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Questions for Docs, but patients too...

Posted by lyn on 8/07/03 at 08:14 (126459)

Help...I posted the following on Ask the Foot Doctors, but would love input from other patients too...any advice or suggestions?

Just returned from the doctor and he is sending me for EMG and NCV tests. I had PF open release almost 9 months ago. It seems like the PF pain is gone and recovery for that has gone slow, but well. However, there has been significant swelling and pain on inside of ankle area and it is just getting worse. Had a cast for 6 weeks to try and get area to calm down. Then, did physical therapy but only got some relief from icing and ultrasound. Exercises seemed to aggravate things. Now, the doctor is talking about nerve damage. Wants to get the nerve testing done to isolate if it is something with Tarsal Tunnel or a different nerve 'deep within my foot.' Swelling is persistent as is pain, especially after walking more than a short distance or standing for awhile. Very limiting. Still using a cane. Limited range of motion. Questions -- 1) Doc didn't say what would happen next if it is nerve damage...are we talking more surgery?, 2) Is there a connection between conditions? Should I be concerned about my other foot? I have been advised that I have prounounced Q-Angle? (genu valgum?) which causes knee pain I have had for years and now the doc seems to think it may have contributed to foot problems too. Does this make sense? I know I've asked a lot of questions, but I am in pain, growing impatient for recovery, wondering about second opinions, etc. Please help...

Re: Questions for Docs, but patients too...

Sharon W on 8/08/03 at 09:49 (126558)


I posted this response on the Tarsal tunnel page but decided to copy it to here, too, just to be sure you'll see it. I do hope one of the docs with answer your questions, but I can see that you realy DO need some answers now...

You asked some difficult questions. But I'll do my best.

1) Doc didn't say what would happen next if it is nerve damage...are we talking more surgery?

I hope not! TTS surgery is risky and it is very important to do all the tests (as your doc seems to realize - and that's wonderful!) to identify as closely as possible what IS happening in your foot and ankle. There are quite a few possibilities and TTS is several of them. I say 'several' of them, because TTS can be caused several different ways, and there are actually more than one condition called TTS. There is the classic TTS that involves entrapment of some kind (it can be caused by different things) inside the tarsal tunnel or lacinate ligament itself. There is also another type of entrapment, called 'DISTAL tarsal tunnel syndrome,' involving the same main nerve (posterior tibial nerve) but further down, after it has branched into the somewhat smaller nerves of the foot. The entrapment in this case is typically found in an area called the 'porta pedis.'

TTS surgery is risky. Statistics quoted for success with this type of surgery vary widely (I've seen as low as 42% and as high as 94% -- but I really don't believe the 94%). The recovery period is long and painful; typical recovery takes about 2-6 months, but in some cases it can take up to a year or even longer. There is a risk of scar tissue developing around the nerve as a result of the surgery and the nerve becoming entrapped all over again. And you should know (even if your doctor never mentions this) that there is a significant risk of being WORSE after that recovery is finally over with, instead of better (just judging by posts on these message boards, I would guess that's probably somewhere around 10%, but the actual figure might be somewhat less).

So since the surgery is risky, before surgery is considered, ALL of the appropriate testing should be done, and other treatments should be attempted if they haven't aready been used for PF (orthotics, for example, and steroid injections into the tarsal tunnel area, and perhaps physical therapy or iontophoresis or immobilization (wearing a cast).

2a) Is there a connection between conditions?

I am not a doctor, just a patient who has TTS and did lots of research before I went through the surgery myself. I don't think you will get one of the doctors to say that there is a direct connection between PF and TTS (although Dr. Ed has said that they may both sometimes be caused by the same biomechanical factors). I doubt if you could even get a doctor to say that there is a connection between PF surgery and TTS. But I can tell you what it looks like to me from reading posts on these boards over the past 2 years.

I think that either there has to be a link between PF and TTS, or there has to be a WHOLE LOT of misdiagnosis of these conditions going on. My own guess is, both things are true...

If the diagnosis is PF and the patient actually has TTS, PF surgery will NOT help the patient -- and in fact, unnecessarily cutting and weakening one of the major support structures of the arch would surely tend to exaggerate any biomechanical problems contributing to the REAL (but not correctly diagnosed) problem, tarsal tunnel syndrome.

But I just touched on one of two factors about PF surgery that I think could lead to the development of TTS -- weakening the arch causes problems with a person's gait, changing the way they walk and changing their whole body's biomechanics. It seems to me that those changes could potentially lead to more pressure being put on the tarsal tunnel area and cause the development of the condition. Even without having surgery, PF can cause you to change the way you walk because you are trying not to step down where it hurts -- and maybe in some cases that could have the same effect.

The other way I see that PF surgery could potentially lead to the development of TTS would be because of scar tissue that grows in the DISTAL tarsal tunnel area, or porta pedis, causing nerve entrapment in the arch area. (I know someone who thinks this is what happened after her endoscopic PF surgery.)

2b) Should I be concerned about my other foot?

In a word, yes. I don't know that much about biomechanics, and I don't know what a Q-angle is, but since your biomechanics seem to be a problem and since your doctor thinks they may be at least part of what has caused these problems with your foot, I would worry about the other foot too and would want to try to whatever I could to PREVENT something from happening to that foot, too.

2c) I have been advised that I have prounounced Q-Angle? (genu valgum?) which causes knee pain I have had for years and now the doc seems to think it may have contributed to foot problems too. Does this make sense?

I don't know. But your feet are the foundation of your body. If something goes wrong with your feet, it tends to put things off balance further up... (But it can go the other way around too.)


Re: OOps

Sharon W on 8/08/03 at 09:58 (126560)

Isee you got an answer on the Doctors' board, from Dr. Z. You should listen to his advice; he's a (VERY!) smart man.


Re: OOps

john K on 8/17/03 at 09:21 (127182)

I am a cynic. If there are any sorts of exercise you can do to help with your problem do that first. I think TTS surgery is a scam. Fixing bones is hard enough but how to fix soft tissue with surgery? I have seen those TTS scars on peoples feet. Think about it.

john king

Re: OOps

lyn on 8/18/03 at 22:19 (127271)

John, did you have TTS surgery? I have been through months of exercise via PT, but no relief. I go for EMG and NCV tests next week, then back to doc for his recommendation of next steps based on test results.

Re: Questions for Docs, but patients too...

lyn on 8/28/03 at 07:22 (128262)

Sharon and Dr. Z...thank you so much for the responses to my questions. I go to see the 'physiatrist' today for NCV and EMG. Nothing has changed with symptoms; in fact, it has been a little worse, probably because we have been so busy and ON MY FEET A LOT getting our children ready for school. Will let you know how it goes. Thanks again...Lyn