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Dr Wander or Z please

Posted by sammy p on 2/09/04 at 15:01 (143997)

Here is a breif synopsis of my problem of which my MRI showed Tenosynovitis of the Flexor Hallucis Longus and Flexor Digitorum Longus particulary more on the FHL tendon.

NATURE: I am experiencing inner ankle pain , in a localized area about 1/2 way between the inner ankle bone and the back of the heeL WITH intermittent tingling sensation on toes on bottom of foot.

LOCATION: Very tender area exactly between inner ankle bone and achllies tendon. When rubbing my finger over this area I feel a slight, tingling in toes.

DURATION:5 months of inner ankle pain , but the tingling just started a week ago.

ONSET: The pain developed gradually after taping my ankle for PF ,i began to feel inner ankle pain and eventually it got worse and persistent. I am a mail carrier requiring alot of walking but been out of work the last 3 months resting.

CHARACTERISTICS: Deep aching pain with occasional tingling of toes and bottom of foot which is intermttent. The pain more my problem, as the tingling does not hurt.

AGGRAVATING: Standing for more than 15-20 minuts in 1 spot, which then walking lessens it to a degree, but I cannot do extended walking without increasing pain. I must say the pain is even present at rest.

TREATMENTS ATTEMPTED:

ORTHOTICS- Full length with plastic arch support with stable heel. Also tried a softer orthoitc arch which did not help.

NSAIDS- vioxx-25mg for 1 month no help. OTC motrin 1200 mg for 14 days no help.

ICE/HEAT: gel packs cold bath moist heat packs temporary.

PHYSICAL THERAPY: stretching aggarvated symptoms in first month of onset, which pod says was probaly a bad idea.

IMMOBILIZATION: 6 Weeks in soft boot cast with weightbearing and 4 weeks on crutches non weightbearing using the soft cast.

CORTISONE INJECTIONS: 2 ABOUT A MONTH APART WHILE IMMOBILZED. Helped slightly, but only for about a week.

ACUPUNTURE: 1 treatment last week which felt some relief, but develpoed the tingling in foot when he tapped the nerve on inside ankle,causing a shooting pain to my big toe, but subsided after initial insertion.

OTHER: currently trying iontophoresis patch which conatins steroidal medincine.

I do not know what else to do as i am struggling in constant pain. I apprecaite your advice on other possible treatment. Chiropractor? Foottrainer? Thank you

Re: Dr Wander or Z please

Dr. David S. Wander on 2/09/04 at 18:45 (144008)

Sam,

Sorry, but I've been very busy but I'll make a quick attempt at answering your questions. Please realize that although you've answered the questions, I still have not examined your foot and therefore can not give a truly accurate response. I understand that the MRI did not show any pathology of the posterior tibial tendon, but did show some possible pathology of the flexor tendons. However, I'm still not convinced that there isn't a problem with the posterior tibial tendon. You've also mentioned tingling in the foot, pain present at rest,and aggravated symptoms during stretching, all which may indicate a nerve entrapment/tarsal tunnel syndrome. Remember, the posterior tibial tendon, and flexor tendons and tibial nerve are all contained within the tarsal tunnel, therefore your doctor may want to start concentrating his efforts on the actual tarsal tunnel, since that seems to be the common factor.

Re: Dr Wander or Z please

Dr. David S. Wander on 2/09/04 at 18:55 (144009)

Sam,

Sorry, my last post was cut short. I would not seek the services of a chiropractor for this problem. I fully understand chiropractic principles and fully understand foot/ankle anatomy and pathology and do not believe that chiropractic care for your present condition would be beneficial. I have no problem trying accupuncture, physical therapy, etc., but would certainly address the entire tarsal tunnel question to your present doctor.
I would avoid any additional steroid injections. Your doctor may want to perform a nerve block with nothing other than local anesthetic, into the tarsal tunnel to see if the symptoms temporarily resolve. This can be an excellent diagnostic tool and may help pinpoint the problem.

Re: Nerve Block

sammy p on 2/10/04 at 06:49 (144032)

Dr Wander,

Thank you very much for the advice. I am concerned about the nerve block. Isn't this the same as a steroid injection for risk of possibly ruputuring the tendon? Wher is the nerve block inserted. Also can acupuncture actually damage the post tibial nerve if it is tapped with a needle?

Re: Acupuncture effects

sammy p on 2/10/04 at 07:05 (144034)

Dr wander,
I would also like to emphasize that i developed this TINGLING sensation in the foot and toes which is off and on AFTER 1 treatment of ACUPUNCTURE.

Please advise,

sammy

Re: Acupuncture effects

Dr. David S. Wander on 2/10/04 at 07:30 (144035)

Sam,

There is very little risk involved with injecting local anesthetic, and rupture of a tendon is NOT a risk of this procedure. Local anesthetic is not the same as a steroid injection. The biggest risk of a local anesthetic block is hitting the nerve and causing some temporary symptoms at the area of injury. The block I've recommended is a diagnostic tool to help your doctor. The accupuncture treatments/needles should certainly not penetrate your tissue enough to 'hit' the tibial nerve. Once again, I haven't examined your foot, but all the structures you've mentioned in your postings run through the tarsal tunnel and I believe that should be explored. If you were in my office, my next step would probably be a diagnostic nerve block in the tarsal tunnel (without any steroid). This will not cause a rupture or weakening of any tendon.