRI or something before jumping into surgery??
He also told me that in surgery, there would be 2 cuts in the foot area, and one cut just around the bottom of the outside of the knee (?) I haven't heard anyone mention a cut in this area?? Any ideas or comments?
A lady that I work with has had this surgery done, she is diabetic, she didn't have the severe pain that I have but she had numbness. I don't have any numbness but my pain is almost unbearable.
Should I try a cortisone injection or something?? I'm deathly afraid of steroids but am now at the point to where I'll do anything, I'm tired of the pain up my legs day in and day out.
The lady did say though, that her surgery was not painful, maybe for a day or so then she was fine.
If anyone happens to see this, please direct me into the right direction so I can see what other treatment options are for this. It's getting harder to get up and go to work everyday.
Also, I have a sit-down job, so I was wondering if it has anything to do with standing on your feet all day at a job.
I also don't recall having an injury that has caused me to have this, they just began to ache and got worse and worse.
Thanks, Libby

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/25/02 at 09:46 (103972)

PF is plantar facaetis, one of the things you said you've been diagnosed with. Many people have BOTH PF and TTS, and it is usually PF that comes first. One of the doctors who posts here has said that he believes this is because both problems are often caused by the same biomechanical faults. Did you receive any treatment(s) for plantar facaetis?

An MRI or a diagnostic ultrasound of your feet would be a very good idea, to help rule out the possiblilty that you have something IN there to take out. These tests don't ALWAYS find it if there's something unusual in your tarsal tunnel -- varicose veins inside the tarsal tunnel are not uncommon and many times an MRI doesn't 'see' them. (It did, in my case, but that's probably because I had SIX of them...)

I would certainly give both physical therapy and steroid injections (into the tarsal tunnel area) a try, before even CONSIDERING tarsal tunnel surgery. The surgery is painful and the recovery period afterward is LONG and FRUSTRATING and usually quite painful.

Wendy and I disagree, to some extent. I think it's clear that a majority of studies have shown TTS to be surgery in MOST cases where it had been correctly diagnosed in the first place, whether there was a 'space-occupying lesion' (a THING to take out) in the tarsal tunnel or not. Of course, TTS surgery will NOT help if the real problem was a pinched nerve in your back, or arthritis, or anything else besides a true entrapment/compression of your posterior tibial nerve. That's why it's absolutely MANDATORY to have the tests before ever even THINKING about surgery.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 12:00 (104030)

Sharon - I'm not sure if we disagree or not, I agree that TTS surgery can be very succesful if there is something in the tunnel to remove. I don't believe the surgery works well if there isn't anything in the tunnel to fix or remove. I'm not sure if that's what you said as well?

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 12:59 (104036)

Wendyn,

I suspect we would agree that TTS surgery is often appropriate when there is something known to be inside the tarsal tunnel that needs to be taken out. And from reading these boards, it's apparent that TTS surgery is done MUCH TOO OFTEN without all the appropriate tests being done first -- in that respect, I imagine you and I would agree as well.

But I do think we disagree about this: I'm convinced there ARE times when TTS surgery works well even though there isn't any specific space-occupying lesion in the tarsal tunnel (indicating that the CAUSE of the TTS is 'idiopathic,' or unknown).

I believe a TTS release done WITHOUT something known to be in the tunnel is appropriate ONLY AFTER all the other possible treatments have failed, and ONLY assuming that nerve conduction tests were clearly positive for TTS that the patient also shows the appropriate clinical signs -- and ONLY AFTER all applicable tests and examinations have been done to rule out systemic causes, PN, sciatica, back problems, circulation problems OTHER than varicosities in the tarsal tunnel, etc.

When TTS surgeries fail, I believe it is more common for them to do so BECAUSE THEY WERE MISDIAGNOSED (or at least incompletely diagnosed) in the first place, than because the cause was idiopathic (maybe related to swelling of unknown origin) and there was nothing IN the tarsal tunnel to take out. If most of the 'nervy' symptoms attributed to TTS were actually caused by something ELSE, it would be very unlikely for a TTS release to 'fix' the problem.

My point about varicose veins in the tarsal tunnel was that they often are not 'seen' by an MRI anyway, so swollen veins might be an example of a situation where there IS actually something in there but nothing shows up on the tests.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 14:48 (104038)

Sharon - I think we agree more than we don't. I agree that all conservative options should be tried - and then if the surgeon and the patient agree that nothing else can be done, surgery is an option (even if nothing is known to be in the tunnel). In these cases, it can be exploratory if nothing else....but patients also need to understand that the surgery can actually make them worse.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 19:43 (104068)

Wendyn,

Doctors should ALWAYS explain to their patients that TTS surgery can make them worse, when it's time to discuss the surgical option(s). Even when something is in the tarsal tunnel that can be taken out, there are risks of excessive scar tissue formation, of neuroma formation, etc. It is definitely a risky procedure, and not one to be done without all due consideration.

Sharon

Re: Surgery AFTER conservative treatment fails for TTS

wendyn on 12/26/02 at 19:48 (104069)

You're right Sharon, but we see an awful lot of people come through here who seem to have a 'it can't hurt' attitude.

Re: Surgery AFTER conservative treatment fails for TTS

Sharon W on 12/26/02 at 20:01 (104072)

I agree. Many people are used to think of surgery as a (painful and expensive) 'quick-fix solution' to medical problems, and so naturally they assume that THIS surgery is like that too. (I mean, good grief, people even think of HEART BYPASS surgery these days as 'routine'!!)

I think the same argument could be made about PF surgery. THAT one certainly isn't risk-free, either, and yet it is done all the time without exhausting conservative options first. People just do not think of surgery as something that can make them WORSE. They think that if the operation itself doesn't kill them, it will make them BETTER...

Sharon