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orthotics and surgery questions

Posted by elliott on 6/01/04 at 09:33 (151690)

My seventh opinion, a podiatrist, has diagnosed medial column instability resulting from the surgeon cutting too deeply into my fascia while doing a TTS release/posterior tibial tenosynovectomy. He has prescribed orthotics, which are by far the best ever--I wish I would have had these from day one; the two others I've had were junk by comparison. I'm not sure, however, that they will be enough at this point to save my foot. I'm currently getting around much better with less of that buckling feeling in my foot, but the foot still aches often and I cannot yet do even non-impact exercise such as elliptical trainer or cycling, which exacerbate the medial column pain and instability. Two questions:

1. Around how long before I see the maximal benefit from my orthotics (i.e., when I can be confident my condition will not improve further)?

2. Assuming the diagnosis is correct, what would be your surgical recommendation?

Thanks for any help you may provide.


Re: orthotics and surgery questions

Ed Davis, DPM on 6/01/04 at 17:16 (151731)

Your pod is making a diagnosis which is a bit of a tough determination. Keep in mind that we are talking of living tissue that does regrow. Assuming that one even cut part of the fascia, the fascia would regrow.
Based on my recollection, you should be seeing the maximum benefits from your orthotics although that does not preclude that they could be adjusted to enhance their support. That amy simply involve heating them to raise the medial column -- some are uncomfortable with such adjustments and others are not. It is something the lab could do if he does not like to make adjustments.

Re: Heh, Elliot( TTS Release/Tenosynovectomy of FHL TEndon

John Martello on 6/01/04 at 18:18 (151733)

Hello Elliot,

I see you have had a Tarsal tunnel release with tenosynovectomy of the post tib tendon. I have a simialr problem which i have been battling for 8 months and have tried all conservative measures. Now i have 2 foot specialists that reccommend the Tarsal tunnel release with tenosynovectomy of the Flexor hallucis and flexor digitorum longus tendons which are in fact close to the post tib in your case.

My question to you is in your experience did this surgery make you WORSE as far as pain or did you get some relief. One Physician tells me he will not even give me odds or success rate , because of the unpredictablre nature of the surgery, whiule the other says 50% copuld get better, other 50% either worse or stays at the same level of pain, but how do they know youyr pain level. He also siad its a personal choice to try if ive tried everyrthing else.

Please advise me on the type of orthotics you are having success with as in your posting. Hard. rigid. soft


Re: orthotics and surgery questions

elliott on 6/02/04 at 09:00 (151767)

Dr. Ed:

It's been 5 years since that surgery. Wouldn't that be enough time for living tissue to regrow? If so, would you question the diagnosis? Remember, he is a DPM.

Can you give me an exact time frame by which one can be very certain of maximal benefit from orthotics? Two months?

My pod makes adjustments in-house if necessary. They are a perfect fit and don't need adjustment. I know from a previous pod that raising the medial side puts strain on my lateral side.

Re: Heh, Elliot( TTS Release/Tenosynovectomy of FHL TEndon

elliott on 6/02/04 at 09:15 (151774)

John M:

If you don't have any obvious nervy problems, I'd be very wary of the diagnosis and think twice about a TTS release--you could end up with nervy pain you didn't have before. How confident are they (and you) about the tendon diagnoses? Sometimes an MRI shows tenosynovitis but it is relatively benign. You have to feel comfortable that what they pick up is the cause and that the surgery is likely to address your problems. In my own case, I had obvious nervy pain, especially after running, to the point I couldn't do it anymore--my foot would have unbearable burning and numbness for more than a day after just a one-mile run. I feel there was a sudden structural change in my foot at the onset of symptoms, but I'm not sure they ever figured it out. The post tib tendon repair I had was probably unnecessary despite the MRI. The surgery fixed my TTS problem but left me with puzzling instability so that at the least I regret having used that surgeon.

Too young for this sh*t? I used to be too young too. Now I'm 5 years older, and I never got to resume running 2 months after surgery as the surgeon had promised.

Re: Heh, Elliot( TTS Release/Tenosynovectomy of FHL TEndon

elliott on 6/02/04 at 09:19 (151775)

PS-my orthotics are full-length, with a graphite base and a softer top that actuallymakes it feels somewhat cushioned. My previous orthotics were too hard, not resolving my pain at all, just perhaps shifting some of it laterally.

Re: orthotics and surgery questions

Ed Davis, DPM on 6/02/04 at 14:47 (151810)

There has been enough time for tissue to regrow. There has been enough time to see the maximum effect of the orthotic in its current state.

Now here is where there are a few tricks. You have discovered that there is a limit to how much the medial side can be lifted before you overload the lateral side. I would consider raising BOTH sides; not a lot -- just ry about 1/16 of an inch at a time to 'test' your tolerance and response.
Here is where the 'art' comes into play. If you respond postively, you may go for another 1/16 of an inch on both sides -- this willl take some 'testing' by both parties willing to give it a try.

Re: orthotics and surgery questions

elliott on 6/03/04 at 08:29 (151872)

Dr. Ed:

Interesting idea about raising the orthotic on both sides; thanks, I'll keep it in mind, but at this point I'm still reluctant to try it for several reasons:

1. The orthotics are such a perfect fit and definitely helping somewhat that I'm reluctant to start tampering with it.

2. I'm still holding out hope that giving it more time will help more. Most of my improvement has come in the last several weeks. There may be less scientific data backing up additional waiting, but my case is not exactly run-of-the-mill either.

3. No one who's gone through TTS wants more pressure on the medial side; that's just the way it is and always will be.

4. After suffering a neuroma and surgery for it, I don't want anything increasing the tightness anywhere on my foot