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8 weeks post tts surgery questions

Posted by Margie B on 2/05/04 at 17:57 (143706)

I had tts surgery on 12/5/03on my left foot.I'd love to hear from people who have had this surgery and about their recovery. I was diagnosed last May, 03 by a podiatrist and my emg/nc tests showed posterior tibial nerve entrapment in both feet. My mri showed fluid in the tarsal tunnels. I was in a wheelchair about 3 weeks and in a cast.My doctor told me to start putting weight on my foot at about 4 weeks and I am still on crutches and partial weight bearing. I started pt at 7 weeks(ultra-sound and elec.stim) I do dorsiflextion and plantarflexion exercises and swim a few times a week.I'm still on Neurontin(1500mg/daily) primarily because I have tts in the other foot too.My incision (3') is still very sore. I have a numb spot in my heel. The outer area of my heel is sore when I am weight bearing. I have some pain and swelling in the area near the incision.(away from the ankle-toward the arch)when walking.I want to know if this pain is normal and will go away as my doctor says. I no longer have the stinging, burning pain in that area but I'm getting a bit impatient to still have pain after 8 weeks post surgery. I'd like to know what to expect from people who've been there! I'm a teacher and had to take a medical leave this year.Sometimes I feel isolated because few people have heard of or understand this syndrome and the pain involved. After reading many posted messages it sounds like others may feel that way. Thanks,
Margie

Re: 8 weeks post tts surgery questions

Terri on 2/05/04 at 21:00 (143716)

Hi Margie! I've had my 1st surgery on Jan. 2, 2004. Although I'm only 6 weeks post-surgery, I too am frustrated by my progress so far. I believe I was, and am, somewhat unrealistic as to where I thought I'd be by now. Most of my discomfort is on the incision site itself, mine is about 5 1/2 inches long though. The middle separated, but didn't come fully open, so now I'm dealing with a longer term wound care issue. Started p.t. this week and it's going very well. That was a happy surprise. My dr didn't put me in a cast after surgery, he gave me a boot instead. I think that is a huge improvement over casting as you can take it off at night and help gain some movement and flexibility earlier. My p.t. therapist was very pleased with my range of movement before we even got started. I'm completely weight bearing since last Thursday, but only with the boot on. I also have a numb spot on my heel, sounds like the same area. My dr told me before surgery that this would happen and it would be permanent. Some feeling may come back, but part of it will be numb forever due to releasing the nerve in that area. My therapist told me to massage the burning/numb spots as you actually have to re-teach the nerves in those areas how to correctly feel again, and learn to separate normal sensations from pain. I remember seeing that same therapy on a Disc. Channel program not too long ago and it makes sense. I've started doing that on my heel and although it really bothers me to do it, I've already noticed it's not quite so sore all the time now.

I hope this helps some. Sounds like we're close to the each other, progress-wise, right now. Would like to keep up with you here and see how we do as time goes on. If this one turns out well, I get to do the other foot. But I'm really gonna think long and hard about it first. I'd like to see at least a 50% improvement minimum. As it is, I can't go through a grocery store without resorting to a wheelchair due to the pain of walking, post surgery. I'm not overweight at all and only 44 with no underlying health issues, this is just so not normal! All I want out of this is to be able to go places with my family and especially my 2 young grandchildren without them having to park me on a bench and take turns babysitting me. It may take a year or two, but then I've been dealing with this for almost 20 years so I guess it's not that bad of a trade-off.

Let me know how you do, and good luck!

Re: TTS

elliott on 2/06/04 at 09:19 (143746)

Terri,

I wish you (and Margie) a complete recovery. (I myself had bilateral TTS release.)

Can you explain what you mean by your Dr. told you before surgery that you would have a numb heel as a result of the surgery and it would be permanent? This does not sound right to me. It sounds to me as if the doctor decided in advance to slice right through your medial calcaneal nerves (which give feeling to the mostly medial side of the heel).

During a standard release, when docs open up and look at the tarsal tunnel, they can see the beginning of these heel nerves, i.e., where they first branch off the main nerve. They should not be cut. Sometimes a decision--whether before or during surgery--is made as to whether to release these branches as they make their way to the heel, e.g., if localized entrapment along these nerves is suspected. I can understand that docs can differ in opinion as to whether a specific case warrants releasing these heel nerves as part of the TTS surgery, but if they do release them, they release them (i.e., free them from surrounding structures), not cut them. Compared to the other two nerves (medial plantar and lateral plantar) released as part of the standard TTS surgery, the medial calcaneal nerves--there can be anywhere between 1 and 4 but most people have 2--are teensy-weensy and so their release must be handled very slowly and carefully. But they should be released, not cut. Only in extraordinary circumstances--e.g., if these nerves are all tangled up in a mess of scarred or torn tissue and are already driving you crazy with localized nerve problems would they likely be cut, since then they can't be released anyway, and maybe cutting them and the permanent numbness that results might be an improvement on what you had before. But I gather from what you said that you didn't have that before. In any case, such a decision likely wouldn't be made until they see what's going on inside; they try to save them if possible.

What exactly were your symptoms pre-op? Did you have an MRI? What did it show?

elliott

Re: 8 weeks post tts surgery questions

lauriel on 2/06/04 at 13:18 (143785)

Margie, I had TTS sugerey on 12/6 of 2003. I was just going back and reading some of my posts here, since I posted a lot of my progressa fter surgery. I am like wow, I was so excited when I took my first walk in April! thalt was 4 months post surgery. You can do a search on my name, I chronicle my ups and downs. PLease letake it slow! it is a very slow healing type of surgery. I am glad to hear they have you on a good after surgery regiment. I remember when I took my first steps without crutches, I had the wierdest nerve senation in my heel, it took me ahwile to get use to, it did go away. I have seen posts here of people after surgery with the numbness in the heel. You might also want to do a search on 'heel numbness'
good luck
Laurie

Re: TTS

Terri on 2/06/04 at 22:32 (143828)

Hi Elliott!

Well pre-op, I was basically a mess. Couldn't be on my feet more than 30-45mins on a good day with pain that left me ruined for the rest of the day, and severe, I mean extremely severe!, cramping throughout the foot, ankle and calves that would go on all night long. Can't arch my feet, squat down, dance, wear heels of any height or go barefoot for that matter. Although I'd been getting progressively worse since my mid to late 20's, the past 4 - 5 years noted a rapid progression. Most of that I feel was due to my previous marriage to a tyrant that had MS and liked to drink too much. He was a lot larger than I, I'm only 5'4 1/2' and 127lbs, he's 6' tall and ballooned up to 250+. He refused to use any type of scooter or walker and leaned on me, quite literally, for walking and basically ran me all day long. Needless to say, he's now an ex-husband, but that's when I really started to have serious trouble.

I didn't have an MRI done. My podiatrist sent me for a test (EMG, ERG, is that right?) and the dr. that administered that test confirmed the diagnosis. My dr and my therapist both said they'd wished I'd been in 10 years ago and might have been able to avoid all this.

I honestly don't know all the names of the nerves but will definitely ask him this week when I go in and post back on what was released and what,if anything, was actually cut. I do know that I have no fat reserves under the skin protecting the nerves. He said he's never seen anything like it before. Most people, even if they're thin, have an average of 2 - 3 layers of fat under the skin. He said I barely had 1. When he made the incision, the nerve literally popped right out at him.

Again, I'll try to update more next week and maybe you can let me know to ask some other questions as well.

Re: 8 weeks post tts surgery questions

chris L on 2/07/04 at 09:51 (143851)

I was very interested to hear about your post op recovery. I had a TTS op on Monday of this week and the day after (still in hospital) I was encouraged to put weight onto the foot. Of course I could not do so. I was sent home with crutches and after two days I was able to walk without crutches for short periods albeit with a bad limp. I have just read on this site that no weight should be put on for up to 4 weeks. As I have not had any pain in the foot (except where the cut is)I have not had to take pain killers either. Am I just exceptionally lucky or am I doing more damage?

Re: 8 weeks post tts surgery questions

Terri on 2/07/04 at 14:29 (143875)

Regarding lack of pain, yes you are exceptionally lucky! As far as doing more damage, well I can't offer an opinion on that. I don't know exactly what was done and I'm not a dr either. You just have to trust that your dr knows what he/she is doing is correct for your prognosis. But make sure that if you are at all uncomfortable, state your reasons clearly and ask for alternatives. I was at p.t. this week and they wanted to do e-stim. They were really pushing it, but my dr had insisted I be careful around the nerves since he had to do a lot of work on me and go way up into the calf area to release nerves in the sheath. I didn't feel comfortable with it and politely declined until I could talk it over with my dr. If he says ok next week, then I'll go ahead.

Again, listen to your body and if you have any questions, talk to your dr.

Re: 8 weeks post tts surgery questions

Margie B on 2/07/04 at 18:25 (143882)

Hi Terri,
Thanks for responding. I appreciated your tips about massage and pt. My pt has never treated anyone with tts and I'm wondering if I should ask to see someone else. My doctor has only ordered ultrasound and now elec. stim, so we'll see.I was also told before the surgery by my podiatrist that heel numbness was a common side effect. I would like to understand this better and I read Elliot's response with interest. I'm planning to ask my doctor for more information on the surgery in regard to the medial calcaneal nerves in relation to the numbness in my heel.The lower part of my incision close to where these nerves lie, is the most painful.Are you using crutches at all? I feel less trapped at home being able to use them than I did with just the wheelchair. I lost 20 lbs. before the surgery and am working on losing another twenty over the next few months! Now that I can swim that should be easier!My doctor said losing weight always helps.
Let's keep in touch-nice to know we're not alone.
Margie

Re: TTS

Margie B on 2/07/04 at 18:33 (143884)

Elliott,
Thanks for the well wishes. I read your response to Terri with much interest.My doc also told me before surgery that the most common side effect was heel numbness. He did not explain why. I did lots of research over the last few months about tts and tried to understand the complexities of foot anatomy. An article my podiatrist gave me about tts release shows a diagram of the tibial nerve and its branches. Interestingly, the medial calcaneal branch pierces the lacinate ligament which as you know, is cut during this surgery. I wonder,(and plan to question my doc further,) what happens to this branch once the ligament it passes through is cut? I was told after surgery I had severe entrapment and a lot of scar tissue. I was in so much pain before surgery I could barely walk. If numbness is left after my post surgery pain (at 8 weeks), I can live with that but I still want to understand this whole syndrome better and what to expect with the healing process. Can you give me some idea of your level of pain and where you felt it in your foot after surgery at 2,3,4 months? Thanks,
Margie

Re: 8 weeks post tts surgery questions

Margie B on 2/07/04 at 18:39 (143885)

Lauriel,
Thanks for your encouragement. I read through most of your posted messages. It sounds like good pt was key for you. My pt has never had a patient with tts but we're only doing ultrasound and elec.stim. for now.
I may ask to see someone else, more knowledgeable if things are not going well. Do you remember if you had heel pain after surgery? If so, did it go away? My doc says it will eventually go away. It seems to be coming from the calcaneal nerve branch. My incision is still very sore. I'm glad you are so well healed and look to you for inspiration and belief I will get better!
Margie

Re: 8 weeks post tts surgery questions

Margie B on 2/07/04 at 18:47 (143886)

Chris,
It sounds like you are doing well but I would definitely speak with your doctor further about weight bearing. I researched this surgery a bit and most sources said 3weeks to one month non-weight bearing. My doctor had me just stand for short periods during the day at about 3 weeks post surgery and start walking around the house at about 4 weeks. I take a list of questions with me for every dr. appt. otherwise the visit is way too short. Keep me posted on your recovery. I wish you well.
Margie

Re: TTS

elliott on 2/09/04 at 10:46 (143984)

Terri:

Please ask the doc specifically how he knew in advance you'd have permanent numbness in your heel.

Did you have any obvious nervy symptoms pre-op (numbness, burning, tingling, etc.)? Could you pin down pre-op where the source of your pain was?

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Re: TTS

elliott on 2/09/04 at 10:55 (143986)

Margie,

In a typical TTS release, nothing should happen to the medial calcaneal nerves when the laciniate ligament is cut. Cutting the ligament gives all your nerves a bit more space there, which often relieves or lessens the symptoms. That is not to say that strange reactions to the surgery won't happen, because they often do.

If you could, please answer the same questions I asked Terri. Thanks.

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Re: 8 weeks post tts surgery questions

lauriel on 2/09/04 at 12:07 (143993)

Margie, glad I could be of some insight on on pain. There is light at the end of that long tunnel! I didnt have the heel pain like you describe but have heard of people here with it after surgery and it does go away. The one thing I have to stress is make sure your PT is massaging the area and show you how to do it, this will prevent scar tissue from developing. My PT did have experience with TTS. I started at 6 weeks and he got me into mobility excercises.

Chris, my Dr expressed under no circumstances to be weight bearing until 4 weeks, and to keep elevated as much as possible in this time frame. That weight bearing too son can make things worse. For the majority of people here, they have been told to keep non wegiht bearing for 3-4 weeks. A few peopl have posted their Drs had them weight bearing soon after.

Laurie

Re: TTS

Margie B on 2/10/04 at 16:01 (144050)

Hello Elliott,
My problem started in Aug.2001 with heel pain in left foot diagnosed as plantar fasciitis.My first podiatrist did mention in his notes (I saw the records two years later)that I had pain in the area of the infracalcaneal nerve. I had all the conservative treatments for pf and eventually two shockwave(Ossatron) treatments 6 months apart.I noted that my heel pain was in the lateral area of my heel, not a typical place for pf. My other foot started to hurt and I started having burning,tingling pain especially at night. I was teaching elem.school full time during this two year period.I was tested with:X-rays, bone scan, EMG and MRI. The first EMG turned up negative but by this time I was having that stabbing pain,(mild at first) near my ankle. I was also having numbness in my feet.My pain got so bad, & 1st pod would not give me pain meds. I changed doctors. He diagnosed TTS & immediately put me on Neurontin. I had typical TTS symptoms(burning, stabbing pain, tingling,numbness,and pain worse after standing/walking.
I also had a pos.Tinel sign and my 2nd EMG was positive for TTS in both feet.Finally I had the TTS surgery,(12/03) I'm concerned with the heel pain I have as well as pain near the incision. I plan to ask my pod more about exactly what he saw & did with the calcaneal branch nerves. Could the release be be the cause of the heel pain? As I mentioned I have a numb spot about 2'diameter. Sorry to be so wordy but as you know these things are complicated! I'd love to know more about your recovery.Thanks

Re: TTS

elliott on 2/11/04 at 13:17 (144106)

Margie:

Did you ever have clearcut nervy problems in your left (operated) foot? I'll add that lateral heel pain likely is not TTS either, as the TTS nerves don't run there. A nerve conduction test is by no means foolproof. One can be more confident of the diagnosis and surgical recommendation if the patient feels nervy symptoms/entrapment specifically at the inner ankle just behind and a drop below it--did you have that?

In a standard TTS release (which is what the vast majority get), they release the nerve and branches in the area of the tarsal tunnel. This should not automatically cause numbness. I had numbness and burning pre-surgery in my right foot brought on with even mild exercise, and it extended to (but apparently did not originate in) the heel. Post-op this was all gone (but my surgeon left me with a serious structural problem I'm still trying to sort out). My left foot started tingling 24/7 shortly before surgery on my right foot, again with tingling extending to but not originating in the heel. That foot was released a year later by a different surgeon. In that foot I had immediate drastic relief except in one small area in the tunnel, which bothered me some and then had a severe relapse of sorts. But over the next year or two, it got a lot better to the point that this surgery is now a success (despite those painful years, I'm lucky I didn't rush into a possibly very risky second surgery). Regardless, neither of my feet had any permanent numbness as a result of the surgery. I recall a surgeon telling me that if a revision were needed and the medial calcaneal nerves were to be released, if he discovered a tangled mess there, he might not be able to save these nerves and permanent numbess would result. Again, in a standard release, this should not happen, and being told that up front is strange.

Re: TTS

Margie B on 2/22/04 at 19:38 (145037)

Elliott,
I did ask my doc about the surgery & the medial calcaneal nerves. He said they were not cut because if they were I would have complete numbness of my heel. He released them as well as he could.
He also said my lateral heel pain was coming from the fascia and should subside. I'm 11 weeks post surgery and am doing better. I'm off crutches, use a cane and the pain is better. Ithank you for your information and support.
Margie

Re: TTS

Dr. Z on 2/22/04 at 19:49 (145038)

Hi Margie,

TTS surgical release can take months up to one year for resolution of your pain. All kinds of nerve type pain, numbness can occur on and off during this period. Swelling is very common and can cause the numbness you are talking about. Some patients will have numbness before the release due to the pressure on the nerves. This should improve with a release but sometimes lasts for forever to some degree. This is what you doctor maybe talking about.