TTS at 18Posted by Kara G. on 4/24/03 at 16:39 (117004)
I learned about 3 weeks ago that I have TTS. It is still in the early stages, so my doctors are hoping to reverse it, but it doesn't look too likely that that will happen. I was first diagnosed with PF when I was 15. I was a cheerleader for my high school and the doctors thought it came from some injury I received there. I was put into physical therapy for 3 months going 2-3 times a week. It worked for awhile, but I would have to tape my foot before games and practices to help cut down on the pain. In August 2002, I went off to college and was walking everywhere. This caused the pain to come back full force and I went to see my doctor in October. He told me the PF had come back and I needed to stay off my foot as much as possible. Things continually got worse, so I was sent to get an MRI to make sure nothing was pinching the nerves. That came out fine and I was sent to have a nerve conduction test done about 2 weeks ago. I now I have to go to physical therapy and most likely get a steroid shot. If these options do not work the way they planned, I will have to get TTS surgery. I am very nervous because I am so young. Are there any recommendations you can give me or any encouraging words of advice? Thank you.
Re: TTS at 18lara t on 4/24/03 at 18:25 (117011)
I imagine others can predict what I am going to say, but I encourage people to consider compression socks/hose before surgery. My TTS was so bad I sometimes crawled across the floor and limited my intake of water and food so I wouldn't have to walk to the bathroom. The doctor recommended surgery, but I couldn't figure out when I could take a few months off. I figured I could live a sedentary life and still do the chauffeuring and stuff they needed. While waiting to figure out a time the doctor gave me some compression socks. The 'socks' were magic for me. They helped immediatley, but it took a few months for them to stabilize where I am now. I didn't get to go back to tennis, but I can live a normal life. Compression socks are easy to try, relatively inexpensive, and if they don't work, quickly reversible. AT twenty years old I might make different decisions. I suspect I would be more inclined to try surgery. My desire to be active would be stronger, the recuperative powers of the body are greater at 20 than 50, and it would be easier to find a few months when I can take off without disrupting the lives of other people (like husbands and children) - but I still haven't had the recommended surgery cuz the socks do so well for me so I don't know if there is a difference between being 20 and being middle-aged.
Re: TTS at 18BrianG on 4/24/03 at 18:28 (117012)
I sure sounds like you have been delt a lousy hand! One thing in your favor is youth. Younger folks are usually able to heal, much quicker than some of us old timers. Don't be too afraid of the cortisone shot. The hurt a little, but can give you some relief. A lot of time the relief is only short term, but not alwyas. You could be the person that gets healed!!
Take your time about surgery. If you feel you have no other choices, spend some time to find the best doctor available. Someone who specializes in the foot and ankle, and has had a good track record.
I don't want to scare you, but if your at all thinking about surgery, please go back in this subject, and read the stories. Some folks have had their lives ruined, due to failed surgery! Remember, once your cut, there is no going back. You should really inform yourself on the good, and the bad, resulting from surgery.
I wish you the best
Re: TTS at 18Pam S. on 4/24/03 at 19:48 (117029)
It is a great idea to get a second or maybe a third opinion before you get the surgery. I am sure this is not what you want to do this summer but pain is a driving force, isn't it. I do believe should you decide to have the surgery, you would recover with flying colors. None of us are drs just people who are obsessed with this topic because we live it 24.7
While you are figuring it all out, wear the compression socks. They helped me too. Not too glamorour but if you wear longer capri pants no one will notice because your toes show if you wear a sandle that covers most of your foot.I am sure you are rolling you eyes!!!!
Brian is right, take your time and find the best surgeon you can who has done lots of this type of surgery. GOOD LUCK
Re: Read This!mike p on 4/26/03 at 18:50 (117203)
I have done the surgery at 25.
Your situation sounds similar to mine, albeit, my pain did not come from cheerleading.
I had the surgery done by a foot specialist about 6 weeks ago.
Surgery of this sort should be the very last option for you! All this stuff that you heal better when younger should not play a factor in considering a surgery.
This type of surgery is atypical of others. It deals with a sensitive nerve, it is a type of neuro surgery. This should concern you greatly because:
1. nerves are unpredictable, a mere touch can have severe consequences
2. a mere touch to its environment, no matter how good the surgeon, can lead to problems.
3. the scar tissue that develops from the surgery can leave you in a worse position than prior to the surgery, you dont know how the scar tissue will settle and neither does your doctor! We all heal differently.
4. for so many reasons, this is a type of surgery that is NEVER done to improve performance of the foot! This surgery is done to improve pain that substantially harms your quality of life. By this I mean walking with extreme pain, not being able to sleep because of the pain- not merely not being able to comfortably walk long distances or to comfortably cheerlead.
5. very few people return to 100 percent after surgery- recovery time is 6 months to a year. this surgery is not one of those arthroscopies people do in which they run a week after the surgery is done.
Note: My surgery was a complete success and I still dont recommend someone doing this surgery unless they have a lot of pain! I write this way becasue I didnt understand the repercussions of the surgery until after i did it. I, too wanted a perfect foot but remember this surgery is not about perfecting the foot, it is about preserving quality of life.
Rarely ever will you see 18 year olds have surgery of this type.
If you have any questions please feel free to ask.
Also, remember that you can learn a lot from this message board, there are a lot of honest people here willing to share their experience. Learn from people's mistakes!
Re: Read This!Pam S. on 4/27/03 at 23:08 (117245)
I think your comments are very compelling. How bad was your pain before the surgery. I would be interested to know those details of how your life was affected. Aren't you happy you are not in pain anymore? I know how you feel, my foot has never exactly felt THE SAME as before but it sure beats that grinding nerve pain. There is nothing worse. It is hard for me to imagine a young girl having to deal with that at such a young age.
Re: TTS at 18Kara G. on 4/28/03 at 20:15 (117305)
Thank you to everyone for your comments so far. I am thinking about trying the compression socks and see how those work. I should be starting physical therapy here soon, but I am limited at the moment because lucky me, I was jsut diagnosed with mono over the weekend and am on a whole new set of meds for that. Because of the new meds I am on for my illness, I haven't started taking the darvoset perscribed to me by the neurologist last Thursday for pain management. I have a feeling that the cortisone shot will have to be done, but hopefully that will work and I won't have to get surgery. I am considering surgery as a last resort, considering I don't know when I could fit the recovery time in. I have a full time job for the summer (doing office work where I get to sit almost all day!) and then I will be off to college again in the fall. So surgery is not looking like a good option right now. I just want to be able to walk around the house without pain again and hang out with my friends like a normal 18 year old.
Re: TTS at 18Pam S. on 4/29/03 at 11:47 (117338)
This will be a quick note, but I just got back with an appt. with an orthopedic foot/ankle who knew alot about TTS. She said, as many others have said on these boards, you should have an MRI of your foot/ankle before you even consider surgery. I was not aware if you have done that or not. She said only 50% success rate if there is not mass or varicose veins impinging on the nerve. She was not an advocate of this type of surgery unless there is a mass etc. because often the pain comes back in several years. I am happy to answer any questions Pam
Re: Physical Therapy & TTSlara t on 4/29/03 at 18:09 (117384)
I remembered seeing something on the internet about PT and Tarsal Tunnel Syndrome. I found the following URL that leads to some information on PT & TTS. I'd be interested in the responses of people who have tried PT.
A Patient's Guide to Rehabilitation for Tarsal Tunnel Syndrome
Your First Visit to Physical Therapy
On your first visit, your physical therapist will want to gather some more information about the history of your condition. You may be given a questionnaire that helps you tell about the day-to-day problems you are having because of your condition. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your therapist gauge how much pain you have now and how your pain and symptoms change once you've had treatment. Your therapist will probably ask some more questions about your condition to begin zeroing in on the source and location of your pain and to know what will be needed to help relieve it. Here are some questions your therapist may ask you:
When and how did your pain start?
Where do you feel your pain now?
Do you have numbness or tingling in your foot?
Are you a runner? If so, what are your mileage, terrain, and footwear?
Physical Therapy Examination
Once all this information has been gathered, your condition will be examined. The main parts of the examination are listed below and may be done in the order chosen by your therapist.
Posture/observation: Your physical therapist may check your overall posture, including the alignment of your hips, knees and ankles. By comparing each side, your therapist can see if changes in your posture are contributing to your tarsal tunnel syndrome. A pronated posture of the ankle and foot may give an indication of treatments that will help you the most. A difference in the length of one leg can cause the foot on the longer side to pronate. By observing your foot, your therapist can see if any of the muscles have started atrophied (shrunken) from compression on the nerve in the tarsal tunnel.
Gait analysis: By watching you walk, jog, or run your therapist can see if your gait has anything to do with your problem. Even subtle changes in your stride, foot and knee position, or hip movement can cause problems with the tarsal tunnel syndrome. Your therapist may want to check your shoes for abnormal wear. If your condition is severe, you may need to use a pair of crutches or a special walking boot until the pain begins to go away.
Neurological screen: Your physical therapist may need to do some tests to check the nerves of your leg and foot. Testing how well you can sense light touch can give an idea if there is a problem with a nerve. A device with two points can be touched to your skin and compared on each foot. If the distance between the two points has to be increased for you to feel it on the sore foot, it can be a signal that there is tension or compression on the posterior tibial nerve. Another test uses percussion over the nerve. If you get a 'zinger' of pain in the foot or behind the inside heel during the test, it is a positive 'Tinel' sign. Muscle testing of the small muscles of the foot may be done as part of the neurological screen.
Range of motion (ROM): Your therapist may want to get an idea of the ROM in your foot and ankle. This is a measurement of how far you can move your ankle in different directions. The ankle is moved up and down (dorsiflexion/plantar flexion) and inward and outward (inversion and eversion). The posterior tibial nerve may be painful when the foot is stretched into dorsiflexion and eversion ('up and out'). Your ROM is written down to compare how much improvement you are making with the treatments.
Strength: Your therapist will test the strength of your muscles. Select tests may be done to compare the strength of the small (intrinsic) muscles of each foot. Other muscles that may be checked include the calf, shin, thigh, and hip muscles. These measurements are compared to your other side. Weakness in key muscles will be addressed with a strengthening program.
Manual examination: You may be given a manual examination of the ankle and foot. Your therapist will carefully move your ankle in different positions to check how the joints of the ankle and foot are moving. When a joint is not moving right, extra strain may be put on the soft tissues of the foot, including the posterior tibial nerve within the tarsal tunnel. This type of exam can help guide your therapist to know where your soreness is coming from and which type of treatment will help you the most.
Special tests: These additional tests may be done to zero in on the area and severity of your condition. Your therapist may use select tests that place your ankle, foot, or toes in different positions in order to check the soft tissues around the ankle. Some tests place a stress directly on the posterior tibial nerve to if there is tension or scarring around the nerve. The test results are like a puzzle that are fit together to get a clearer picture of your problem and how to best help your condition.
Palpation: Palpation is when your therapist feels the soft tissues around the sore area. This is done to check the skin for changes in temperature, see whether you have swelling, and to pinpoint the area of soreness. You may note soreness in the inside edge of the foot. Palpation is also done to see if the muscles have atrophied from compression on the nerve. This can help your therapist get a good idea about which treatments will help you the most.
Treatment plan: Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. The plan also lists the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.
Physical Therapy Treatment
CONTROLLING PAIN AND SYMPTOMS
Your therapist may choose from one or more of the following treatment interventions to help control your pain and symptoms.
Rest: Rest is an important part of treatment. If you are having pain with an activity or movement, it should be a signal that there is still irritation going on. You should try to avoid all movements and activities that increase your pain. If your pain is severe, you may be issued a pair of crutches or even a special walking boot to take pressure off the posterior tibialis tendon.
Heel lift: A length difference in one leg can cause the foot on the longer side to pronate, to flatten, constricting the tarsal tunnel and stretching the posterior tibial nerve. If this is found to be a cause of your symptoms, your therapist may place the right sized heel lift in the shoe of the shorter leg. This can help align the pronated foot, opening the tunnel and easing tension on the nerve.
Ice: Ice makes the blood vessels in the sore area become narrower, called vasoconstriction. This helps control inflammation that is causing pain and can easily be done as part of a home program. Some ways to put ice on include cold packs, ice bags, or ice massage. Cold packs or ice bags are generally put on the sore area for 10 to 15 minutes. Ice massage is done by rubbing an ice cube or ice cup on a sore spot or tender point. It's as easy as freezing a small paper cup full of water. Once the water freezes, simply tear off the top inch of the cup and rub the exposed ice on the sore spot for three to five minutes, or until it feels numb.
Ultrasound: An ultrasound machine produces high frequency sound waves that are directed toward the sore area. Passing through the body's tissues, these waves vibrate molecules. This causes friction and warmth as the sound passes through the tissue. The rest of the sound changes to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are a way for your therapist to reach tissues that are over two inches below the surface of your skin.
Phoresis: This means to 'carry or transmit.' There are two methods that therapists can use to transmit substances across the skin. Phonophoresis uses the high frequency sound waves of ultrasound to 'push' a steroid medication (cortisone) through the skin. Iontophoresis uses a small machine that produces a mild electrical charge, which is used to carry medicine, usually a steroid, through the skin. The steroid is a strong anti-inflammatory medication that actually stops the pain-causing chemical reaction within the cells of the sore tissue in your body. Either type of phoresis may be used in place of a cortisone injection.
Foot Alignment: Supporting the foot and arch can take tension off the posterior tibial nerve and reduce the symptoms of tarsal tunnel syndrome.
Arch taping/strapping: When the foot is pronated and the arch is flattened, supportive arch taping or strapping can take tension off the posterior tibial nerve, keeping it from getting inflamed and sore. Taping or strapping may be discontinued when your pain and symptoms go away. If symptoms come back, you may need to be fit with a pair of custom orthotics.
Orthotics: Your therapist may choose to evaluate your feet to see whether the alignment of your feet is affecting your condition. If so, your therapist may want to have a special shoe orthotic made. A flattened arch (pronation) puts strain on the posterior tibial nerve and constricts the tarsal tunnel. Putting a supportive orthotic in your shoe supports the arch and repositions the foot, opening the tarsal tunnel and easing tension on the nerve.
THERAPEUTIC EXERCISE AND FUNCTIONAL TRAINING
Improving range of motion: When movement of a joint is limited, the pain and symptoms of a tarsal tunnel syndrome may worsen. Improving ankle and foot movement can help keep take some of the pressure off the sore tendon. Getting more motion can give you the relief you need for daily activities. If you don't have full range of motion, your therapist has several ways to help get more movement including graded joint mobilization, manual stretching, and select exercises. Active movement and stretching as part of a home program can also help restore movement and get you better faster.
Flexibility: Tightness in the muscles of the calf (the gastrocnemius and soleus) can force the foot to flatten or overpronate, constricting the tarsal tunnel and stretching the posterior tibial nerve. If your therapist notes tightness in these muscles, you may be given stretching exercises to improve their flexibility.
Strengthening: As healing continues different types of exercises are used. Exercises to help support the arch can be used early on to help take stress off the posterior tibial nerve. Other exercises can be used to strengthen the small muscles of the foot. These can include toe curls, picking up small items with your toes, and resistance exercises done in a bucket of rice or sand. As your condition gets better, more vigorous exercises will be used to increase endurance, strength, and control in the muscles of the lower leg, ankle, and foot.
Progressive resistive exercises (PREs): Many choices of PREs are now used in rehabilitation. Some of these choices include pulley systems, free weights, rubber tubing, manual resistance, and computerized exercise devices. Using PREs is a way to apply graded resistance to muscle groups to gradually help them gain endurance and strength. These exercises typically start with lighter weights with lots of repetitions, and as endurance increases, more weight is gradually used with fewer repetitions.
Progressive exercise: Exercises will be given to help improve strength, muscle control, and endurance in the leg, ankle, and foot. Here are some types of exercises that may be used to help your condition:
Functional exercises: Your program may also address key muscle groups of the calf, shin, thigh, and hip. Exercises can be used to simulate day-to-day activities like stair climbing, pivoting, and squatting. Higher-level exercises, like agilities, progressive running and cutting, plyometrics, and heavy resistive training can be done to prepare for specific job or sport demands.
Closed chain exercises: These are exercises in which the foot is kept on the ground while movement and resistance take place in the joints and muscles above. These types of exercises are important because they are so much like the activities we do every day. For example, a partial squat exercise is the same action as lowering yourself onto a chair or couch. A calf press is basically the action of rising up on your toes. These exercises add strength and stability around the muscles and joints of the leg, ankle, and foot.
Proprioception exercises: These are exercises that help retrain your position sense, also called 'joint sense'. If you close your eyes and hold up your hand, you know what your hand is doing, even though you don't 'see' it. We get position sense by way of our vision, middle ear balance, and from tiny receptors in the ligaments and joints. When we close our eyes, we rely on middle ear balance and these special receptors to keep us upright. These special balance exercises help stabilize the foot by getting the small foot muscles to add support to the arch. This can help prevent over pronation. Examples include balancing on one leg with your eyes open/closed, walking on uneven or soft surfaces, or practicing on a special balance board. Some therapists use special manual exercises to help with balance and proprioception.
Home program: Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will give you some ideas to help take care of any more soreness at home. You'll be given some ways to keep working on the range of motion and strength too. Before you are done with therapy, more measurements will be taken to see how well you're doing now compared to when you first started in therapy.