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formation of scar tissue after epf and poss. of 2nd epf

Posted by Stacey on 9/17/03 at 19:50 (130380)

First of all I would like to say that I really appreciate you Dr.s taking your time to help us out.
I have seen 4 doctors for my PF over the past 3 yrs. (tried all cons)
Have had EPF in both feet one year ago. About one mo. after procedure started feeling the same tightening in fascia already. Dr. performed Ossitron on right foot twice since then because he considered surgery a failure.
In July I seem to have developed TTS on top of it all in right foot.
I have now started seeing a new Dr. and he is contradicting things my old Dr. said-so I am very confused now. (but happier with new DR)
He wants to do OPEN procedure-where he will be able to FEEL around and see if there is indeed scar tissue that formed and tightened things up. He will then snip the scar tissue. He also wants to remove the bone spurs AND do the TTS surgery on the right foot. So as you can see-I have alot to think about. My left foot feels exactly the same as before surgery. My right foot is worse-pain in eentire foot within first hour of day-all day. Pain in ankle, heel and arch. Numbness in ankle and bottom of foot.

1. If scar tissue formed right away after surgery first time-why would it not do it the second time?

2. Is bone spur removal done much anymore? He explained that the spur may be pushing on nerves?? Had me do the 'pull your pinky toe away from your foot' test)

3. Is it important to get the TTS taken care of? This really concerns me since it has worsened in just one month. Please help!!! Thx-Stacey

Re: formation of scar tissue after epf and poss. of 2nd epf

Dr. David S. Wander on 9/17/03 at 20:23 (130387)


Your 'new' doctor seems extremely aggressive. Although it may eventually be necessary to perform an open procedure to remove scar tissue and explore the area, I personally do not believe removing your spur is going to change any outcome. Dr. Z and I seem to disagree on this, but it is VERY well documented that the actual spur is rarely, if ever the cause of the pain. Removing the spur is bone surgery, and can result in bone infection, stress fracture of the heel bone, periostitis, etc. Once again, if the spur is not causing the pain I would leave it alone, and I'm not convinced that the 'pinky' test proves that the spur is pushing on the nerves. That statement actually is ridiculous. It is certainly possible that scar tissue is causing a nerve entrapment. The surgeries you are considering can result in dramatic relief, or can unfortunately result in significant long term discomfort. Tarsal tunnel surgery seems to work great, or fail miserably with little between. Although this may all seem confusing, the aggressiveness of your 'new' doctor concerns me and the 'pinky' test REALLY concerns me. I'm curious as to the opinion of some of the other doctors on this board. Dr. Z, be nice.

Re: formation of scar tissue after epf and poss. of 2nd epf

Stacey on 9/17/03 at 21:20 (130394)

Hi Dr.
Thank you for the reply.
Now this Doctor said there is a POSSIBILITY that the pinky test could be indicative of a nerve being compressed. He did not empasize that point very much. But I do agree with you that it is aggressive and I did not like the idea of the spur removal at all. Actually was not even considering it. But I am seriously considering open and TTS.
Spur removal aside, why would this open procedure work a second time??
What is going to keep the scar tissue from forming this time? Or is it just better because it is open and he can explore a bit better? I felt the fascia tightening up about a month after the procedure-told my doc and he immediately put me in physical therapy to stretch it-but obviously did not help. Is this a common occurance?
So can you give me a success rate percentage wise on the TTS surgery?
Thank you for your help.

Re: formation of scar tissue after epf and poss. of 2nd epf

Stacey on 9/17/03 at 21:25 (130395)

How do you know if the bone spur IS what is causing pain??

Re: formation of scar tissue after epf and poss. of 2nd epf

Dr. Z on 9/17/03 at 23:10 (130404)

IS your achilles tendon short? The sucess rate for TTS surgery is about 60-70% .

Re: formation of scar tissue after epf and poss. of 2nd epf

Dieter on 9/18/03 at 05:44 (130413)


This sounds like a complex problem. Firstly, it is an atypical clinical presentation for plantar fasciitis to persist so long. How much do you know about what diagnostic tests were performed to assist with the diagnosis? I am suspicious of bilateral heel pain - there are medical conditions that can cause pain in the heel and need to be ruled out before embraking on invasive treatments. Was this done?

Also you state you have tried all conservative treatments - but which ones?

Here in England provision of services is not driven by finances - healthcare is free. I often talk with my patients about operations for this condition. The vast majority of patients DECLINE surgery when they know all the facts and pros & cons.

You have had EPF - did you ask your doctor how many times he has done this operation? Does he also perform open operations for this condition? It is possible I guess, that surgical trauma is responsible for the symptoms you are now experiencing. I am not sure I would personally opt for MORE surgery if this is the case, but of course it depends on how much pain there is.

What diagnostic tests have been performed to collaborate the diagnosis of tarsal tunnel syndrome? I personally would not wish to have an operation without some tests to determine the likely cause of the nerve impingment. TTS is not common and in 13 years of practice I have yet to confirm a case. What conservative treatments have been suggested to help with this? It is possible the heel pain / PF is causing an alteration in your gait. In such a case EVERYTHING may start to hurt.

Also after the extracorporal shock wave therapy it can take some months for tissue to heal and pain to settle.

Regarding the removal of 'bone' - the procedure does appear to be performed when there is evidence on x-ray of a 'prominent' spur. This is in spite of the fact that foot professionals do not consider the spur relevant in causing pain. If the fatty pad of the heel is thin the spur may protrude and cause loaclized pain but this is uncommon and would not explain your symptoms. Some post operative audits have shown patients to benefit from the spur removal anyway. It could be that extensive surgery in the area helps in some way. But there are certainly additional risk factors, pointed out previously.

My impresion based on the information you have given is back off and give the matter more time to see if nature will heal. Some patients take up to 12 months following surgery on feet before they feel happy. In the meantime I would recommend pain managment, possibly with assistance from a pain clinic. Physiotherapy might help also. If after a year you are no better off, reconsider your options. Sometimes aggressive surgery is the answer and its likely that open surgery is required to manage any scar tissue - how else can the surgeon see the structures that are affected.
Before any further surgery I would recommend follow up with orthoses, and persistent daily stretching of the calf muscles and plantar fascia utilising the aids found on this website, if this isn't already being done.


Consultant Podiatric Surgeon, England

Re: formation of scar tissue after epf and poss. of 2nd epf

Stacey W on 9/18/03 at 10:24 (130429)

Dear DFellner,
I have had blood test done to rule out things like arthritis-they came out negative. Should I have them done again? MRI shows no fractures, etc.
My old doctor wanted me to have a venogram done (thinking it may be causing the TTS) but I refused and went to see a different doctor. My old doctor scared me even more then the new doctor! The new doctor tells me there is no reason for a venogram and even if I had varicose veins deep inside he would be able to see them on the surface. Do you agree?
Conservative: Heat, ice and stretch (daily), taping, soft and hard orthotics, cort. injections (5), night splints (hurt right foot badly after half hour), walking boot, just tried cast but it put too much pressure on my other foot walking on crutches, iontopheresis, anti-inflams help but I have to be careful I get gastritis, pain meds help, support socks. I did not ask my doc. how many times he performed surgery.:(
I had nerve conduction test done-came up negative. Two doctors basing TTS diagnosis on classic signs of numbness and pain in specific areas. MRI shows inflammation in the ankle area. I am in a ton of pain-it has now been one year since surgery and two months since last Ossitron and things are getting worse-think I should wait even longer? I am so confused-are any of you doctors in FL or close to FL? I am willing to travel just to find someone I am comfortable with! I am terrified to let anyone touch my feet anymore-is it possible I could get disability in the meantime?

Re: formation of scar tissue after epf and poss. of 2nd epf

Dr. Z on 9/18/03 at 11:48 (130435)

Ok. How about pain management?. An evaluation of the lower pain. A posterior tibial nerve block in the foot can help to end and or reduce your pain. I would even consider a lower back epidural nerve block to break up your pain cycle if the posterior nerve block failed to remove your foot pain

Re: formation of scar tissue after epf and poss. of 2nd epf

Stacey on 9/18/03 at 13:24 (130451)

Are these pretty safe? Never heard of using it for foot pain. Should I try them before surgery? I just made an appt. for pain clinic. Oct. 6 appointment. Am willing to try it.

Re: TTS symptoms came about after tibial nerve block

Stacey on 9/18/03 at 16:07 (130469)

Dr Z,
After doing some quick research,
I can tell you that my old Dr. gave me what I assume was a tibial nerve block (in the ankle) during my second Ossitron treatment. When I awoke from the procedure I right away questioned the nurses about the numbness. They told me it is from the nerve block. It never felt that way with the first Ossitron treatment. Most of the nuimbness went away that evening, but
It has been ever since THEN that I have had the new numbness/tingling. If you tap inside ankle-feels like shock and shoots. Numbness on bottom of foot. Pain in ankle keeps getting worse. Now my old doctor was very concerned about it-he mentioned it may have happened as a result of the needle from the nerve block. He gave me a cort. injection in the area to 'calm things down'-which worked a little bit after about a week. But after that he suddenly gave me to a new Dr. in the same office who then diagnosed me with TTS and said it was prob. from pronation, varicose veins, back trouble, etc. So at this point I was getting angry becasue it was very obvious to me that this all happened as a result of something during that Ossitron treatment, so that is why I started seeing this new Dr (different office)-who is contradicting things my old Dr. said and says that it is unlikely that the nerve block caused the TTS. I am not out to blame anyone-just want to know what the heck is going on! Is this confusing?
Please tell me what you think of all that also.

Re: TTS symptoms came about after tibial nerve block

Dr. Z on 9/18/03 at 19:08 (130482)

The development of posterior tibial neuritis is one of the complication when giving a PT block. There is a case of this board that had the same problem. I believe neurotonin and about nine month of time helped her with this very painful problem

Re: TTS symptoms came about after tibial nerve block

Dieter on 9/26/03 at 06:54 (131113)

I agree. Nerve pain related to 'needle trauma' from the local anaesthetic should settle in time. Nerves heal well usually. Normally patients would indicate problems soon after the surgery.

The dilated vein theory and venogram has to be a long shot! Can anyone cite a published confirmed case of this? Also seems too coincidental to be valid.

I have also had good results when patients received Amitriptyline concurrently. Better option at this point than more surgery.

No idea where you stand with income support. Works differently in the UK.